1
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Parekh DS, Eaton WA, Thein SL. Recent developments in the use of pyruvate kinase activators as a new approach for treating sickle cell disease. Blood 2024; 143:866-871. [PMID: 38118071 PMCID: PMC10940061 DOI: 10.1182/blood.2023021167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 12/22/2023] Open
Abstract
ABSTRACT Pyruvate kinase (PK) is a key enzyme in glycolysis, the sole source of adenosine triphosphate, which is essential for all energy-dependent activities of red blood cells. Activating PK shows great potential for treating a broad range of hemolytic anemias beyond PK deficiency, because they also enhance activity of wild-type PK. Motivated by observations of sickle-cell complications in sickle-trait individuals with concomitant PK deficiency, activating endogenous PK offers a novel and promising approach for treating patients with sickle-cell disease.
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Affiliation(s)
- Dina S. Parekh
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - William A. Eaton
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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2
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Lyu J, Ni M, Weiss MJ, Xu J. Metabolic regulation of erythrocyte development and disorders. Exp Hematol 2024; 131:104153. [PMID: 38237718 PMCID: PMC10939827 DOI: 10.1016/j.exphem.2024.104153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/07/2024] [Accepted: 01/08/2024] [Indexed: 02/01/2024]
Abstract
The formation of new red blood cells (RBC) (erythropoiesis) has served as a paradigm for understanding cellular differentiation and developmental control of gene expression. The metabolic regulation of this complex, coordinated process remains poorly understood. Each step of erythropoiesis, including lineage specification of hematopoietic stem cells, proliferation, differentiation, and terminal maturation into highly specialized oxygen-carrying cells, has unique metabolic requirements. Developing erythrocytes in mammals are also characterized by unique metabolic events such as loss of mitochondria with switch to glycolysis, ejection of nucleus and organelles, high-level heme and hemoglobin synthesis, and antioxidant requirement to protect hemoglobin molecules. Genetic defects in metabolic enzymes, including pyruvate kinase and glucose-6-phosphate dehydrogenase, cause common erythrocyte disorders, whereas other inherited disorders such as sickle cell disease and β-thalassemia display metabolic abnormalities associated with disease pathophysiology. Here we describe recent discoveries on the metabolic control of RBC formation and function, highlight emerging concepts in understanding the erythroid metabolome, and discuss potential therapeutic benefits of targeting metabolism for RBC disorders.
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Affiliation(s)
- Junhua Lyu
- Center of Excellence for Leukemia Studies, Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Min Ni
- Division of Molecular Oncology, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Mitchell J Weiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Jian Xu
- Center of Excellence for Leukemia Studies, Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN.
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3
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Musallam KM, Cappellini MD, Coates TD, Kuo KHM, Al-Samkari H, Sheth S, Viprakasit V, Taher AT. Αlpha-thalassemia: A practical overview. Blood Rev 2024; 64:101165. [PMID: 38182489 DOI: 10.1016/j.blre.2023.101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
α-Thalassemia is an inherited blood disorder characterized by decreased synthesis of α-globin chains that results in an imbalance of α and β globin and thus varying degrees of ineffective erythropoiesis, decreased red blood cell (RBC) survival, chronic hemolytic anemia, and subsequent comorbidities. Clinical presentation varies depending on the genotype, ranging from a silent or mild carrier state to severe, transfusion-dependent or lethal disease. Management of patients with α-thalassemia is primarily supportive, addressing either symptoms (eg, RBC transfusions for anemia), complications of the disease, or its transfusion-dependence (eg, chelation therapy for iron overload). Several novel therapies are also in development, including curative gene manipulation techniques and disease modifying agents that target ineffective erythropoiesis and chronic hemolytic anemia. This review of α-thalassemia and its various manifestations provides practical information for clinicians who practice beyond those regions where it is found with high frequency.
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Affiliation(s)
- Khaled M Musallam
- Center for Research on Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - M Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca' Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | - Thomas D Coates
- Hematology Section, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kevin H M Kuo
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanny Al-Samkari
- Center for Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sujit Sheth
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Vip Viprakasit
- Department of Pediatrics & Thalassemia Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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4
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Liu T, Padyana AK, Judd ET, Jin L, Hammoudeh D, Kung C, Dang L. Structure-Based Design of AG-946, a Pyruvate Kinase Activator. ChemMedChem 2024; 19:e202300559. [PMID: 38109501 DOI: 10.1002/cmdc.202300559] [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: 10/17/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
Pyruvate kinase (PK) is the enzyme that catalyzes the conversion of phosphoenolpyruvate and adenosine diphosphate to pyruvate and adenosine triphosphate in glycolysis and plays a crucial role in regulating cell metabolism. We describe the structure-based design of AG-946, an activator of PK isoforms, including red blood cell-specific forms of PK (PKR). This was designed to have a pseudo-C2-symmetry matching its allosteric binding site on the PK enzyme, which increased its potency toward PKR while reducing activity against off-targets observed from the original scaffold. AG-946 (1) demonstrated activation of human wild-type PK (half-maximal activation concentration [AC50 ]=0.005 μM) and a panel of mutated PK proteins (K410E [AC50 =0.0043 μM] and R510Q [AC50 =0.0069 μM]), (2) displayed a significantly longer half-time of activation (>150-fold) compared with 6-(3-methoxybenzyl)-4-methyl-2-(methylsulfinyl)-4,6-dihydro-5H-thieno[2',3':4,5]pyrrolo[2,3-d]pyridazin-5-one, and (3) stabilized PKR R510Q, an unstable mutant PKR enzyme, and preserved its catalytic activity under increasingly denaturing conditions. As a potent, oral, small-molecule allosteric activator of wild-type and mutant PKR, AG-946 was advanced to human clinical trials.
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Affiliation(s)
- Tao Liu
- Ensem Therapeutics, 880 Winter St, Waltham, MA 02451, USA
| | | | - Evan T Judd
- Novartis Institute for Biomedical Research, 250 Massachusetts Ave, Cambridge, MA 02139, USA
| | - Lei Jin
- Agios Pharmaceuticals, Inc., 88 Sidney St, Cambridge, MA, USA
| | - Dalia Hammoudeh
- Agios Pharmaceuticals Inc., 88 Sidney St, Cambridge, MA, USA
| | - Charles Kung
- Remix Therapeutics, 100 Forge Rd, Watertown, MA 02472, USA
| | - Lenny Dang
- Verolix, Inc., 800 Boylston St. Unit 900147, Boston, MA, 02199, USA
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5
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Chatzinikolaou PN, Margaritelis NV, Paschalis V, Theodorou AA, Vrabas IS, Kyparos A, D'Alessandro A, Nikolaidis MG. Erythrocyte metabolism. Acta Physiol (Oxf) 2024; 240:e14081. [PMID: 38270467 DOI: 10.1111/apha.14081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/11/2023] [Accepted: 01/01/2024] [Indexed: 01/26/2024]
Abstract
Our aim is to present an updated overview of the erythrocyte metabolism highlighting its richness and complexity. We have manually collected and connected the available biochemical pathways and integrated them into a functional metabolic map. The focus of this map is on the main biochemical pathways consisting of glycolysis, the pentose phosphate pathway, redox metabolism, oxygen metabolism, purine/nucleoside metabolism, and membrane transport. Other recently emerging pathways are also curated, like the methionine salvage pathway, the glyoxalase system, carnitine metabolism, and the lands cycle, as well as remnants of the carboxylic acid metabolism. An additional goal of this review is to present the dynamics of erythrocyte metabolism, providing key numbers used to perform basic quantitative analyses. By synthesizing experimental and computational data, we conclude that glycolysis, pentose phosphate pathway, and redox metabolism are the foundations of erythrocyte metabolism. Additionally, the erythrocyte can sense oxygen levels and oxidative stress adjusting its mechanics, metabolism, and function. In conclusion, fine-tuning of erythrocyte metabolism controls one of the most important biological processes, that is, oxygen loading, transport, and delivery.
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Affiliation(s)
- Panagiotis N Chatzinikolaou
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
| | - Nikos V Margaritelis
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
| | - Vassilis Paschalis
- School of Physical Education and Sport Science, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios A Theodorou
- Department of Life Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Ioannis S Vrabas
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
| | - Antonios Kyparos
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michalis G Nikolaidis
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
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6
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Njeim R, Naouss B, Bou-Fakhredin R, Haddad A, Taher A. Unmet needs in β-thalassemia and the evolving treatment landscape. Transfus Clin Biol 2024; 31:48-55. [PMID: 38128605 DOI: 10.1016/j.tracli.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023]
Abstract
β-thalassemias are genetic disorders causing an imbalance in hemoglobin production, leading to varying degrees of anemia, with two clinical phenotypes: transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). Red blood cell transfusions and iron chelation therapy are the conventional treatment options for the management of β-thalassemia. Currently available conventional therapies in thalassemia have many challenges and limitations. Accordingly, multiple novel therapeutic approaches are currently being developed for the treatment of β-thalassemias. These strategies can be classified into three categories based on their efforts to address different aspects of the underlying pathophysiology of β-thalassemia: correction of the α/β globin chain imbalance, addressing ineffective erythropoiesis, and targeting iron dysregulation. Managing β- thalassemia presents challenges due to the many complications that can manifest, limited access and availability of blood products, and lack of compliance/adherence to treatment. Novel therapies targeting ineffective erythropoiesis and thus improving anemia and reducing the need for chronic blood transfusions seem promising. However, the complex nature of the disease itself requires personalized treatment plans for each patient. Collaborations and partnerships between thalassemia centers can also help share knowledge and resources, particularly in regions with higher prevalence and limited resources. This review will explore the different conventional treatment modalities available today for the management of β-thalassemia, discuss the unmet needs and challenges associated with them in addition to exploring the role of some novel therapeutic agents in the field.
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Affiliation(s)
- Ryan Njeim
- Department of Internal Medicine, Lebanese University, Beirut, Lebanon
| | - Bilal Naouss
- Department of Laboratory Medicine, Lebanese University, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Antoine Haddad
- Department of Clinical Pathology and Blood Bank, Sacré-Coeur Hospital, Lebanese University, Beirut, Lebanon
| | - Ali Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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7
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El-Beshlawy A, Dewedar H, Hindawi S, Alkindi S, Tantawy AA, Yassin MA, Taher AT. Management of transfusion-dependent β-thalassemia (TDT): Expert insights and practical overview from the Middle East. Blood Rev 2024; 63:101138. [PMID: 37867006 DOI: 10.1016/j.blre.2023.101138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
β-Thalassemia is one of the most common monogenetic diseases worldwide, with a particularly high prevalence in the Middle East region. As such, we have developed long-standing experience with disease management and devising solutions to address challenges attributed to resource limitations. The region has also participated in the majority of clinical trials and development programs of iron chelators and more novel ineffective erythropoiesis-targeted therapy. In this review, we provide a practical overview of management for patients with transfusion-dependent β-thalassemia, primarily driven by such experiences, with the aim of transferring knowledge to colleagues in other regions facing similar challenges.
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Affiliation(s)
- Amal El-Beshlawy
- Department of Pediatric Hematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hany Dewedar
- Thalassemia Center, Latifa Hospital, Dubai, United Arab Emirates
| | - Salwa Hindawi
- Department of Hematology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Salam Alkindi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Azza A Tantawy
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed A Yassin
- Department of Hematology and Oncology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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8
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van Dijk MJ, Rab MAE, van Oirschot BA, Bos J, Derichs C, Rijneveld AW, Cnossen MH, Nur E, Biemond BJ, Bartels M, Jans JJM, van Solinge WW, Schutgens REG, van Wijk R, van Beers EJ. One-year safety and efficacy of mitapivat in sickle cell disease: follow-up results of a phase 2, open-label study. Blood Adv 2023; 7:7539-7550. [PMID: 37934880 PMCID: PMC10761354 DOI: 10.1182/bloodadvances.2023011477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 11/09/2023] Open
Abstract
Targeting the primary pathogenic event of sickle cell disease (SCD), the polymerization of sickle hemoglobin (HbS), may prevent downstream clinical events. Mitapivat, an oral pyruvate kinase (PK) activator, has therapeutic potential by increasing adenosine triphosphate (ATP) and decreasing 2,3-diphosphoglycerate (2,3-DPG), a glycolytic red blood cell (RBC) intermediate. In the previously reported 8-week dose-finding period of this phase 2, investigator-initiated, open-label study, mitapivat was well tolerated and showed efficacy in SCD. Here, the 1-year fixed-dose extension period is reported in which 9 of 10 included patients (90%) aged ≥16 years with SCD (HbSS, HbS/β0, or HbS/β+) continued with mitapivat. Mostly mild treatment-emergent adverse events (AEs) (most commonly, transaminase increase and headache) were still reported. Apart from the reported nontreatment-related serious AE (SAE) of a urinary tract infection in the dose-finding period, 1 nontreatment-related SAE occurred in the fixed-dose extension period in a patient who died of massive pulmonary embolism due to COVID-19. Importantly, sustained improvement in Hb level (mean increase, 1.1 ± 0.7 g/dL; P = .0014) was seen, which was accompanied by decreases in markers of hemolysis. In addition, the annualized rate of vaso-occlusive events reduced significantly from a historic baseline of 1.33 ± 1.32 to 0.64 ± 0.87 (P = .0489) when combining the dose-finding period and fixed-dose extension period. Cellularly, the ATP:2,3-DPG ratio and Hb-oxygen affinity significantly increased and RBC sickling (point of sickling) nonsignificantly reduced. Overall, this study demonstrated 1-year safety and efficacy of treatment with mitapivat in SCD, supporting further evaluation in ongoing phase 2/3 study (RISE UP, NCT05031780). This trial was registered at https://www.clinicaltrialsregister.eu/ as NL8517 and EudraCT 2019-003438-18.
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Affiliation(s)
- Myrthe J. van Dijk
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Minke A. E. Rab
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Brigitte A. van Oirschot
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jennifer Bos
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cleo Derichs
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anita W. Rijneveld
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - Bart J. Biemond
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije Bartels
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Judith J. M. Jans
- Section Metabolic Diagnostics, Department of Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter W. van Solinge
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E. G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard van Wijk
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eduard J. van Beers
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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9
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Kuo KH. Pyruvate kinase activators: targeting red cell metabolism in thalassemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:114-120. [PMID: 38066911 PMCID: PMC10727068 DOI: 10.1182/hematology.2023000468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thalassemia is an inherited red blood cell disorder whereby the qualitative and/or quantitative imbalance in α- to β-globin ratio results in hemolysis and ineffective erythropoiesis. Oxidative stress, from the precipitated excess globin and free iron, is a major factor that drives hemolysis and ineffective erythropoiesis. Pyruvate kinase activity and adenosine triphosphate availability are reduced due to the overwhelmed cellular antioxidant system from the excessive oxidative stress. Mitapivat, a pyruvate kinase activator in development as a treatment for thalassemia, was shown to increase hemoglobin and reduce hemolysis in a small phase 2 single-arm trial of patients with α- and β-thalassemia. The ongoing phase 3 studies with mitapivat and the phase 2 study with etavopivat will examine the role of pyruvate kinase activators as disease modifying agents in thalassemia.
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Affiliation(s)
- Kevin H.M. Kuo
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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10
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Hodroj MH, Akiki N, Bou-Fakhredin R, Taher AT. Beta-thalassemia: is cure still a dream? Minerva Med 2023; 114:850-860. [PMID: 37534831 DOI: 10.23736/s0026-4806.23.08501-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
β-thalassemia is a monogenic disorder characterized by decreased hemoglobin production, resulting in chronic anemia. There are several factors affecting the clinical presentation of patients with β-thalassemia, and several complications such as iron overload or ineffective erythropoiesis have been linked to this disease. Until nowadays, several conservative therapies namely blood transfusions, iron chelation, and the FDA-approved drug Luspatercept have been adopted alongside other debatable permanent cures. Other clinical trials are being conducted to develop better and safer management techniques for these patients. This review will discuss the different treatment strategies of β-thalassemia including novel therapies, besides all possible curative therapies that are being developed for this disease.
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Affiliation(s)
- Mohammad H Hodroj
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nathalie Akiki
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ali T Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon -
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11
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Matte A, Wilson AB, Gevi F, Federti E, Recchiuti A, Ferri G, Brunati AM, Pagano MA, Russo R, Leboeuf C, Janin A, Timperio AM, Iolascon A, Gremese E, Dang L, Mohandas N, Brugnara C, De Franceschi L. Mitapivat reprograms the RBC metabolome and improves anemia in a mouse model of hereditary spherocytosis. JCI Insight 2023; 8:e172656. [PMID: 37676741 PMCID: PMC10619498 DOI: 10.1172/jci.insight.172656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/05/2023] [Indexed: 09/09/2023] Open
Abstract
Hereditary spherocytosis (HS) is the most common, nonimmune, hereditary, chronic hemolytic anemia after hemoglobinopathies. The genetic defects in membrane function causing HS lead to perturbation of the RBC metabolome, with altered glycolysis. In mice genetically lacking protein 4.2 (4.2-/-; Epb42), a murine model of HS, we showed increased expression of pyruvate kinase (PK) isoforms in whole and fractioned RBCs in conjunction with abnormalities in the glycolytic pathway and in the glutathione (GSH) system. Mitapivat, a PK activator, metabolically reprogrammed 4.2-/- mouse RBCs with amelioration of glycolysis and the GSH cycle. This resulted in improved osmotic fragility, reduced phosphatidylserine positivity, amelioration of RBC cation content, reduction of Na/K/Cl cotransport and Na/H-exchange overactivation, and decrease in erythroid vesicles release in vitro. Mitapivat treatment significantly decreased erythrophagocytosis and beneficially affected iron homeostasis. In mild-to-moderate HS, the beneficial effect of splenectomy is still controversial. Here, we showed that splenectomy improves anemia in 4.2-/- mice and that mitapivat is noninferior to splenectomy. An additional benefit of mitapivat treatment was lower expression of markers of inflammatory vasculopathy in 4.2-/- mice with or without splenectomy, indicating a multisystemic action of mitapivat. These findings support the notion that mitapivat treatment should be considered for symptomatic HS.
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Affiliation(s)
- Alessandro Matte
- Department of Medicine, University of Verona, and Azienda Ospedaliera Universitaria Verona, Policlinico GB Rossi, Verona, Italy
| | - Anand B. Wilson
- Department of Medicine, University of Verona, and Azienda Ospedaliera Universitaria Verona, Policlinico GB Rossi, Verona, Italy
| | - Federica Gevi
- Department of Ecological and Biological Sciences, University of Tuscia, Viterbo, Italy
| | - Enrica Federti
- Department of Medicine, University of Verona, and Azienda Ospedaliera Universitaria Verona, Policlinico GB Rossi, Verona, Italy
| | - Antonio Recchiuti
- Department of Medical, Oral, and Biotechnology Science, “G.d’Annunzio” University of Chieti – Pescara, Center for Advanced Studies and Technology, Chieti, Italy
| | - Giulia Ferri
- Department of Medical, Oral, and Biotechnology Science, “G.d’Annunzio” University of Chieti – Pescara, Center for Advanced Studies and Technology, Chieti, Italy
| | | | | | - Roberta Russo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Naples, Italy
- CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Christophe Leboeuf
- INSERM, Paris, France
- Université Paris 7 — Denis Diderot, Paris, France
- Assistance Publique — Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Anne Janin
- INSERM, Paris, France
- Université Paris 7 — Denis Diderot, Paris, France
- Assistance Publique — Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Anna Maria Timperio
- Department of Ecological and Biological Sciences, University of Tuscia, Viterbo, Italy
| | - Achille Iolascon
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Naples, Italy
- CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Elisa Gremese
- Division of Clinical Immunology, Fondazione Policlinico Universitario A. Gemelli–Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
- Immunology Core Facility, Fondazione Policlinico Universitario A. Gemelli–IRCCS, Rome, Italy
| | - Lenny Dang
- Agios Pharmaceuticals Inc., Cambridge, Massachusetts, USA
| | | | - Carlo Brugnara
- Department of Laboratory Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucia De Franceschi
- Department of Medicine, University of Verona, and Azienda Ospedaliera Universitaria Verona, Policlinico GB Rossi, Verona, Italy
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12
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Guerra A, Parhiz H, Rivella S. Novel potential therapeutics to modify iron metabolism and red cell synthesis in diseases associated with defective erythropoiesis. Haematologica 2023; 108:2582-2593. [PMID: 37345473 PMCID: PMC10542825 DOI: 10.3324/haematol.2023.283057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/15/2023] [Indexed: 06/23/2023] Open
Abstract
Under normal conditions, iron metabolism is carefully regulated to sustain normal cellular functions and the production of hemoglobin in erythroid cells. Perturbation to the erythropoiesis-iron metabolism axis can result in iron imbalances and cause anemia or organ toxicity. Various congenital and acquired diseases associated with abnormal red cell production are characterized by aberrant iron absorption. Several recent studies have shown that improvements in red blood cell production also ameliorate iron metabolism and vice versa. Many therapeutics are now under development with the potential to improve a variety of hematologic diseases, from β-thalassemia and iron-refractory iron deficiency anemia to anemia of inflammation and polycythemia vera. This review summarizes selected mechanisms related to red cell production and iron metabolism and describes potential therapeutics and their current uses. We also consider the potential application of the discussed therapeutics on various diseases, alone or in combination. The vast repertoire of drugs under development offers new opportunities to improve the clinical care of patients suffering from congenital or acquired red blood cell disorders with limited or no treatment options.
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Affiliation(s)
- Amaliris Guerra
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA
| | - Hamideh Parhiz
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA; RNA Institute, University of Pennsylvania, Philadelphia, PA
| | - Stefano Rivella
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA; Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA; RNA Institute, University of Pennsylvania, Philadelphia, PA, USA; Cell and Molecular Biology affinity group (CAMB), University of Pennsylvania, Philadelphia, PA, USA; Raymond G. Perelman Center for Cellular and Molecular Therapeutics-CHOP; Penn Center for Musculoskeletal Disorders, CHOP, Philadelphia, PA, USA; Institute for Regenerative Medicine, University of Pennsylvania, Philadelphia, PA.
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13
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Saliba AN, Musallam KM, Taher AT. How I treat non-transfusion-dependent β-thalassemia. Blood 2023; 142:949-960. [PMID: 37478396 PMCID: PMC10644094 DOI: 10.1182/blood.2023020683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023] Open
Abstract
The intricate interplay of anemia and iron overload under the pathophysiological umbrella of ineffective erythropoiesis in non-transfusion-dependent β-thalassemia (NTDT) results in a complex variety of clinical phenotypes that are challenging to diagnose and manage. In this article, we use a clinical framework rooted in pathophysiology to present 4 common scenarios of patients with NTDT. Starting from practical considerations in the diagnosis of NTDT, we delineate our strategy for the longitudinal care of patients who exhibit different constellations of symptoms and complications. We highlight the use of transfusion therapy and novel agents, such as luspatercept, in the patient with anemia-related complications. We also describe our approach to chelation therapy in the patient with iron overload. Although tackling every specific complication of NTDT is beyond the scope of this article, we touch on the management of the various morbidities and multisystem manifestations of the disease.
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Affiliation(s)
| | - Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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14
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van Dijk MJ, de Wilde JRA, Bartels M, Kuo KHM, Glenthøj A, Rab MAE, van Beers EJ, van Wijk R. Activation of pyruvate kinase as therapeutic option for rare hemolytic anemias: Shedding new light on an old enzyme. Blood Rev 2023; 61:101103. [PMID: 37353463 DOI: 10.1016/j.blre.2023.101103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023]
Abstract
Novel developments in therapies for various hereditary hemolytic anemias reflect the pivotal role of pyruvate kinase (PK), a key enzyme of glycolysis, in red blood cell (RBC) health. Without PK catalyzing one of the final steps of the Embden-Meyerhof pathway, there is no net yield of adenosine triphosphate (ATP) during glycolysis, the sole source of energy production required for proper RBC function and survival. In hereditary hemolytic anemias, RBC health is compromised and therefore lifespan is shortened. Although our knowledge on glycolysis in general and PK function in particular is solid, recent advances in genetic, molecular, biochemical, and metabolic aspects of hereditary anemias have improved our understanding of these diseases. These advances provide a rationale for targeting PK as therapeutic option in hereditary hemolytic anemias other than PK deficiency. This review summarizes the knowledge, rationale, (pre)clinical trials, and future advances of PK activators for this important group of rare diseases.
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Affiliation(s)
- Myrthe J van Dijk
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jonathan R A de Wilde
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marije Bartels
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Andreas Glenthøj
- Danish Red Blood Center, Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Minke A E Rab
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Hematology, Erasmus Medical Center Rotterdam, the Netherlands
| | - Eduard J van Beers
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Richard van Wijk
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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15
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Lidonnici MR, Scaramuzza S, Ferrari G. Gene Therapy for Hemoglobinopathies. Hum Gene Ther 2023; 34:793-807. [PMID: 37675899 DOI: 10.1089/hum.2023.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
β-Thalassemia and sickle cell disease are autosomal recessive disorders of red blood cells due to mutations in the adult β-globin gene, with a worldwide diffusion. The severe forms of hemoglobinopathies are fatal if untreated, and allogeneic bone marrow transplantation can be offered to a limited proportion of patients. The unmet clinical need and the disease incidence have promoted the development of new genetic therapies based on the engineering of autologous hematopoietic stem cells. Here, the steps of ex vivo gene therapy development are reviewed along with results from clinical trials and recent new approaches employing cutting edge gene editing tools.
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Affiliation(s)
- Maria Rosa Lidonnici
- San Raffaele-Telethon Institute for Gene Therapy (SR-TIGET), San Raffaele Scientific Institute, Milan, Italy; and
| | - Samantha Scaramuzza
- San Raffaele-Telethon Institute for Gene Therapy (SR-TIGET), San Raffaele Scientific Institute, Milan, Italy; and
| | - Giuliana Ferrari
- San Raffaele-Telethon Institute for Gene Therapy (SR-TIGET), San Raffaele Scientific Institute, Milan, Italy; and
- University Vita-Salute San Raffaele, Milan, Italy
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16
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Zhang Y, Xie H, Liang G, Qin Y, Wei X, Ning S, Liang Y, Liang X, Xie Y, Lin Z, Zhu D, Lin J, Xiong F, Xu X, Shang X. A novel gain-of-function PIP4K2A mutation elevates the expression of β-globin and aggravates the severity of α-thalassemia. Br J Haematol 2023; 202:1018-1023. [PMID: 37423903 DOI: 10.1111/bjh.18967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
Haemoglobin H (Hb H) disease (intermediate status of α-thalassemia) shows marked phenotypic variability from asymptomatic to severe anaemia. Apart from the combined β-thalassemia allele ameliorating clinical severity, reports of genetic modifier genes affecting the phenotype of Hb H disease are scarce which bring inconvenience to precise diagnosis and genetic counselling of the patients. Here, we present a novel mutation (c.948C>A, p.S316R) in the PIP4K2A gene in a female Hb H disease patient who displayed moderate anaemia and a relatively high Hb H level. Haematological analysis in her family members revealed that individuals carrying this mutation have upregulated β-globin expression, leading to a more imbalanced β/α-globin ratio and more Hb H inclusion bodies in peripheral red blood cells. According to functional experiments, the mutant PIP4K2A protein exhibits enhanced protein stability, increased kinase activity and a stronger regulatory effect on downstream proteins, suggesting a gain-of-function mutation. Moreover, introduction of the S316R mutation into HUDEP-2 cells increased expression of β-globin, further inhibiting erythroid differentiation and terminal enucleation. Thus, the S316R mutation is a novel genetic factor associated with β-globin expression, and the PIP4K2A gene is a new potential modifier gene affecting the α-thalassemia phenotype.
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Affiliation(s)
- Yanxia Zhang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Hongting Xie
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Guanxia Liang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Yunrong Qin
- Department of Clinical Laboratory, Yulin Women and Children Health Care Hospital, Yulin, China
| | - Xiaofeng Wei
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Sisi Ning
- Department of Clinical Laboratory, Yulin Women and Children Health Care Hospital, Yulin, China
| | - Yi Liang
- Department of Clinical Laboratory, Yulin Women and Children Health Care Hospital, Yulin, China
| | - Xiongda Liang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Yuling Xie
- Department of Clinical Laboratory, Yulin Women and Children Health Care Hospital, Yulin, China
| | - Zezhang Lin
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Dina Zhu
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Jiaqiong Lin
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Fu Xiong
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Xiangming Xu
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Innovation Center for Diagnostics and Treatment of Thalassemia, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xuan Shang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- Innovation Center for Diagnostics and Treatment of Thalassemia, Nanfang Hospital, Southern Medical University, Guangzhou, China
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17
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Ginzburg Y, An X, Rivella S, Goldfarb A. Normal and dysregulated crosstalk between iron metabolism and erythropoiesis. eLife 2023; 12:e90189. [PMID: 37578340 PMCID: PMC10425177 DOI: 10.7554/elife.90189] [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: 06/16/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023] Open
Abstract
Erythroblasts possess unique characteristics as they undergo differentiation from hematopoietic stem cells. During terminal erythropoiesis, these cells incorporate large amounts of iron in order to generate hemoglobin and ultimately undergo enucleation to become mature red blood cells, ultimately delivering oxygen in the circulation. Thus, erythropoiesis is a finely tuned, multifaceted process requiring numerous properly timed physiological events to maintain efficient production of 2 million red blood cells per second in steady state. Iron is required for normal functioning in all human cells, the erythropoietic compartment consuming the majority in light of the high iron requirements for hemoglobin synthesis. Recent evidence regarding the crosstalk between erythropoiesis and iron metabolism sheds light on the regulation of iron availability by erythroblasts and the consequences of insufficient as well as excess iron on erythroid lineage proliferation and differentiation. In addition, significant progress has been made in our understanding of dysregulated iron metabolism in various congenital and acquired malignant and non-malignant diseases. Finally, we report several actual as well as theoretical opportunities for translating the recently acquired robust mechanistic understanding of iron metabolism regulation to improve management of patients with disordered erythropoiesis, such as anemia of chronic inflammation, β-thalassemia, polycythemia vera, and myelodysplastic syndromes.
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Affiliation(s)
- Yelena Ginzburg
- Division of Hematology and Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUnited States
| | - Xiuli An
- LFKRI, New York Blood CenterNew YorkUnited States
| | - Stefano Rivella
- Department of Pediatrics, Division of Hematology, The Children’s Hospital of PhiladelphiaPhiladelphiaUnited States
- Cell and Molecular Biology affinity group (CAMB), University of PennsylvaniaPhiladelphiaUnited States
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics at the Children’s Hospital of PhiladelphiaPhiladelphiaUnited States
- Penn Center for Musculoskeletal Disorders at the Children’s Hospital of PhiladelphiaPhiladelphiaUnited States
- Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
- Institute for Regenerative Medicine at University of PennsylvaniaPhiladelphiaUnited States
- RNA Institute at University of PennsylvaniaPhiladelphiaUnited States
| | - Adam Goldfarb
- Department of Pathology, University of VirginiaCharlottesvilleUnited States
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18
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Musallam KM, Taher AT, Kattamis A, Kuo KHM, Sheth S, Cappellini MD. Profile of Luspatercept in the Treatment of Anemia in Adults with Non-Transfusion-Dependent β-Thalassemia (NTDT): Design, Development and Potential Place in Therapy. Drug Des Devel Ther 2023; 17:1583-1591. [PMID: 37255740 PMCID: PMC10226484 DOI: 10.2147/dddt.s368584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/20/2023] [Indexed: 06/01/2023] Open
Abstract
Over the past decade, evidence has been mounting on the detrimental clinical sequelae of untreated anemia in patients with non-transfusion-dependent β-thalassemia (NTDT). There are no pharmacologic agents that are specifically approved for the management of anemia in NTDT, and available options such as splenectomy, transfusion therapy, and hydroxyurea each come with their own shortcomings, especially for long-term use. Luspatercept is an erythroid maturation agent that has been evaluated in a Phase 2, randomized trial and showed a significant benefit in raising hemoglobin level by at least 1 g/dL in adults with NTDT and a baseline hemoglobin level ≤10 g/dL. These data led to luspatercept's approval by the European Commission for the treatment of anemia in adults with NTDT and presents the first evidence-based approach for a novel agent that is able to ameliorate anemia in this patient population.
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Affiliation(s)
- Khaled M Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Sujit Sheth
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca’ Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
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19
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Matte A, Federti E, De Franceschi L. Erythrocyte pyruvate kinase activation in red cell disorders. Curr Opin Hematol 2023; 30:93-98. [PMID: 36853806 DOI: 10.1097/moh.0000000000000758] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW In red cells, pyruvate kinase is a key enzyme in the final step of glycolytic degradative process, which generates a constant energy supply via ATP production. This commentary discusses recent findings on pyruvate kinase activators as new therapeutic option in hereditary red cell disorders such as thalassemic syndromes or sickle cell disease (SCD). RECENT FINDINGS Mitapivat and etavopivat are two oral pyruvate kinase activators. Studies in a mouse model for β thalassemia have shown beneficial effects of mitapivat on both red cell survival and ineffective erythropoiesis, with an amelioration of iron homeostasis. This was confirmed in a proof-of-concept study in patients with nontransfusion-dependent thalassemias. Both mitapivat and etavopivat have been evaluated in mouse models for SCD, showing an increased 2-3DPG/ATP ratio and a reduction in haemolysis as well as in sickling. These data were confirmed in proof-of-concept clinical studies with both molecules carried in patients with SCD. SUMMARY Preclinical and clinical evidence indicate that pyruvate kinase activators represent new therapeutic option in hemoglobinopathies or SCD. Other red cell disorders such as hereditary spherocytosis or hereditary anaemias characterized by defective erythropoiesis might represent additional areas to investigate the therapeutic impact of pyruvate kinase activators.
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Affiliation(s)
- Alessandro Matte
- Department of Medicine, University of Verona and AOUI Verona, Verona, Italy
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20
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Luke N, Hillier K, Al-Samkari H, Grace RF. Updates and advances in pyruvate kinase deficiency. Trends Mol Med 2023; 29:406-418. [PMID: 36935283 PMCID: PMC11088755 DOI: 10.1016/j.molmed.2023.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 03/19/2023]
Abstract
Mutations in the PKLR gene lead to pyruvate kinase (PK) deficiency, causing chronic hemolytic anemia secondary to reduced red cell energy, which is crucial for maintenance of the red cell membrane and function. Heterogeneous clinical manifestations can result in significant morbidity and reduced health-related quality of life. Treatment options have historically been limited to supportive care, including red cell transfusions and splenectomy. Current disease-modifying treatment considerations include an oral allosteric PK activator, mitapivat, which was recently approved for adults with PK deficiency, and gene therapy, which is currently undergoing clinical trials. Studies evaluating the role of PK activators in other congenital hemolytic anemias are ongoing. The long-term effect of treatment with disease-modifying therapy in PK deficiency will require continued evaluation.
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Affiliation(s)
- Neeti Luke
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Kirsty Hillier
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA.
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21
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Abstract
Advances in understanding the underlying pathophysiology of β-thalassemia have enabled efforts toward the development of novel therapeutic modalities. These can be classified into three major categories based on their ability to target different features of the underlying disease pathophysiology: correction of the α/β globin chain imbalance, targeting ineffective erythropoiesis, and targeting iron dysregulation. This article provides an overview of these different emerging therapies that are currently in development for β-thalassemia.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Ali T Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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22
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Abstract
Clinical manifestations of α-thalassemia range from no symptoms to severe transfusion-dependent anemia. Alpha thalassemia trait is deletion of 1 to 2 α-globin genes, whereas α-thalassemia major (ATM; Barts hydrops fetalis) is the deletion all 4 α genes. All other genotypes of intermediate severity are categorized as HbH disease, a vastly heterogenous group. Clinical spectrum is classified as mild, moderate, and severe by symptoms and need for intervention. Anemia in prenatal period may be fatal without intrauterine transfusions. New therapies to modify HbH disease or provide cure for ATM are under development.
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Affiliation(s)
- Ashutosh Lal
- UCSF School of Medicine, UCSF Benioff Children's Hospital, 747 52nd Street, Oakland, CA 94609, USA.
| | - Elliott Vichinsky
- UCSF School of Medicine, UCSF Benioff Children's Hospital, 747 52nd Street, Oakland, CA 94609, USA
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23
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Cappellini MD, Taher AT, Verma A, Shah F, Hermine O. Erythropoiesis in lower-risk myelodysplastic syndromes and beta-thalassemia. Blood Rev 2022; 59:101039. [PMID: 36577601 DOI: 10.1016/j.blre.2022.101039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
The hematologic disorders myelodysplastic syndromes and beta-thalassemia are characterized by ineffective erythropoiesis and anemia, often managed with regular blood transfusions. Erythropoiesis, the process by which sufficient numbers of functional erythrocytes are produced from hematopoietic stem cells, is highly regulated, and defects can negatively affect the proliferation, differentiation, and survival of erythroid precursors. Treatments that directly target the underlying mechanisms of ineffective erythropoiesis are limited, and management of anemia with regular blood transfusions imposes a significant burden on patients, caregivers, and health care systems. There is therefore a strong unmet need for treatments that can restore effective erythropoiesis. Novel therapies are beginning to address this need by targeting a variety of mechanisms underlying erythropoiesis. Herein, we provide an overview of the role of ineffective erythropoiesis in myelodysplastic syndromes and beta-thalassemia, discuss unmet needs in targeting ineffective erythropoiesis, and describe current management strategies and emerging treatments for these disorders.
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Affiliation(s)
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Halim and Aida Daniel Academic and Clinical Center, Beirut, Lebanon.
| | - Amit Verma
- Albert Einstein College of Medicine, New York, NY, USA.
| | - Farrukh Shah
- Department of Haematology, Whittington Health NHS Trust, London, UK.
| | - Olivier Hermine
- Department of Hematology, Hôpital Necker, Assistance Publique Hôpitaux de Paris, University Paris Cité, Paris, France; INSERM U1163 and CNRS 8254, Imagine Institute, Université Sorbonne Paris Cité, Paris, France.
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24
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Affiliation(s)
- H Franklin Bunn
- From the Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston
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25
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Untreated Anemia in Nontransfusion-dependent β-thalassemia: Time to Sound the Alarm. Hemasphere 2022; 6:e806. [DOI: 10.1097/hs9.0000000000000806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022] Open
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26
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Musallam KM, Taher AT, Cappellini MD. Right in time: Mitapivat for the treatment of anemia in α- and β-thalassemia. Cell Rep Med 2022; 3:100790. [PMID: 36260990 PMCID: PMC9589095 DOI: 10.1016/j.xcrm.2022.100790] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Kuo and colleagues1 evaluated the safety and efficacy of mitapivat, an oral pyruvate kinase activator, in adults with non-transfusion-dependent α-thalassemia or β-thalassemia. The high rate of hemoglobin response and good tolerability encourages further development in thalassemia.
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Affiliation(s)
- Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca' Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy,Corresponding author
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27
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Song AB, Al-Samkari H. An evaluation of mitapivat for the treatment of hemolytic anemia in adults with pyruvate kinase deficiency. Expert Rev Hematol 2022; 15:875-885. [PMID: 36124781 DOI: 10.1080/17474086.2022.2125865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pyruvate kinase deficiency (PKD) is the most common cause of congenital nonspherocytic hemolytic anemia. Until recently, treatment had been limited to supportive management including red blood cell transfusions, splenectomy, and management of chronic disease complications such as iron overload and decreased bone mineral density. AREAS COVERED We discuss preclinical data and phase 1, 2, and 3 clinical studies evaluating mitapivat for adult patients with hemolytic anemia secondary to PKD. Mitapivat has been shown to offer early and durable improvement in hemoglobin with reduction in transfusion burden, and preliminary data suggest it can induce a negative iron balance in many patients without the use of dedicated iron chelators. EXPERT OPINION Mitapivat is a first-in-class allosteric activator of pyruvate kinase and the first FDA-approved disease directed therapy for PKD. It has a favorable safety profile and clear clinical efficacy. Given the considerable genetic heterogeneity of PKD and the rapid effect on improving hemoglobin and reducing hemolysis, a therapeutic trial of mitapivat should be considered in all patients with PKD who are not homozygous for the PKLR R479H mutation. Further investigations are needed regarding long-term safety and efficacy profiles and whether long-term PKD-associated complications can be reduced or even reversed.
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Affiliation(s)
- Andrew B Song
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Hematology, Massachusetts General Hospital, Boston, Massachusetts, USA
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The Roles of Mitophagy and Autophagy in Ineffective Erythropoiesis in β-Thalassemia. Int J Mol Sci 2022; 23:ijms231810811. [PMID: 36142738 PMCID: PMC9502731 DOI: 10.3390/ijms231810811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 01/19/2023] Open
Abstract
β-Thalassemia is one of the most common genetically inherited disorders worldwide, and it is characterized by defective β-globin chain synthesis leading to reduced or absent β-globin chains. The excess α-globin chains are the key factor leading to the death of differentiating erythroblasts in a process termed ineffective erythropoiesis, leading to anemia and associated complications in patients. The mechanism of ineffective erythropoiesis in β-thalassemia is complex and not fully understood. Autophagy is primarily known as a cell recycling mechanism in which old or dysfunctional proteins and organelles are digested to allow recycling of constituent elements. In late stage, erythropoiesis autophagy is involved in the removal of mitochondria as part of terminal differentiation. Several studies have shown that autophagy is increased in earlier erythropoiesis in β-thalassemia erythroblasts, as compared to normal erythroblasts. This review summarizes what is known about the role of autophagy in β-thalassemia erythropoiesis and shows that modulation of autophagy and its interplay with apoptosis may provide a new therapeutic route in the treatment of β-thalassemia. Literature was searched and relevant articles were collected from databases, including PubMed, Scopus, Prospero, Clinicaltrials.gov, Google Scholar, and the Google search engine. Search terms included: β-thalassemia, ineffective erythropoiesis, autophagy, novel treatment, and drugs during the initial search. Relevant titles and abstracts were screened to choose relevant articles. Further, selected full-text articles were retrieved, and then, relevant cross-references were scanned to collect further information for the present review.
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Longo F, Piga A. Does Hepcidin Tuning Have a Role among Emerging Treatments for Thalassemia? J Clin Med 2022; 11:5119. [PMID: 36079046 PMCID: PMC9457499 DOI: 10.3390/jcm11175119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/21/2022] [Accepted: 08/27/2022] [Indexed: 01/19/2023] Open
Abstract
The treatments available for thalassemia are rapidly evolving, with major advances made in gene therapy and the modulation of erythropoiesis. The latter includes the therapeutic potential of hepcidin tuning. In thalassemia, hepcidin is significantly depressed, and any rise in hepcidin function has a positive effect on both iron metabolism and erythropoiesis. Synthetic hepcidin and hepcidin mimetics have been developed to the stage of clinical trials. However, they have failed to produce an acceptable efficacy/safety profile. It seems difficult to avoid iron over-restricted erythropoiesis when directly using hepcidin as a drug. Indirect approaches, each one with their advantages and disadvantages, are many and in full development. The ideal approach is to target erythroferrone, the main inhibitor of hepcidin expression, the plasma concentrations of which are greatly increased in iron-loading anemias. Potential means of improving hepcidin function in thalassemia also include acting on TMPRSS6, TfR1, TfR2 or ferroportin, the target of hepcidin. Only having a better understanding of the crosslinks between iron metabolism and erythropoiesis will elucidate the best single option. In the meantime, many potential combinations are currently being explored in preclinical studies. Any long-term clinical study on this approach should include the wide monitoring of functions, as the effects of hepcidin and its modulators are not limited to iron metabolism and erythropoiesis. It is likely that some of the aspects of hepcidin tuning described briefly in this review will play a role in the future treatment of thalassemia.
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Affiliation(s)
- Filomena Longo
- Thalassemia Reference Centre, 10043 Orbassano, Italy
- Regional HUB Centre for Thalassaemia and Haemoglobinopathies, Department of Medicine, Azienda Ospedaliero Universitaria S. Anna, 44124 Ferrara, Italy
| | - Antonio Piga
- Thalassemia Reference Centre, 10043 Orbassano, Italy
- University of Torino, 10043 Torino, Italy
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Affiliation(s)
- Antonis Kattamis
- Division of Paediatric Haematology-Oncology, First Department of Paediatrics, National and Kapodistrian University of Athens School of Medicine, Athens 11527, Greece.
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