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Castro OL, De Franceschi L, Ganz T, Kanter J, Kato GJ, Pasricha SR, Rivella S, Wood JC. Iron restriction in sickle cell disease: When less is more. Am J Hematol 2024; 99:1349-1359. [PMID: 38400590 DOI: 10.1002/ajh.27267] [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: 10/22/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024]
Abstract
Primum non nocere! Can iron deficiency, an abnormality that causes anemia, benefit people with sickle cell disease (SCD) who already have an anemia? The published literature we review appears to answer this question in the affirmative: basic science considerations, animal model experiments, and noncontrolled clinical observations all suggest a therapeutic potential of iron restriction in SCD. This is because SCD's clinical manifestations are ultimately attributable to the polymerization of hemoglobin S (HbS), a process strongly influenced by intracellular HbS concentration. Even small decrements in HbS concentration greatly reduce polymerization, and iron deficiency lowers erythrocyte hemoglobin concentration. Thus, iron deficiency could improve SCD by changing its clinical features to those of a more benign anemia (i.e., a condition with fewer or no vaso-occlusive events). We propose that well-designed clinical studies be implemented to definitively determine whether iron restriction is a safe and effective option in SCD. These investigations are particularly timely now that pharmacologic agents are being developed, which may directly reduce red cell hemoglobin concentrations without the need for phlebotomies to deplete total body iron.
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Affiliation(s)
- Oswaldo L Castro
- Center for Sickle Cell Disease, Howard University, Washington, District of Columbia, USA
| | | | - Tomas Ganz
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Julie Kanter
- Division of Hematology and Oncology, University of Alabama, Birmingham, Birmingham, Alabama, USA
| | - Gregory J Kato
- Hematology Therapeutic Area, CSL Behring, King of Prussia, Pennsylvania, USA
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Stefano Rivella
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; RNA Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- RNA Gene Therapeutics Group, RNA Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John C Wood
- Division of Cardiology, Department of Pediatrics and Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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Modi NB, Shames R, Lickliter JD, Gupta S. Pharmacokinetics, pharmacodynamics, and tolerability of an aqueous formulation of rusfertide (PTG-300), a hepcidin mimetic, in healthy volunteers: A double-blind first-in-human study. Eur J Haematol 2024. [PMID: 38785334 DOI: 10.1111/ejh.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Rusfertide is a potent peptide mimetic of hepcidin being investigated for the treatment of polycythemia vera. This randomized, placebo-controlled, double-blind study evaluated the safety, pharmacokinetics, and pharmacodynamics of single and repeated subcutaneous doses of an aqueous formulation of rusfertide in healthy adult males. METHODS Subjects received single doses of 1, 3, 10, 20, 40, or 80 mg rusfertide or placebo. A separate cohort of subjects received two doses of 40 mg rusfertide or placebo 1 week apart. Blood samples for pharmacokinetics and pharmacodynamics were collected, and adverse events, clinical laboratory tests, 12-lead electrocardiograms, and vital signs were monitored. RESULTS Rusfertide was well tolerated. There were no serious or severe treatment-emergent adverse events, and no patterns of clinically important adverse events, or laboratory, vital sign, or electrocardiogram abnormalities. Mean maximum rusfertide plasma concentration (Cmax) and area under the concentration-time curve increased with dose, but less than dose proportionally. Median time to Cmax was 2-4.5 h for 40 and 80 mg rusfertide and 8-24 h for lower doses. Apparent clearance and half-life increased with dose. Single doses of rusfertide 1-80 mg were associated with dose-dependent decreases in serum iron and transferrin-iron saturation. CONCLUSIONS Rusfertide was well tolerated and showed dose-dependent pharmacokinetics and pharmacodynamics.
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Affiliation(s)
- Nishit B Modi
- Protagonist Therapeutics, Inc., Newark, California, USA
| | | | | | - Suneel Gupta
- Protagonist Therapeutics, Inc., Newark, California, USA
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Settakorn K, Hantrakool S, Petiwathayakorn T, Hutachok N, Tantiworawit A, Charoenkwan P, Chalortham N, Chompupoung A, Paradee N, Koonyosying P, Srichairatanakool S. A randomized placebo-controlled clinical trial of oral green tea epigallocatechin 3-gallate on erythropoiesis and oxidative stress in transfusion-dependent β-thalassemia patients. Front Mol Biosci 2024; 10:1248742. [PMID: 38328786 PMCID: PMC10848917 DOI: 10.3389/fmolb.2023.1248742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/28/2023] [Indexed: 02/09/2024] Open
Abstract
β-Thalassemia patients suffer from ineffective erythropoiesis and increased red blood cell (RBC) hemolysis. Blood transfusion, erythropoietic enhancement, and antioxidant supplementation can ameliorate chronic anemia. Green tea extract (GTE) is comprised of catechin derivatives, of which epigallocatechin-3-gallate (EGCG) is the most abundant, presenting free-radical scavenging, iron-chelating, and erythropoiesis-protective effects. The present study aimed to evaluate the effects of GTE tablets on the primary outcome of erythropoiesis and oxidative stress parameters in transfusion-dependent β-thalassemia (TDT) patients. Twenty-seven TDT patients were randomly divided into placebo and GTE tablet (50 and 100 mg EGCG equivalent) groups and assigned to consume the product once daily for 60 days. Blood was collected for analysis of hematological, biochemical, and oxidative stress parameters. Accordingly, consumption of GTE tablets improved blood hemoglobin levels when compared with the placebo; however, there were more responders to the GTE tablets. Interestingly, amounts of nonheme iron in RBC membranes tended to decrease in both GTE tablet groups when compared with the placebo. Importantly, consumption of GTE tablets lowered plasma levels of erythroferrone (p < 0.05) and reduced bilirubin non-significantly and dose-independently. Thus, GTE tablets could improve RBC hemolysis and modulate erythropoiesis regulators in transfusion-dependent thalassemia patients.
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Affiliation(s)
- Kornvipa Settakorn
- Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sasinee Hantrakool
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Nuntouchaporn Hutachok
- Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pimlak Charoenkwan
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nopphadol Chalortham
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | | | - Narisara Paradee
- Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pimpisid Koonyosying
- Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Mulas O, Mola B, Costa A, Pittau F, Mantovani D, Dessì S, Fronteddu A, La Nasa G, Caocci G. Renin-angiotensin inhibitors reduce thrombotic complications in Essential Thrombocythemia and Polycythemia Vera patients with arterial hypertension. Ann Hematol 2023; 102:2717-2723. [PMID: 37603060 PMCID: PMC10492873 DOI: 10.1007/s00277-023-05417-w] [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: 08/02/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
Essential Thrombocythemia (ET) and Polycythemia Vera (PV) are chronic myeloproliferative neoplasms (MPNs) characterized by thrombotic and hemorrhagic complications, leading to a high risk of disability and mortality. Although arterial hypertension was found to be the most significant modifiable cardiovascular (CV) risk factor in the general population, little is known about its role in MPNs as well as a possible role of renin-angiotensin system inhibitors (RASi) in comparison with other anti-hypertensive treatments. We investigated a large cohort of 404 MPN adult patients, 133 diagnosed with PV and 271 with ET. Over half of the patients (53.7%) reported hypertension at MPN diagnosis. The 15-year cumulative incidence of thrombotic-adverse events (TAEs) was significantly higher in patients with hypertension (66.8 ± 10.3% vs 38.5 ± 8.4%; HR = 1.83; 95%CI 1.08-3.1). Multivariate analysis showed that PV diagnosis and hypertension were independently associated with a higher risk of developing TAEs (HR = 3.5; 95%CI 1.928-6.451, p < 0.001 and HR = 1.8; 95%CI 0.983-3.550, p = 0.05, respectively). In multivariate analysis, the diagnosis of PV confirmed a significant predictive role in developing TAEs (HR = 4.4; 95%CI 1.92-10.09, p < 0.01), also considering only MPN patients with hypertension. In addition, we found that the use of RASi showed a protective effect from TAEs both in the whole cohort of MPN with hypertension (HR = 0.46; 95%CI 0.21-0.98, p = 0.04) and in the subgroup of thrombotic high-risk score patients (HR = 0.49; 95%CI 0.24-1.01, p = 0.04). In particular, patients with ET and a high risk of thrombosis seem to benefit most from RASi treatment (HR = 0.27; 95%CI 0.07-1.01, p = 0.03). Hypertension in MPN patients represents a significant risk factor for TAEs and should be adequately treated.
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Affiliation(s)
- Olga Mulas
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy
| | - Brunella Mola
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Alessandro Costa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesca Pittau
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Daniela Mantovani
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy
| | - Samuele Dessì
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonella Fronteddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giorgio La Nasa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
- Hematology Unit, Businco Hospital, ARNAS Brotzu Cagliari, Cagliari, Italy.
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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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Girelli D, Busti F. Manipulating hepcidin in polycythemia vera. Blood 2023; 141:3132-3134. [PMID: 37383006 DOI: 10.1182/blood.2023020509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Affiliation(s)
- Domenico Girelli
- University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona
| | - Fabiana Busti
- University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona
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Bennett C, Jackson VE, Pettikiriarachchi A, Hayman T, Schaeper U, Moir-Meyer G, Fielding K, Ataide R, Clucas D, Baldi A, Garnham AL, Li-Wai-Suen CSN, Loughran SJ, Baxter EJ, Green AR, Alexander WS, Bahlo M, Burbury K, Ng AP, Pasricha SR. Iron homeostasis governs erythroid phenotype in polycythemia vera. Blood 2023; 141:3199-3214. [PMID: 36928379 PMCID: PMC10646816 DOI: 10.1182/blood.2022016779] [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: 04/22/2022] [Revised: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023] Open
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm driven by activating mutations in JAK2 that result in unrestrained erythrocyte production, increasing patients' hematocrit and hemoglobin concentrations, placing them at risk of life-threatening thrombotic events. Our genome-wide association study of 440 PV cases and 403 351 controls using UK Biobank data showed that single nucleotide polymorphisms in HFE known to cause hemochromatosis are highly associated with PV diagnosis, linking iron regulation to PV. Analysis of the FinnGen dataset independently confirmed overrepresentation of homozygous HFE variants in patients with PV. HFE influences the expression of hepcidin, the master regulator of systemic iron homeostasis. Through genetic dissection of mouse models of PV, we show that the PV erythroid phenotype is directly linked to hepcidin expression: endogenous hepcidin upregulation alleviates erythroid disease whereas hepcidin ablation worsens it. Furthermore, we demonstrate that in PV, hepcidin is not regulated by expanded erythropoiesis but is likely governed by inflammatory cytokines signaling via GP130-coupled receptors. These findings have important implications for understanding the pathophysiology of PV and offer new therapeutic strategies for this disease.
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Affiliation(s)
- Cavan Bennett
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Victoria E. Jackson
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Anne Pettikiriarachchi
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Thomas Hayman
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | | | - Gemma Moir-Meyer
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Katherine Fielding
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ricardo Ataide
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Infectious Diseases, Peter Doherty Institute, University of Melbourne, Parkville, VIC, Australia
| | - Danielle Clucas
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Andrew Baldi
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Alexandra L. Garnham
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Bioinformatics Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Connie S. N. Li-Wai-Suen
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Bioinformatics Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Stephen J. Loughran
- Wellcome–MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, United Kingdom
- Department of Haematology, University of Cambridge, Cambridge, United Kingdom
| | - E. Joanna Baxter
- Wellcome–MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, United Kingdom
- Department of Haematology, University of Cambridge, Cambridge, United Kingdom
| | - Anthony R. Green
- Wellcome–MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, United Kingdom
- Department of Haematology, University of Cambridge, Cambridge, United Kingdom
| | - Warren S. Alexander
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Melanie Bahlo
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Kate Burbury
- Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ashley P. Ng
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
- Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
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