1
|
Giordano G, Cutuli MA, Lucchesi A, Magnifico I, Venditti N, Vergalito F, Gasperi M, Di Marco R. Iron Support in Erythropoietin Treatment in Myelodysplastic Syndrome Patients Affected by Low-Risk Refractory Anaemia: Real-Life Evidence from an Italian Setting. Acta Haematol 2019; 143:155-162. [PMID: 31533096 DOI: 10.1159/000501329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 06/01/2019] [Indexed: 11/19/2022]
Abstract
Refractory anaemia (RA) among myelodysplastic syndrome (MDS) is associated with a partial functional iron deficit and may require transfusions. In low-risk lymphoma and solid tumour patients, iron support improves erythropoietin (EPO) cost-effectiveness in treating anaemia. The aim of this study is to see if oral sucrosomial iron support improves the cost-effectiveness of EPO treatment in MDS patients affected by low-risk RA. We treated patients with EPO only or with EPO plus oral sucrosomial iron or intravenous (i.v.) iron. The need for transfusions was lowest in the group taking oral iron (p = 0.016) or not receiving supplementation at all (p = 0.022). We compared costs of EPO with i.v. ferric gluconate or oral sucrosomial iron supplementation or no iron supplementation. The oral iron group had fewer side effects, fewer patient medical visits in the out-patient setting, and fewer transfusions; this led to higher savings on direct hospital costs and indirect patient costs (lost days at work) and translated into a 50% abatement of overall expenditures. EPO treatment-related expenditures in MDS-RA patients were lowest with oral sucrosomial iron supplementation (Sideral®), with a longer interval between EPO administration in maintenance treatment, quicker hemoglobin recovery, lower ferritin increase and fewer blood transfusions.
Collapse
Affiliation(s)
- Giulio Giordano
- Division of Internal Medicine, Hematology Service, Regional Hospital "A. Cardarelli,", Campobasso, Italy,
| | - Marco Alfio Cutuli
- Department of Medicine and Health Sciences "V. Tiberio," University of Molise, Campobasso, Italy
| | - Alessandro Lucchesi
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Irene Magnifico
- Department of Medicine and Health Sciences "V. Tiberio," University of Molise, Campobasso, Italy
| | - Noemi Venditti
- Department of Medicine and Health Sciences "V. Tiberio," University of Molise, Campobasso, Italy
| | - Franca Vergalito
- Department of Medicine and Health Sciences "V. Tiberio," University of Molise, Campobasso, Italy
| | - Maurizio Gasperi
- Division of Internal Medicine, Hematology Service, Regional Hospital "A. Cardarelli,", Campobasso, Italy
- Division of Internal Medicine, Regional Hospital "A. Cardarelli,", Campobasso, Italy
| | - Roberto Di Marco
- Department of Medicine and Health Sciences "V. Tiberio," University of Molise, Campobasso, Italy
| |
Collapse
|
2
|
Iron overload promotes mitochondrial fragmentation in mesenchymal stromal cells from myelodysplastic syndrome patients through activation of the AMPK/MFF/Drp1 pathway. Cell Death Dis 2018; 9:515. [PMID: 29725013 PMCID: PMC5938711 DOI: 10.1038/s41419-018-0552-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/14/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022]
Abstract
Iron overload (IO) has been reported to contribute to mesenchymal stromal cell (MSC) damage, but the precise mechanism has yet to be clearly elucidated. In this study, we found that IO increased cell apoptosis and lowered cell viability in MSCs, accompanied by extensive mitochondrial fragmentation and autophagy enhancement. All these effects were reactive oxygen species (ROS) dependent. In MSCs with IO, the ATP concentrations were significantly reduced due to high ROS levels and low electron respiratory chain complex (ETC) II/III activity. Reduced ATP phosphorylated AMP-activated protein kinase (AMPK). Activation of AMPK kinase complexes triggered mitochondrial fission. Moreover, gene knockout of AMPK via CRISPR/Cas9 reduced cell apoptosis, enhanced cell viability and attenuated mitochondrial fragmentation and autophagy caused by IO in MSCs. Further, AMPK-induced mitochondrial fragmentation of MSCs with IO was mediated via phosphorylation of mitochondrial fission factor (MFF), a mitochondrial outer-membrane receptor for the GTPase dynamin-related protein 1 (Drp1). Gene knockdown of MFF reversed AMPK-induced mitochondrial fragmentation in MSCs with IO. In addition, MSCs from IO patients with myelodysplastic syndrome (MDS) showed increased cell apoptosis, decreased cell viability, higher ROS levels, lower ATP concentrations and increased mitochondrial fragmentation compared with MSCs from non-IO patients. In addition, iron chelation or antioxidant weakened the activity of the AMPK/MFF/Drp1 pathway in MDS-MSCs with IO from several patients, accompanied by attenuation of mitochondrial fragmentation and autophagy. Taken together, the AMPK/MFF/Drp1 pathway has an important role in the damage to MDS-MSCs caused by IO.
Collapse
|
3
|
Meunier M, Ancelet S, Lefebvre C, Arnaud J, Garrel C, Pezet M, Wang Y, Faure P, Szymanski G, Duployez N, Preudhomme C, Biard D, Polack B, Cahn JY, Moulis JM, Park S. Reactive oxygen species levels control NF-κB activation by low dose deferasirox in erythroid progenitors of low risk myelodysplastic syndromes. Oncotarget 2017; 8:105510-105524. [PMID: 29285268 PMCID: PMC5739655 DOI: 10.18632/oncotarget.22299] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/26/2017] [Indexed: 11/25/2022] Open
Abstract
Anemia is a frequent cytopenia in myelodysplastic syndromes (MDS) and most patients require red blood cell transfusion resulting in iron overload (IO). Deferasirox (DFX) has become the standard treatment of IO in MDS and it displays positive effects on erythropoiesis. In low risk MDS samples, mechanisms improving erythropoiesis after DFX treatment remain unclear. Herein, we addressed this question by using liquid cultures with iron overload of erythroid precursors treated with low dose of DFX (3μM), which corresponds to DFX 5 mg/kg/day, an unusual dose used for iron chelation. We highlight a decreased apoptosis rate and an increased proportion of cycling cells, both leading to higher proliferation rates. The iron chelation properties of low dose DFX failed to activate the Iron Regulatory Proteins and to support iron depletion, but low dose DFX dampers intracellular reactive oxygen species. Furthermore low concentrations of DFX activate the NF-κB pathway in erythroid precursors triggering anti-apoptotic and anti-inflammatory signals. Establishing stable gene silencing of the Thioredoxin (TRX) 1 genes, a NF-κB modulator, showed that fine-tuning of reactive oxygen species (ROS) levels regulates NF-κB. These results justify a clinical trial proposing low dose DFX in MDS patients refractory to erythropoiesis stimulating agents.
Collapse
Affiliation(s)
- Mathieu Meunier
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Sarah Ancelet
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | | | - Josiane Arnaud
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | - Catherine Garrel
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | - Mylène Pezet
- Plateforme de Microscopie Photonique - Cytométrie en Flux, Institut Albert Bonniot, La Tronche, France
| | - Yan Wang
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Patrice Faure
- Unité de Biochimie Hormonale et Nutritionnelle, Département de Biologie - Toxicologie - Pharmacologie, CHU Grenoble Alpes, Grenoble, France
| | | | - Nicolas Duployez
- Laboratory of Hematology and Tumor Bank, INSERM UMR-S 1172, Cancer Research Institute of Lille, CHRU of Lille, University Lille Nord de France, Lille, France
| | - Claude Preudhomme
- Laboratory of Hematology and Tumor Bank, INSERM UMR-S 1172, Cancer Research Institute of Lille, CHRU of Lille, University Lille Nord de France, Lille, France
| | - Denis Biard
- CEA, Institut de Biologie François Jacob, SEPIA, Team Cellular Engineering and Human Syndromes, Université Paris-Saclay, Fontenay-aux-Roses, France
| | - Benoit Polack
- Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France.,Laboratory of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Yves Cahn
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| | - Jean Marc Moulis
- Université Grenoble Alpes, Laboratory of Fundamental and Applied Bioenergetics, and Environmental and Systems Biology, Grenoble, France.,INSERM U1055, Grenoble, France.,CEA-Grenoble, Bioscience and Biotechnology Institute, Grenoble, France
| | - Sophie Park
- CHU Grenoble Alpes, University Clinic of Hematology, Grenoble, France.,Université Grenoble Alpes, CNRS UMR 5525, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG ThEREx, Grenoble, France
| |
Collapse
|
4
|
Murray C, De Gelder T, Pringle N, Johnson JC, Doherty M. Management of iron overload in the Canadian hematology/oncology population: Implications for nursing practice. Can Oncol Nurs J 2016; 26:19-28. [PMID: 31148725 PMCID: PMC6516318 DOI: 10.5737/236880762611928] [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: 11/05/2022] Open
Abstract
Red blood cell (RBC) transfusions are vital for many patients with chronic anemias associated with oncologic/hematologic disorders. However, repeated transfusions over time can lead to iron overload, which, if left untreated, can increase the risk of further malignancy and end-organ damage. Nurses and other health care professionals may not be aware of the significant implications of RBC transfusions and iron overload in patients with hematological/oncological disorders. This article was developed by a group of Canadian nurse practitioners and specialized oncology nurses to help improve health care professionals' understanding of iron overload in oncology patients and its associated risks, as well as provide a practical guide for the management of patients receiving treatment for this potentially serious condition.
Collapse
Affiliation(s)
- Cindy Murray
- Nurse Practitioner, Blood and Marrow Disorder Program - Transfusion Outpatient Clinic, University Health Network (UHN) Princess Margaret Cancer Centre, Toronto, ON
| | - Tammy De Gelder
- Nurse Practitioner, Hamilton Health Sciences, Juravinski Hospital and Cancer Centre, Hamilton, ON
| | - Nancy Pringle
- Specialized Oncology Nurse, Leukemia Clinic, UHN Princess Margaret Cancer Centre, Toronto, ON
| | - J Colleen Johnson
- Nurse Practitioner, Red Blood Cell Disorders Clinic, UHN, Toronto General Division, Toronto, ON
| | - Mary Doherty
- Nurse Practitioner, Blood and Marrow Disorder Program - Transfusion Outpatient Clinic, University Health Network (UHN) Princess Margaret Cancer Centre, Toronto, ON
| |
Collapse
|
5
|
Petrou E, Mavrogeni S, Karali V, Kolovou G, Kyrtsonis MC, Sfikakis PP, Panayiotidis P. The role of magnetic resonance imaging in the evaluation of transfusional iron overload in myelodysplastic syndromes. Rev Bras Hematol Hemoter 2015; 37:252-8. [PMID: 26190429 PMCID: PMC4519711 DOI: 10.1016/j.bjhh.2015.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 03/03/2015] [Accepted: 03/31/2015] [Indexed: 12/23/2022] Open
Abstract
Myelodysplastic syndromes represent a group of heterogeneous hematopoietic neoplasms derived from an abnormal multipotent progenitor cell, characterized by a hyperproliferative bone marrow, dysplasia of the cellular hemopoietic elements and ineffective erythropoiesis. Anemia is a common finding in myelodysplastic syndrome patients, and blood transfusions are the only therapeutic option in approximately 40% of cases. The most serious side effect of regular blood transfusion is iron overload. Currently, cardiovascular magnetic resonance using T2 is routinely used to identify patients with myocardial iron overload and to guide chelation therapy, tailored to prevent iron toxicity in the heart. This is a major validated non-invasive measure of myocardial iron overloading and is superior to surrogates such as serum ferritin, liver iron, ventricular ejection fraction and tissue Doppler parameters. The indication for iron chelation therapy in myelodysplastic syndrome patients is currently controversial. However, cardiovascular magnetic resonance may offer an excellent non-invasive, diagnostic tool for iron overload assessment in myelodysplastic syndromes. Further studies are needed to establish the precise indications of chelation therapy and the clinical implications of this treatment on survival in myelodysplastic syndromes.
Collapse
|
6
|
Clark O, Faleiros EJDM. Cost of the treatment of myelodisplastic syndrome in Brazil. Rev Bras Hematol Hemoter 2013; 33:31-4. [PMID: 23284240 PMCID: PMC3521432 DOI: 10.5581/1516-8484.20110011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 11/23/2010] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Myelodysplastic syndrome is an incurable and rare hematological disease that affects the production of blood cells. One aim of treatment is to maintain the blood-cell count to near-normal levels. This is mainly achieved with hematopoietic- growth factors and transfusions. Our objective was to determine the cost of supportive treatment/care for patients with low and intermediate I risk myelodysplastic syndrome in respect to private healthcare plans in Brazil. METHOD We adapted the National Comprehensive Cancer Network treatment guidelines for intermediate risk myelodysplastic syndrome patients to the Brazilian reality, adopting a decision tree to explore treatment combinations. Then, we calculated the costs for each branch of the tree, according to national prices. We also estimated total costs for a cohort of 100 patients, distributed across treatment combinations according to the expected epidemiology. We assumed a horizon of one year of treatment. RESULTS The mean cost of treatment for low and intermediate I risk myelodysplastic syndrome is US$ 42,758/patient/year. This cost can vary from US$ 24,282 to US$ 121,952, according to patient characteristics and the treatment used. Overall, patients that require immunotherapy with antithymocyte globulins are associated with the highest cost. Those that achieve disease stability solely with the use of erythropoietin were associated with the lowest cost. CONCLUSION In Brazil, treatment of low and intermediate I risk myelodysplastic syndrome is associated with a mean cost of the order of US$ 42,700/patient/year. New types of therapy have the potential to change this scenario if they can diminish the requirements for supportive care.
Collapse
|
7
|
Shah J, Kurtin SE, Arnold L, Lindroos-Kolqvist P, Tinsley S. Management of Transfusion-Related Iron Overload in Patients With Myelodysplastic Syndromes. Clin J Oncol Nurs 2012; 16 Suppl:37-46. [DOI: 10.1188/12.cjon.s1.37-46] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
8
|
Abstract
Despite significant improvements in our understanding of the pathophysiology of Diamond Blackfan anemia (DBA), there have been few advances in therapy. The cornerstones of treatment remain corticosteroids, chronic red blood cell transfusions, and hematopoietic stem cell transplantation, each of which is fraught with complications. In this article, we will review the history of therapies that have been offered to patients with DBA, summarize the current standard of care, including management of side effects, and discuss novel therapeutics that are being developed in the context of the research into the roles of ribosomal haplo-insufficiency and p53 activation in Diamond Blackfan anemia.
Collapse
Affiliation(s)
- Anupama Narla
- Brigham and Women's Hospital, Department of Medicine, Boston, MA, USA
| | | | | |
Collapse
|
9
|
D’Alò F, Greco M, Criscuolo M, Voso MT. New treatments for myelodysplastic syndromes. Mediterr J Hematol Infect Dis 2010; 2:e2010021. [PMID: 21415972 PMCID: PMC3033133 DOI: 10.4084/mjhid.2010.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 08/10/2010] [Indexed: 12/31/2022] Open
Abstract
In the last decade, significant advances have been made in the treatment of patients with Myelodysplastic Syndromes (MDS). Although best supportive care continues to have an important role in the management of MDS, to date the therapeutic approach is diversified according to the IPSS risk group, karyotype, patient's age, comorbidities, and compliance. Hematopoietic growth factors play a major role in lower risk MDS patients, and include high dose erithropoiesis stimulating agents and thrombopoietic receptor agonists. Standard supportive care should also include iron chelating therapy to reduce organ damage related to iron overload in transfusion-dependent patients. Biologic therapies have been introduced in MDS, as lenalidomide, which has been shown to induce transfusion independence in most lower risk MDS patients with del5q. Hypomethylating agents have shown efficacy in INT-2/high risk MDS patients, reducing the risk of leukemic transformation and increasing survival. Other agents under development for the treatment of MDS include histone deacetylase inhibitors, farnesyltransferase inhibitors, clofarabine and ezatiostat.
Collapse
Affiliation(s)
- Francesco D’Alò
- Istituto di Ematologia, Università Cattolica Sacro Cuore, Rome, Italy
| | - Mariangela Greco
- Istituto di Ematologia, Università Cattolica Sacro Cuore, Rome, Italy
| | | | - Maria Teresa Voso
- Istituto di Ematologia, Università Cattolica Sacro Cuore, Rome, Italy
| |
Collapse
|