1
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Zagadailov E, Al-Samkari H, Boscoe AN, McGee B, Shi S, Macaulay D, Shi L, Garcia-Horton V. Mortality among US veterans with a physician-documented diagnosis of pyruvate kinase deficiency. Hematology 2024; 29:2290746. [PMID: 38095306 DOI: 10.1080/16078454.2023.2290746] [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: 06/07/2023] [Accepted: 11/12/2023] [Indexed: 12/18/2023] Open
Abstract
Real-world studies of pyruvate kinase (PK) deficiency and estimates of mortality are lacking. This retrospective observational study aimed to identify patients with PK deficiency and compare their overall survival (OS) to that of a matched cohort without PK deficiency. Patients with ≥1 diagnosis code related to PK deficiency were selected from the US Veterans Health Administration (VHA) database (01/1995-07/2019); patients with a physician-documented diagnosis were included (PK deficiency cohort; index: date of first diagnosis code related to PK deficiency). Patients in the PK deficiency cohort were matched 1:5 to patients from the general VHA population (non-PK deficiency cohort; index: random visit date during match's index year). OS from index was compared between the two cohorts. Eighteen patients in the PK deficiency cohort were matched to 90 individuals in the non-PK deficiency cohort (both cohorts: mean age 57 years, 94% males; median follow-up 6.0 and 8.0 years, respectively). At follow-up, patients in the non-PK deficiency cohort had significantly longer OS than the PK deficiency cohort (median OS: 17.1 vs. 10.9 years; hazard ratio: 2.3; p = 0.0306). During their first-year post-index, 75% and 40% of the PK deficiency cohort had laboratory-confirmed anemia and iron overload, respectively. Among patients who died, cause of death was highly heterogeneous. These results highlight the increased risk of mortality and substantial clinical burden among patients with PK deficiency. While the intrinsic characteristics of the VHA database may limit the generalizability of the results, this is the first real-world study to characterize mortality in patients with PK deficiency.
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Affiliation(s)
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Bryan McGee
- Agios Pharmaceuticals, Inc., Cambridge, MA, USA
| | | | | | - Lizheng Shi
- School of Public Health & Tropical Medicine, Tulane University, New Orleans, LA, USA
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2
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Glenthøj A, Grace RF, Lander C, van Beers EJ, Glader B, Kuo KHM, Yan Y, McGee B, Boscoe AN, Li J, Bianchi P. Comorbidities and complications in adult and paediatric patients with pyruvate kinase deficiency: Analysis from the Peak Registry. Br J Haematol 2024; 205:613-623. [PMID: 39118415 DOI: 10.1111/bjh.19601] [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: 08/25/2023] [Accepted: 06/06/2024] [Indexed: 08/10/2024]
Abstract
Pyruvate kinase (PK) deficiency, a rare, congenital haemolytic anaemia caused by mutations in the PKLR gene, is associated with many clinical manifestations, but the full disease burden has yet to be characterised. The Peak Registry (NCT03481738) is an observational, longitudinal registry of adult and paediatric patients with PK deficiency. Here, we described comorbidities and complications in these patients by age at most recent visit and PKLR genotype. As of 13 May 2022, 241 patients were included in the analysis. In total, 48.3% had undergone splenectomy and 50.5% had received chelation therapy. History of iron overload (before enrolment/during follow-up) was common (52.5%), even in never-transfused patients (20.7%). Neonatal complications and symptoms included jaundice, splenomegaly and hepatomegaly, with treatment interventions required in 41.5%. Among adults, osteopenia/osteoporosis occurred in 19.0% and pulmonary hypertension in 6.7%, with median onset ages of 37, 33 and 22 years, respectively. Biliary events and bone health problems were common across PKLR genotypes. Among 11 patients who had thromboembolic events, eight had undergone prior splenectomy. Patients with PK deficiency may have many complications, which can occur early in and throughout life. Awareness of their high disease burden may help clinicians better provide appropriate monitoring and management of these patients.
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MESH Headings
- Humans
- Registries
- Pyruvate Kinase/deficiency
- Pyruvate Kinase/genetics
- Male
- Female
- Adult
- Child
- Anemia, Hemolytic, Congenital Nonspherocytic/genetics
- Anemia, Hemolytic, Congenital Nonspherocytic/epidemiology
- Pyruvate Metabolism, Inborn Errors/genetics
- Pyruvate Metabolism, Inborn Errors/epidemiology
- Adolescent
- Child, Preschool
- Infant
- Comorbidity
- Middle Aged
- Splenectomy
- Young Adult
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/epidemiology
- Iron Overload/etiology
- Iron Overload/epidemiology
- Bone Diseases, Metabolic/etiology
- Bone Diseases, Metabolic/epidemiology
- Infant, Newborn
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Affiliation(s)
- Andreas Glenthøj
- Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Carl Lander
- Thrive with PK Deficiency, Bloomington, Minnesota, USA
| | - Eduard J van Beers
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bertil Glader
- Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | - Yan Yan
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Bryan McGee
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Audra N Boscoe
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Junlong Li
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Paola Bianchi
- Hematology Unit, Pathophysiology of Anemia Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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McCracken R, Boscoe A, Marathe P, Osman K. Reporting on Therapeutic Advancements Requires Accurate Language. Am J Ther 2024:00045391-990000000-00198. [PMID: 39037710 DOI: 10.1097/mjt.0000000000001787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Affiliation(s)
- Rebecca McCracken
- Global Scientific Communications & Publications, Agios Pharmaceuticals, Inc., Cambridge, MA
| | - Audra Boscoe
- VP, HEOR & Data Science Analytics, Agios Pharmaceuticals, Inc., Cambridge, MA
| | - Punit Marathe
- VP, Research and DMPK, Agios Pharmaceuticals, Inc., Cambridge, MA
| | - Kareem Osman
- VP, Clinical Development, Agios Pharmaceuticals, Inc., Cambridge, MA
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Kuo KHM, Grace RF, van Beers EJ, Barcellini W, Glenthøj A, Holzhauer S, Beynon V, Morris S, Li J, Zagadailov E, Patel P, Al-Samkari H. Clinically meaningful improvements in patient-reported outcomes in mitapivat-treated patients with pyruvate kinase deficiency. Am J Hematol 2024; 99:1415-1419. [PMID: 38712615 DOI: 10.1002/ajh.27312] [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: 09/29/2023] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 05/08/2024]
Abstract
Clinically meaningful benefits in the signs, symptoms, and impacts of #PKDeficiency as assessed by disease-specific patient-reported outcome measures were observed in mitapivat-treated adult patients in two phase 3 clinical trials.
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Affiliation(s)
- Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eduard J van Beers
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas Glenthøj
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Vanessa Beynon
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Susan Morris
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Junlong Li
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | | | - Parija Patel
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Chueh HW, Shim YJ, Jung HL, Kim N, Hwang SM, Kim M, Choi HS. Current Status of Molecular Diagnosis of Hereditary Hemolytic Anemia in Korea. J Korean Med Sci 2024; 39:e162. [PMID: 38742293 PMCID: PMC11091231 DOI: 10.3346/jkms.2024.39.e162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
Hereditary hemolytic anemia (HHA) is considered a group of rare hematological diseases in Korea, primarily because of its unique ethnic characteristics and diagnostic challenges. Recently, the prevalence of HHA has increased in Korea, reflecting the increasing number of international marriages and increased awareness of the disease. In particular, the diagnosis of red blood cell (RBC) enzymopathy experienced a resurgence, given the advances in diagnostic techniques. In 2007, the RBC Disorder Working Party of the Korean Society of Hematology developed the Korean Standard Operating Procedure for the Diagnosis of Hereditary Hemolytic Anemia, which has been continuously updated since then. The latest Korean clinical practice guidelines for diagnosing HHA recommends performing next-generation sequencing as a preliminary step before analyzing RBC membrane proteins and enzymes. Recent breakthroughs in molecular genetic testing methods, particularly next-generation sequencing, are proving critical in identifying and providing insight into cases of HHA with previously unknown diagnoses. These innovative molecular genetic testing methods have now become important tools for the management and care planning of patients with HHA. This review aims to provide a comprehensive overview of recent advances in molecular genetic testing for the diagnosis of HHA, with particular emphasis on the Korean context.
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Affiliation(s)
- Hee Won Chueh
- Department of Pediatrics, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Lim Jung
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Namhee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Hyoung Soo Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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6
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Nasiri A, Haroon A, Alzahrani H. Clinical and Demographic Characteristics of Pyruvate Kinase Deficiency Patients: A Comprehensive Case Series Analysis. Cureus 2024; 16:e60035. [PMID: 38736761 PMCID: PMC11085967 DOI: 10.7759/cureus.60035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Pyruvate kinase deficiency (PKD) is a rare autosomal recessive disorder characterized by mutations in the PKLR gene, causing impaired glycolysis in red blood cells and leading to diverse clinical manifestations. The prevalence of PKD in Saudi Arabia remains understudied, particularly in the context of consanguinity and non-specialized medical facilities. Methods We conducted a retrospective analysis of seven PKD patients of Arab ethnicity, focusing on demographics, medical history, clinical features, laboratory results, treatments, and outcomes. Results Our patient cohort comprised five males and two females, aged 10 to 38 years, of Arab ethnicity. Consanguinity was prevalent, and hereditary connections were identified in five patients. PKD exhibited varying clinical presentations, with early-onset symptoms including neonatal jaundice and symptomatic anemia. One patient experienced severe hepatic disease progression leading to multiorgan failure. Blood transfusions were universally required, indicating the severity of the disorder. Anemia severity varied among patients, with diverse hematological irregularities. Splenectomy was performed for most patients, improving hemoglobin levels and transfusion needs in some cases. Iron chelation was administered, although iron overload persisted. Thrombocytosis and venous thromboembolism were observed post splenectomy. Jaundice and gallstones were common, leading to cholecystectomy. Laboratory findings remained consistent, with heightened reticulocyte counts and altered enzyme levels. Discussion PKD is a rare disorder characterized by diverse clinical manifestations. Prevalence estimation is complex due to various factors, and its diagnosis is challenged by clinical similarities with other disorders. Our cohort exhibited a spectrum of complications, highlighting the necessity for tailored interventions. Iron overload remained a concern, necessitating continuous monitoring. Although endocrine disorders and osteoporosis were absent in our cohort, vigilance is essential due to the disease's progressive nature. Genetic factors were prominent, supporting the genetic basis of PKD. Splenectomy improved anemia but had a limited impact on gallstones. Iron overload management and bone health remain crucial considerations. Conclusion This study offers comprehensive insights into the clinical and demographic characteristics of PKD patients, illustrating the complex nature of the disorder. The findings underscore the need for personalized management strategies and vigilant monitoring to address the diverse clinical manifestations and challenges associated with PKD.
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Affiliation(s)
- Abdulrahman Nasiri
- Department of Internal Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Alfadil Haroon
- Section of Hematology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Hazzaa Alzahrani
- Section of Hematology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
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7
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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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8
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Al-Samkari H, Shehata N, Lang-Robertson K, Bianchi P, Glenthøj A, Sheth S, Neufeld EJ, Rees DC, Chonat S, Kuo KHM, Rothman JA, Barcellini W, van Beers EJ, Pospíšilová D, Shah AJ, van Wijk R, Glader B, Mañú Pereira MDM, Andres O, Kalfa TA, Eber SW, Gallagher PG, Kwiatkowski JL, Galacteros F, Lander C, Watson A, Elbard R, Peereboom D, Grace RF. Diagnosis and management of pyruvate kinase deficiency: international expert guidelines. Lancet Haematol 2024; 11:e228-e239. [PMID: 38330977 DOI: 10.1016/s2352-3026(23)00377-0] [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: 10/20/2023] [Revised: 12/04/2023] [Accepted: 12/13/2023] [Indexed: 02/10/2024]
Abstract
Pyruvate kinase (PK) deficiency is the most common cause of chronic congenital non-spherocytic haemolytic anaemia worldwide, with an estimated prevalence of one in 100 000 to one in 300 000 people. PK deficiency results in chronic haemolytic anaemia, with wide ranging and serious consequences affecting health, quality of life, and mortality. The goal of the International Guidelines for the Diagnosis and Management of Pyruvate Kinase Deficiency was to develop evidence-based guidelines for the clinical care of patients with PK deficiency. These clinical guidelines were developed by use of GRADE methodology and the AGREE II framework. Experts were invited after consideration of area of expertise, scholarly contributions in PK deficiency, and country of practice for global representation. The expert panel included 29 expert physicians (including adult and paediatric haematologists and other subspecialists), geneticists, laboratory specialists, nurses, a guidelines methodologist, patients with PK deficiency, and caregivers from ten countries. Five key topic areas were identified, the panel prioritised key questions, and a systematic literature search was done to generate evidence summaries that were used in the development of draft recommendations. The expert panel then met in person to finalise and vote on recommendations according to a structured consensus procedure. Agreement of greater than or equal to 67% among the expert panel was required for inclusion of a recommendation in the final guideline. The expert panel agreed on 31 total recommendations across five key topics: diagnosis and genetics, monitoring and management of chronic complications, standard management of anaemia, targeted and advanced therapies, and special populations. These new guidelines should facilitate best practices and evidence-based PK deficiency care into clinical practice.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nadine Shehata
- Departments of Medicine and Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Paola Bianchi
- Hematology Unit, Pathophysiology of Anemias Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas Glenthøj
- Danish Red Blood Cell Center, Department of Hematology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Sujit Sheth
- Division of Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Ellis J Neufeld
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - David C Rees
- Department of Paediatric Haematology, King's College London, King's College Hospital, London, UK
| | - Satheesh Chonat
- Pediatric Hematology/Oncology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Kevin H M Kuo
- Division of Medical Oncology and Hematology, University Health Network, University of Toronto, ON, Canada
| | | | - Wilma Barcellini
- Hematology Unit, Pathophysiology of Anemias Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eduard J van Beers
- Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
| | - Dagmar Pospíšilová
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Ami J Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucile Packard Children Hospital, Stanford School of Medicine, Palo Alto, CA, USA
| | - Richard van Wijk
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Bertil Glader
- Division of Pediatric Hematology/Oncology, Lucile Packard Children Hospital, Stanford School of Medicine, Palo Alto, CA, USA
| | - Maria Del Mar Mañú Pereira
- Rare Anaemia Disorders Research Laboratory, Institut de Recerca - Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Oliver Andres
- Centre of Inherited Blood Cell Disorders, University Hospital Würzburg, Würzburg, Germany
| | - Theodosia A Kalfa
- Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stefan W Eber
- Department of Pediatrics, Practice for Pediatric Hematology and Hemostaseology, University Children's Hospital, Technical University, Munich, Germany
| | - Patrick G Gallagher
- Department of Pediatrics, Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Janet L Kwiatkowski
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carl Lander
- Thrive with Pyruvate Kinase Deficiency Foundation, Bloomington, MN, USA
| | | | - Riyad Elbard
- Thalassemia International Federation, Nicosia, Cyprus
| | | | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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Heidarian Y, Tourigny JP, Fasteen TD, Mahmoudzadeh NH, Hurlburt AJ, Nemkov T, Reisz JA, D’Alessandro A, Tennessen JM. Metabolomic analysis of Drosophila melanogaster larvae lacking pyruvate kinase. G3 (BETHESDA, MD.) 2023; 14:jkad228. [PMID: 37792629 PMCID: PMC10755183 DOI: 10.1093/g3journal/jkad228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/02/2023] [Accepted: 09/24/2023] [Indexed: 10/06/2023]
Abstract
Pyruvate kinase (Pyk) is a rate-limiting enzyme that catalyzes the final metabolic reaction in glycolysis. The importance of this enzyme, however, extends far beyond ATP production, as Pyk is also known to regulate tissue growth, cell proliferation, and development. Studies of this enzyme in Drosophila melanogaster are complicated by the fact that the fly genome encodes 6 Pyk paralogs whose functions remain poorly defined. To address this issue, we used sequence distance and phylogenetic approaches to demonstrate that the gene Pyk encodes the enzyme most similar to the mammalian Pyk orthologs, while the other 5 Drosophila Pyk paralogs have significantly diverged from the canonical enzyme. Consistent with this observation, metabolomic studies of 2 different Pyk mutant strains revealed that larvae lacking Pyk exhibit a severe block in glycolysis, with a buildup of glycolytic intermediates upstream of pyruvate. However, our analysis also unexpectedly reveals that pyruvate levels are unchanged in Pyk mutants, indicating that larval metabolism maintains pyruvate pool size despite severe metabolic limitations. Consistent with our metabolomic findings, a complementary RNA-seq analysis revealed that genes involved in lipid metabolism and protease activity are elevated in Pyk mutants, again indicating that loss of this glycolytic enzyme induces compensatory changes in other aspects of metabolism. Overall, our study provides both insight into how Drosophila larval metabolism adapts to disruption of glycolytic metabolism as well as immediate clinical relevance, considering that Pyk deficiency is the most common congenital enzymatic defect in humans.
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Affiliation(s)
- Yasaman Heidarian
- Department of Biology, Indiana University, Bloomington, IN 47405, USA
| | - Jason P Tourigny
- Department of Biology, Indiana University, Bloomington, IN 47405, USA
| | - Tess D Fasteen
- Department of Biology, Indiana University, Bloomington, IN 47405, USA
| | | | | | - Travis Nemkov
- Department of Biochemistry and Molecular Genetics, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jason M Tennessen
- Department of Biology, Indiana University, Bloomington, IN 47405, USA
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10
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Grace RF. Pyruvate kinase activators for treatment of pyruvate kinase deficiency. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:97-106. [PMID: 38066940 PMCID: PMC10985542 DOI: 10.1182/hematology.2023000466] [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
Pyruvate kinase (PK) deficiency is a congenital hemolytic anemia with wide-ranging clinical symptoms and complications associated with significant morbidity and reduced health-related quality of life in both children and adults. The management of patients with PK deficiency has been historically challenging due to difficulties in the diagnostic evaluation, heterogeneity of clinical manifestations, and treatment options limited to supportive care with transfusions and splenectomy. An oral allosteric PK activator, mitapivat, is now a clinically available disease-modifying treatment for adults with PK deficiency. Phase 2 and 3 clinical trials of mitapivat have demonstrated sustained improvements in hemolytic anemia, hematopoiesis, and quality of life in many adults with PK deficiency and a generally reassuring safety profile with continued dosing. Additional long-term benefits include rapid and ongoing reduction in iron overload and potential stabilization of bone health. Clinical trials of treatment with mitapivat in children with PK deficiency are ongoing. In addition to disease-modifying treatment with PK activators, gene therapy is a potentially curative treatment currently under evaluation in clinical trials. With the availability of disease-targeted therapies, accurately diagnosing PK deficiency in patients with chronic hemolytic anemia is critical. PK activation and gene therapy have the potential to change the natural history of PK deficiency by improving clinical manifestations and patient quality of life and decreasing the risk of long-term complications.
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Affiliation(s)
- Rachael F. Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
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11
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Dunlea E, Crushell E, Cotter M, Blau N, Ferreira CR. Clinical and biochemical footprints of inherited metabolic disease. XVI. Hematological abnormalities. Mol Genet Metab 2023; 140:107735. [PMID: 37989003 DOI: 10.1016/j.ymgme.2023.107735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023]
Abstract
Many classical inherited metabolic diseases (IMDs) are associated with significant hematological complications such as anemia or thrombosis. While these may not be the prominent presenting feature of these conditions, management of these issues is important for optimal outcomes in people with IMDs. Some disorders that are included in the nosology of inherited metabolic disorders, such as inherited disorders of red cell energy metabolism, have purely hematological features, and have typically been cared for by a hematologist. In the 16th issue of the Footprints series, we identified 265 IMDs associated with hematological abnormalities. We review the major hematological manifestations of IMDs, suggest further investigation of hematological findings, and discuss treatment options available for specific hematological complications of IMDs.
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Affiliation(s)
- Eoghan Dunlea
- Dept of Haematology, Children's Health Ireland, Temple Street, Dublin, Ireland; School of Medicine, Trinity College, Dublin, Ireland.
| | - Ellen Crushell
- National Centre for Inherited Metabolic Disorders, Children's Health Ireland, Temple Street, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Melanie Cotter
- Dept of Haematology, Children's Health Ireland, Temple Street, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
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12
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Andrae DA, Grace RF, Jewett A, Foster B, Klaassen RJ, Salek S, Li J, Tai F, Boscoe AN, Zagadailov E. Psychometric validation of the Pyruvate Kinase Deficiency Diary and Pyruvate Kinase Deficiency Impact Assessment in adults in the phase 3 ACTIVATE trial. J Patient Rep Outcomes 2023; 7:112. [PMID: 37943362 PMCID: PMC10636000 DOI: 10.1186/s41687-023-00650-3] [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: 03/30/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Pyruvate kinase (PK) deficiency is a rare hereditary disorder characterized by chronic hemolytic anemia and serious sequalae which negatively affect patient quality of life. This study aimed to psychometrically validate the first disease-specific patient-reported outcome (PRO) instruments: the 7-item PK Deficiency Diary (PKDD) and 12-item PK Deficiency Impact Assessment (PKDIA), designed to assess signs, symptoms, and impacts of PK deficiency in patients enrolled in the ACTIVATE global phase 3 study of mitapivat versus placebo (NCT03548220). METHODS All validation analyses for the PKDD and PKDIA were performed on blinded data, with analyses on item integrity, scoring, reliability, and validity conducted on data from screening and baseline. Completion rates and baseline response distributions were characterized using descriptive statistics. Item response modelling was used to inform a weighted scoring system. Reliability was assessed by internal consistency and test-retest reliability; and validity by convergent and known-groups analyses. RESULTS Of the 80 adults enrolled, baseline data were available for 77 (96.3%) and 78 (97.5%) patients for the PKDD and PKDIA, respectively. Item responses skewed right, indicating that mean values exceeded median values, especially for items utilizing a 0-10 numeric scale, which were subsequently recoded to a 0-4 scale; 4 items were removed from the PKDIA due to redundancy or low relevance to the trial population. Both the PKDD and PKDIA demonstrated high internal consistency (McDonald's coefficient ω = 0.86 and 0.90, respectively), test-retest reliability (intra-class coefficients of 0.94 and 0.87, respectively), and convergent validity with other PROs (linear correlation coefficients [|r|] between 0.30-0.73 and 0.50-0.82, respectively). CONCLUSIONS The findings provide evidence of validity and reliability for the PKDD and PKDIA, the first disease-specific PRO measures for PK deficiency, and can therefore increase understanding of, and more accurately capture, the wider impact of PK deficiency on health-related quality of life. Trial registration ClinicalTrials.gov, NCT03548220. Registered June 07, 2018; https://www. CLINICALTRIALS gov/ct2/show/NCT03548220 .
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Affiliation(s)
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Robert J Klaassen
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Sam Salek
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Junlong Li
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Feng Tai
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Audra N Boscoe
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA.
| | - Erin Zagadailov
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
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13
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Xie F, Gan L, Lei L, Cai T, Gao Y, Liu X, Cai B, Zhou L. Clinical outcome and genotype analysis of four Chinese children with pyruvate kinase deficiency. Mol Genet Genomic Med 2023; 11:e2239. [PMID: 37466302 PMCID: PMC10655518 DOI: 10.1002/mgg3.2239] [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: 02/22/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Pyruvate kinase deficiency (PKD) is a rare congenital hemolytic anemia. Here, we summarized the clinical features and laboratory examinations of four Chinese children with PKD and analyze genomic mutations. METHOD Collected and analyzed the clinical data of all children and their parents and completed the relevant laboratory examinations of all children. Analyzed the sequences of related genes in children by second-generation sequencing technology and verified the suspected mutations in children's family by Sanger sequencing method or second-generation sequencing technology. RESULTS A total of six mutations in gene PKLR were detected in four cases. Except for c.1510C>T (P1) and c.941T>C (P2 and P4), which had been reported in previous studies, the other four novel gene mutations were reported for the first time, including a rare homozygous mutation with large fragment deletion. All those gene mutations cause changes in the amino acids encoded by the gene, as well as subsequent changes in protein structure or loss of function. CONCLUSION Compound heterozygous or homozygous mutations in the coding region of PKLR gene are the causes of PKD in these four Chinese children. The second-generation sequencing technology is an effective means to diagnose PKD. The mutations of c.457-c.462delATCGCC, c.1297T>C, c.1096C>T and Exon4-10del of PKLR reported in this article have not been included in the Thousand Genome Database, dbSNP(v138) and ExAC Database. The PKLR gene mutations found in these children with PKD can provide references for further research of the genetic characteristics of PKD and subsequent gene therapy.
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Affiliation(s)
- Fei Xie
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Lu Gan
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Lei Lei
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Tengguang Cai
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Yu Gao
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Xiaoying Liu
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Bin Cai
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
| | - Lin Zhou
- Department of PediatricsThe First Affiliated Hospital of Naval Medical UniversityShanghaiChina
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14
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Zhuang-Yan A, Shirley M. Mitapivat: A Review in Pyruvate Kinase Deficiency in Adults. Drugs 2023; 83:1613-1620. [PMID: 37991635 DOI: 10.1007/s40265-023-01961-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/23/2023]
Abstract
Mitapivat (Pyrukynd®), an oral, allosteric activator of pyruvate kinase (PK), is approved in the USA for the treatment of haemolytic anaemia in adults with PK deficiency and in the EU and UK for the treatment of PK deficiency in adults. Mitapivat acts by restoring activity of the red blood cell (RBC) PK enzyme, which is dysfunctional due to genetic mutations in the PKLR gene in patients with PK deficiency. In the double-blind placebo-controlled phase III ACTIVATE trial in adults with PK deficiency who were not regularly RBC transfused, mitapivat was superior to placebo in improving haemoglobin levels. In the single-arm phase III ACTIVATE-T trial in adults with PK deficiency who were regularly RBC transfused, a reduction in RBC transfusion burden was observed with mitapivat. In both trials, mitapivat improved other clinical parameters of haemolysis and patient-reported health-related quality of life. At the approved twice-daily dosage range, mitapivat was generally well tolerated, with adverse events generally being mild to moderate in severity. Results from an ongoing extension study in previously enrolled phase III trial patients will be of interest. Currently available data indicate that mitapivat, the first approved disease-modifying drug for PK deficiency in adults, is a valuable treatment option for this rare disease.
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Affiliation(s)
- Amy Zhuang-Yan
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Matt Shirley
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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15
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Wu H, Wu L, Zhang Q, Zhang BF. Case report: A rare case of pyruvate kinase deficiency and Crigler-Najjar syndrome type II with a novel pathogenic variant of PKLR and UGT1A1 mutation. Front Genet 2023; 14:1229271. [PMID: 37671043 PMCID: PMC10475990 DOI: 10.3389/fgene.2023.1229271] [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: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 09/07/2023] Open
Abstract
Pyruvate Kinase Deficiency (PKD) and Crigler-Najjar syndrome are rare autosomal recessive liver diseases. PKD is caused by homozygous or compound heterozygous mutations in the PKLR gene, leading to non-spherocytic hereditary hemolytic anemia. On the other hand, Crigler-Najjar syndrome (CNS-II) is characterized by the loss or reduced activity of UDP-glucuronosyltransferase, resulting in elevated levels of unconjugated bilirubin, which is the primary cause of disease manifestation. To date, there have been no reported cases of patients with both conditions. In this case report, we present the unique clinical course of a 15-year-old Chinese patient with both PKD and CNS-II. The patient was admitted for evaluation of hyperbilirubinemia and exhibited yellowish skin color, icteric sclera, and splenomegaly upon physical examination. Extensive laboratory examinations ruled out viral, hemolytic, autoimmune, and inborn or acquired metabolic etiologies of liver injury. Histopathological findings indicated benign recurrent intrahepatic cholestasis (BRIC) and hemosiderosis. Surprisingly, targeted next-generation sequencing (NGS) of the patient's blood did not reveal any mutation sites associated with BRIC. Instead, it identified a novel homozygous pathogenic variant of the PKLR gene [c.1276C>T (p.Arg426Trp)] and a rare heterozygous variant of UGT1A1 gene [c.-55_-54insAT, c.1091C>T (p.Pro364Leu)]. These findings strongly suggest a diagnosis of PKD and CNS-II in the patient. Treatment with 500 mg/day of ursodeoxycholic acid proved to be effective, rapidly reducing the patient's total bilirubin levels and shortening the symptomatic period. This case highlights the importance of genetic diagnosis in accurately identifying the underlying cause of hyperbilirubinemia, especially in patients with rare hereditary diseases. Furthermore, NGS can provide valuable insights into the genotype-phenotype correlation of PKD and CNS-II.
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Affiliation(s)
- Huan Wu
- Department of Infectious Diseases, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Long Wu
- Department of Anus and Intestinal Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Quan Zhang
- Department of Infectious Diseases, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Bao-fang Zhang
- Department of Infectious Diseases, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
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16
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Dulmovits BM, Wild KT, Flibotte J, Lambert MP, Kwiatkowski J, Thom CS. Neonatal Thrombocytopenia as a Presenting Finding in de novo Pyruvate Kinase Deficiency. Neonatology 2023; 120:661-665. [PMID: 37473739 PMCID: PMC11027091 DOI: 10.1159/000531242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/22/2023] [Indexed: 07/22/2023]
Abstract
Thrombocytopenia is a common laboratory abnormality encountered in critically ill neonates. The broad differential for thrombocytopenia, and its association with potentially severe neonatal pathology, often presents a diagnostic dilemma prompting extensive evaluation. Hemolysis due to red cell enzymopathies is a rare cause of neonatal thrombocytopenia that is typically brief and self-limiting. Here, we present a case of thrombocytopenia, refractory to transfusion, associated with anemia and hyperbilirubinemia in a neonate with pyruvate kinase deficiency (PKD) arising from compound heterozygous PKLR mutations. The nature of the thrombocytopenia in this patient created considerable diagnostic uncertainty, which was ultimately resolved by whole-exome sequencing. This case emphasizes that inherited red cell defects, such as PKD, are important to consider in cases of neonatal thrombocytopenia.
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MESH Headings
- Infant, Newborn
- Humans
- Thrombocytopenia, Neonatal Alloimmune
- Anemia, Hemolytic, Congenital Nonspherocytic/complications
- Anemia, Hemolytic, Congenital Nonspherocytic/diagnosis
- Anemia, Hemolytic, Congenital Nonspherocytic/genetics
- Pyruvate Metabolism, Inborn Errors/diagnosis
- Pyruvate Metabolism, Inborn Errors/genetics
- Pyruvate Metabolism, Inborn Errors/complications
- Pyruvate Kinase/genetics
- Anemia
- Infant, Newborn, Diseases
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Affiliation(s)
- Brian M Dulmovits
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - K Taylor Wild
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - John Flibotte
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michele P Lambert
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Janet Kwiatkowski
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher S Thom
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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17
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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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18
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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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19
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Feugray G, Grall M, Dumesnil C, Benhamou Y, Brunel V, Le Cam Duchez V, Lahary A, Billoir P. Hypercoagulability evaluation in congenital red blood cell disorders using thrombin generation assay. Thromb Res 2023:S0049-3848(23)00082-8. [PMID: 37024320 DOI: 10.1016/j.thromres.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/27/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023]
Affiliation(s)
- Guillaume Feugray
- Univ Rouen Normandie, INSERM EnVI UMR 1096, F-76000 Rouen, France; Department of General Biochemistry, CHU Rouen, F-76000, France.
| | - Maximilien Grall
- Department of Internal Medecine, CHU Rouen, F-76000 Rouen, France
| | - Cécile Dumesnil
- Department of Pediatric Onco-Hematology, CHU Rouen, F-76000, France
| | - Ygal Benhamou
- Univ Rouen Normandie, INSERM EnVI UMR 1096, F-76000 Rouen, France; Department of Internal Medecine, CHU Rouen, F-76000 Rouen, France
| | - Valery Brunel
- Department of General Biochemistry, CHU Rouen, F-76000, France
| | - Véronique Le Cam Duchez
- Univ Rouen Normandie, INSERM EnVI UMR 1096, F-76000 Rouen, France; Department of Vascular Hemostasis Unit, CHU Rouen, F-76000 Rouen, France
| | - Agnès Lahary
- Department of Hematology Laboratory, CHU Rouen, F-76000 Rouen, France
| | - Paul Billoir
- Univ Rouen Normandie, INSERM EnVI UMR 1096, F-76000 Rouen, France; Department of Vascular Hemostasis Unit, CHU Rouen, F-76000 Rouen, France
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20
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Grace RF, van Beers EJ, Vives Corrons JL, Glader B, Glenthøj A, Kanno H, Kuo KHM, Lander C, Layton DM, Pospíŝilová D, Viprakasit V, Li J, Yan Y, Boscoe AN, Bowden C, Bianchi P. The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry: rationale and study design. BMJ Open 2023; 13:e063605. [PMID: 36958777 PMCID: PMC10040033 DOI: 10.1136/bmjopen-2022-063605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION Pyruvate kinase (PK) deficiency is a rare, under-recognised, hereditary condition that leads to chronic haemolytic anaemia and potentially serious secondary complications, such as iron overload, cholecystitis, pulmonary hypertension and extramedullary haematopoiesis. It is an autosomal recessive disease caused by homozygous or compound heterozygous mutations in the PKLR gene. Due to its rarity and clinical heterogeneity, information on the natural history and long-term clinical course of PK deficiency is limited, presenting major challenges to patient management, the development of new therapies and establishing disease-specific treatment recommendations. The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry is an initiative to address the gaps in the knowledge of PK deficiency. This manuscript describes the objectives, study design and methodology for the Peak Registry. METHODS AND ANALYSIS The Peak Registry is an observational, longitudinal, global registry of adult and paediatric patients with a genetically confirmed diagnosis of PK deficiency. The Peak Steering Committee is composed of 11 clinicians and researchers with experience in the diagnosis and management of PK deficiency from 10 countries, a patient representative and representatives from the sponsor (Agios Pharmaceuticals). The registry objective is to foster an understanding of the longitudinal clinical implications of PK deficiency, including its natural history, treatments and outcomes, and variability in clinical care. The aim is to enrol up to 500 participants from approximately 60 study centres across 20 countries over 7 years, with between 2 and 9 years of follow-up. Data will include demographics, diagnosis history, genotyping, transfusion history, relevant clinical events, medications, emergency room visits and hospitalisations. ETHICS AND DISSEMINATION Registry protocol and informed consent forms are approved by institutional review boards/independent ethics committees at each study site. The study is being conducted in accordance with the Declaration of Helsinki. Registry data will be published in peer-reviewed journal articles and conference publications. TRIAL REGISTRATION NUMBER NCT03481738.
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Affiliation(s)
- Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Eduard J van Beers
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Joan-Lluis Vives Corrons
- Institute for Leukaemia Research Josep Carreras ENERCA Coordinator, University of Barcelona, Barcelona, Spain
| | - Bertil Glader
- Stanford University School of Medicine, Stanford, California, USA
| | - Andreas Glenthøj
- Danish Red Blood Cell Center, Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Hitoshi Kanno
- Department of Transfusion Medicine and Cell Processing, Tokyo Women's Medical University, Tokyo, Japan
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | | | - D Mark Layton
- Hammersmith Hospital, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Dagmar Pospíŝilová
- Department of Pediatrics, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Vip Viprakasit
- Siriaj Hospital, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Junlong Li
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Yan Yan
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Audra N Boscoe
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Chris Bowden
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Paola Bianchi
- Hematology Unit, Pathophysiology of Anemias Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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21
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Evaluation of the main regulators of systemic iron homeostasis in pyruvate kinase deficiency. Sci Rep 2023; 13:4395. [PMID: 36927785 PMCID: PMC10020532 DOI: 10.1038/s41598-023-31571-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Iron homeostasis and dyserythropoiesis are poorly investigated in pyruvate kinase deficiency (PKD), the most common glycolytic defect of erythrocytes. Herein, we studied the main regulators of iron balance and erythropoiesis, as soluble transferrin receptor (sTfR), hepcidin, erythroferrone (ERFE), and erythropoietin (EPO), in a cohort of 41 PKD patients, compared with 42 affected by congenital dyserythropoietic anemia type II (CDAII) and 50 with hereditary spherocytosis (HS). PKD patients showed intermediate values of hepcidin and ERFE between CDAII and HS, and clear negative correlations between log-transformed hepcidin and log-EPO (Person's r correlation coefficient = - 0.34), log-hepcidin and log-ERFE (r = - 0.47), and log-hepcidin and sTfR (r = - 0.44). sTfR was significantly higher in PKD; EPO levels were similar in PKD and CDAII, both higher than in HS. Finally, genotype-phenotype correlation in PKD showed that more severe patients, carrying non-missense/non-missense genotypes, had lower hepcidin and increased ERFE, EPO, and sTFR compared with the others (missense/missense and missense/non-missense), suggesting a higher rate of ineffective erythropoiesis. We herein investigated the main regulators of systemic iron homeostasis in the largest cohort of PKD patients described so far, opening new perspectives on the molecular basis and therapeutic approaches of this disease.
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22
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Dongerdiye R, Bokde M, More TA, Saptarshi A, Devendra R, Chiddarwar A, Warang P, Kedar P. Targeted next-generation sequencing identifies eighteen novel mutations expanding the molecular and clinical spectrum of PKLR gene disorders in the Indian population. Ann Hematol 2023; 102:1029-1036. [PMID: 36892591 DOI: 10.1007/s00277-023-05152-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
Pyruvate kinase deficiency (PKD) is an autosomal recessive condition, caused due to homozygous or compound heterozygous mutation in the PKLR gene resulting in non-spherocytic hereditary hemolytic anemia. Clinical manifestations in PKD patients vary from moderate to severe lifelong hemolytic anemia either requiring neonatal exchange transfusion or blood transfusion support. Measuring PK enzyme activity is the gold standard approach for diagnosis but residual activity must be related to the increased reticulocyte count. The confirmatory diagnosis is provided by PKLR gene sequencing by conventional as well as targeted next-generation sequencing involving genes associated with enzymopathies, membranopathies, hemoglobinopathies, and bone marrow failure disorders. In this study, we report the mutational landscape of 45 unrelated PK deficiency cases from India. The genetic sequencing of PKLR revealed 40 variants comprising 34 Missense Mutations (MM), 2 Nonsense Mutations (NM), 1 Splice site, 1 Intronic, 1 Insertion, and 1 Large Base Deletion. The 17 novel variants identified in this study are A115E, R116P, A423G, K313I, E315G, E318K, L327P, M377L, A423E, R449G, H507Q, E538K, G563S, c.507 + 1 G > C, c.801_802 ins A (p.Asp268ArgfsTer48), IVS9dsA-T + 3, and one large base deletion. In combination with previous reports on PK deficiency, we suggest c.880G > A, c.943G > A, c.994G > A, c.1456C > T, c.1529G > A are the most frequently observed mutations in India. This study expands the phenotypic and molecular spectrum of PKLR gene disorders and also emphasizes the importance of combining both targeted next-generation sequencing with bioinformatics analysis and detailed clinical evaluation to elaborate a more accurate diagnosis and correct diagnosis for transfusion dependant hemolytic anemia in a cohort of the Indian population.
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Affiliation(s)
- Rashmi Dongerdiye
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Meghana Bokde
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Tejashree Anil More
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Arati Saptarshi
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Rati Devendra
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Ashish Chiddarwar
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Prashant Warang
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India
| | - Prabhakar Kedar
- Department of Haematogenetics, ICMR-National Institute of Immunohematology, 13th Floor, NMS Building, King Edward Memorial (KEM) Hospital Campus, Parel, 400012, Mumbai, India.
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23
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Fañanas-Baquero S, Morín M, Fernández S, Ojeda-Perez I, Dessy-Rodriguez M, Giurgiu M, Bueren JA, Moreno-Pelayo MA, Segovia JC, Quintana-Bustamante O. Specific correction of pyruvate kinase deficiency-causing point mutations by CRISPR/Cas9 and single-stranded oligodeoxynucleotides. Front Genome Ed 2023; 5:1104666. [PMID: 37188156 PMCID: PMC10175809 DOI: 10.3389/fgeed.2023.1104666] [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: 11/21/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Pyruvate kinase deficiency (PKD) is an autosomal recessive disorder caused by mutations in the PKLR gene. PKD-erythroid cells suffer from an energy imbalance caused by a reduction of erythroid pyruvate kinase (RPK) enzyme activity. PKD is associated with reticulocytosis, splenomegaly and iron overload, and may be life-threatening in severely affected patients. More than 300 disease-causing mutations have been identified as causing PKD. Most mutations are missense mutations, commonly present as compound heterozygous. Therefore, specific correction of these point mutations might be a promising therapy for the treatment of PKD patients. We have explored the potential of precise gene editing for the correction of different PKD-causing mutations, using a combination of single-stranded oligodeoxynucleotides (ssODN) with the CRISPR/Cas9 system. We have designed guide RNAs (gRNAs) and single-strand donor templates to target four different PKD-causing mutations in immortalized patient-derived lymphoblastic cell lines, and we have detected the precise correction in three of these mutations. The frequency of the precise gene editing is variable, while the presence of additional insertions/deletions (InDels) has also been detected. Significantly, we have identified high mutation-specificity for two of the PKD-causing mutations. Our results demonstrate the feasibility of a highly personalized gene-editing therapy to treat point mutations in cells derived from PKD patients.
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Affiliation(s)
- Sara Fañanas-Baquero
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Matías Morín
- Servicio de Genética, Hospital Universitario Ramón y Cajal, IRYCIS and Centro de Investigaciones Biomédicas en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Sergio Fernández
- Servicio de Genética, Hospital Universitario Ramón y Cajal, IRYCIS and Centro de Investigaciones Biomédicas en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Isabel Ojeda-Perez
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Mercedes Dessy-Rodriguez
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Miruna Giurgiu
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Juan A. Bueren
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Miguel Angel Moreno-Pelayo
- Servicio de Genética, Hospital Universitario Ramón y Cajal, IRYCIS and Centro de Investigaciones Biomédicas en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Jose Carlos Segovia
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
- *Correspondence: Jose Carlos Segovia, ; Oscar Quintana-Bustamante,
| | - Oscar Quintana-Bustamante
- Division of Hematopoietic Innovative Therapies, Centro de Investigaciones Energéticas Medioambientales y Tecnológicas and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIEMAT/CIBERER), Madrid, Spain
- Advanced Therapies Unit, Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
- *Correspondence: Jose Carlos Segovia, ; Oscar Quintana-Bustamante,
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24
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Joshi R, Myers E, Kokhanov A. Congenital Disorders of Red Blood Cells. Neoreviews 2022; 23:e813-e828. [PMID: 36450647 DOI: 10.1542/neo.23-12-e813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
See Bonus NeoBriefs videos and downloadable teaching slides Understanding the physiologic process of red blood cell development in utero and subsequent erythropoiesis in the neonate is crucial as this determines red blood cell structure and therefore function, which is vital to neonatal health. Infants frequently experience anemia, and special consideration must be given to the evaluation of these infants to determine the correct etiology. Traditionally, anemia is conceptualized in terms of inadequate red blood cell production, increased red blood cell destruction, or whole blood loss. This framework translates well to inherited red blood cell defects, which include genetic abnormalities in bone marrow productivity or structure of the red blood cell membrane, enzymes, or hemoglobin. This article highlights fetal and neonatal erythropoiesis and the underlying etiologies of the inherited red blood cell disorders, as well as reviews the appropriate diagnostic evaluation and next steps in management. It is imperative that neonatal clinicians remain informed about these disorders to enable early recognition and treatment, and ultimately to improve outcomes in affected infants.
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Affiliation(s)
- Rhucha Joshi
- Division of Neonatal Medicine, Department of Pediatrics, University of California Irvine, Irvine, CA
| | - Erin Myers
- Department of Pediatrics, University of California Irvine, Irvine, CA
| | - Artemiy Kokhanov
- Department of Neonatology, MemorialCare Miller Children's and Women's Hospital Long Beach, Long Beach, CA
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25
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Mitapivat in adult patients with pyruvate kinase deficiency receiving regular transfusions (ACTIVATE-T): a multicentre, open-label, single-arm, phase 3 trial. THE LANCET HAEMATOLOGY 2022; 9:e724-e732. [DOI: 10.1016/s2352-3026(22)00214-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023]
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26
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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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27
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Fattizzo B, Cavallaro F, Marcello APML, Vercellati C, Barcellini W. Pyruvate Kinase Deficiency: Current Challenges and Future Prospects. J Blood Med 2022; 13:461-471. [PMID: 36072510 PMCID: PMC9444143 DOI: 10.2147/jbm.s353907] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/23/2022] [Indexed: 01/19/2023] Open
Abstract
Pyruvate kinase deficiency (PKD) is a rare autosomal recessive disease marked by chronic hemolytic anemia of various severity and frequent complications including gallstones, splenomegaly, iron overload, and others. Disease phenotype is highly heterogeneous and changes over time with children, adolescents and adult patients displaying different transfusion requirement and rates of complications. The diagnosis relies on the initial clinical suspicion in a patient with chronic hemolysis and exclusion of other more common congenital forms of hemolytic anemias; it is supported by the demonstration of reduced PK enzyme activity, and further confirmed by the detection of (homozygous or compound heterozygous) mutations of PKLR gene. Therapy is mainly supportive, with vitamin supplementation and transfusions (based on symptoms and patient growth rather than on fixed Hb thresholds). Splenectomy is widely performed, although it is less effective than in membrane defects and carries thrombotic and infectious risk. In the last decade, the allosteric PK enzyme activator mitapivat showed dramatic clinical benefit in clinical trials and gene therapy is also being studied to substitute the defective enzyme. In this review, we provide an insight in the current challenges of PKD diagnosis and management and discuss the future application of novel drugs and gene therapy, including a focus on quality of life.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Correspondence: Bruno Fattizzo, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Hematology Unit, Via F. Sforza 35, Milan, 20122, Italy, Tel +39 0255033477, Email
| | - Francesca Cavallaro
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Cristina Vercellati
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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28
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Abstract
The World Health Organization estimates that approximately a quarter of the world's population suffers from anemia, including almost half of preschool-age children. Globally, iron deficiency anemia is the most common cause of anemia. Other important causes of anemia in children are hemoglobinopathies, infection, and other chronic diseases. Anemia is associated with increased morbidity, including neurologic complications, increased risk of low birth weight, infection, and heart failure, as well as increased mortality. When approaching a child with anemia, detailed historical information, particularly diet, environmental exposures, and family history, often yield important clues to the diagnosis. Dysmorphic features on physical examination may indicate syndromic causes of anemia. Diagnostic testing involves a stepwise approach utilizing various laboratory techniques. The increasing availability of genetic testing is providing new mechanistic insights into inherited anemias and allowing diagnosis in many previously undiagnosed cases. Population-based approaches are being taken to address nutritional anemias. Novel pharmacologic agents and advances in gene therapy-based therapeutics have the potential to ameliorate anemia-associated disease and provide treatment strategies even in the most difficult and complex cases.
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Affiliation(s)
- Patrick G Gallagher
- Departments of Pediatrics, Pathology, and Genetics, Yale University School of Medicine, New Haven, CT
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29
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Hsu CC, Senussi NH, Fertrin KY, Kowdley KV. Iron overload disorders. Hepatol Commun 2022; 6:1842-1854. [PMID: 35699322 PMCID: PMC9315134 DOI: 10.1002/hep4.2012] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/06/2022] [Accepted: 04/16/2022] [Indexed: 01/19/2023] Open
Abstract
Iron overload disorders represent a variety of conditions that lead to increased total body iron stores and resultant end-organ damage. An elevated ferritin and transferrin-iron saturation can be commonly encountered in the evaluation of elevated liver enzymes. Confirmatory homeostatic iron regulator (HFE) genetic testing for C282Y and H63D, mutations most encountered in hereditary hemochromatosis, should be pursued in evaluation of hyperferritinemia. Magnetic resonance imaging with quantitative assessment of iron content or liver biopsy (especially if liver disease is a cause of iron overload) should be used as appropriate. A secondary cause for iron overload should be considered if HFE genetic testing is negative for the C282Y homozygous or C282Y/H63D compound heterozygous mutations. Differential diagnosis of secondary iron overload includes hematologic disorders, iatrogenic causes, or chronic liver diseases. More common hematologic disorders include thalassemia syndromes, myelodysplastic syndrome, myelofibrosis, sideroblastic anemias, sickle cell disease, or pyruvate kinase deficiency. If iron overload has been excluded, evaluation for causes of hyperferritinemia should be pursued. Causes of hyperferritinemia include chronic liver disease, malignancy, infections, kidney failure, and rheumatic conditions, such as adult-onset Still's disease or hemophagocytic lymphohistiocytosis. In this review, we describe the diagnostic testing of patients with suspected hereditary hemochromatosis, the evaluation of patients with elevated serum ferritin levels, and signs of secondary overload and treatment options for those with secondary iron overload.
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Affiliation(s)
- Christine C. Hsu
- Medstar Georgetown University HospitalMedstar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Nizar H. Senussi
- Gastroenterology and HepatologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Kleber Y. Fertrin
- Division of HematologyDepartment of MedicineUniversity of WashingtonWashingtonUSA
| | - Kris V. Kowdley
- Liver Institute Northwest and Elson S. Floyd College of MedicineWashington State UniversityWashingtonUSA
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30
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Johnson S, Grace RF, Despotovic JM. Diagnosis, monitoring, and management of pyruvate kinase deficiency in children. Pediatr Blood Cancer 2022; 69:e29696. [PMID: 35452178 DOI: 10.1002/pbc.29696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase (PK) deficiency is a rare, congenital red blood cell disorder caused by a single gene defect. The spectrum of genotypes, variants, and phenotypes are broad, commonly requiring a multimodal approach including enzyme and genetic testing for accurate and reliable diagnosis. Similarly, management of primary and secondary sequelae of PK deficiency varies, mainly including supportive care with transfusions and surgical interventions to improve symptoms and quality of life. Given the risk of acute and long-term complications of PK deficiency and its treatment, regular monitoring and management of iron burden and organ dysfunction is critical. Therefore, all children and adolescents with PK deficiency should receive regular hematology care with visits at least every 6 months regardless of transfusion status. We continue to learn more about the spectrum of symptoms and complications of PK deficiency and best practice for monitoring and management through registry efforts (NCT03481738). The treatment of PK deficiency has made strides over the last few years with newer disease-modifying therapies being developed and studied, with the potential to change the course of disease in childhood and beyond.
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Affiliation(s)
- Shaniqua Johnson
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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31
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Songdej D, Kadegasem P, Tangbubpha N, Sasanakul W, Deelertthaweesap B, Chuansumrit A, Sirachainan N. Whole-exome sequencing uncovered genetic diagnosis of severe inherited haemolytic anaemia: Correlation with clinical phenotypes. Br J Haematol 2022; 198:1051-1064. [PMID: 35819869 DOI: 10.1111/bjh.18356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 01/19/2023]
Abstract
Next-generation sequencing has shed light on the diagnosis of previously unsolved cases of inherited haemolytic anaemia (IHA). We employed whole-exome sequencing to explore the molecular diagnostic spectrum of 21 unrelated Thai paediatric patients with non-thalassemic IHA, presenting hydrops fetalis and/or becoming transfusion-dependent for 1 year or more or throughout their lifespan. Anaemia was detected prenatally, within the first month and the fifth year of life in three, 12 and six patients respectively. Molecular diagnosis obtained from all patients revealed SPTB as the most frequently mutated gene (four reported, three novel), found in 31 of 42 studied alleles. The other two mutated genes identified were ANK1 (three novel) and KLF1 (two reported). Four recurring mutations within exon 29/30 (NM_001024858.2) accounted for the vast majority (90%) of mutated SPTB alleles, biallelic inheritance of which resulted in the most severe phenotypes: hydrops fetalis and life-long transfusion dependency. Dominant ANK1 (n = 3) and SPTB (n = 2) mutations and biallelic class 2 KLF1 mutations (n = 1) led to a shorter period of transfusion dependency. Our study demonstrated that mutated SPTB causing red-cell membranopathy is likely the most common cause of severe non-thalassemic IHA among Thai patients. This urges carrier screening in the population to prevent subsequent, severely affected births.
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Affiliation(s)
- Duantida Songdej
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Praguywan Kadegasem
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noppawan Tangbubpha
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Werasak Sasanakul
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Bhurichaya Deelertthaweesap
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ampaiwan Chuansumrit
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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32
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van Vuren A, Kerkhoffs JL, Schols S, Rijneveld A, Nur E, Peereboom D, Gandon Y, Welsing P, van Wijk R, Schutgens R, van Solinge W, Marx J, Leiner T, Biemond B, van Beers E. Proton pump inhibition for secondary hemochromatosis in hereditary anemia: a phase III placebo-controlled randomized cross-over clinical trial. Am J Hematol 2022; 97:924-932. [PMID: 35472008 PMCID: PMC9325377 DOI: 10.1002/ajh.26581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 01/19/2023]
Abstract
Iron overload is a severe general complication of hereditary anemias. Treatment with iron chelators is hampered by important side‐effects, high costs, and the lack of availability in many countries with a high prevalence of hereditary anemias. In this phase III randomized placebo‐controlled trial, we assigned adults with non‐transfusion‐dependent hereditary anemias with mild‐to‐moderate iron overload to receive esomeprazole (at a dose of 40 mg twice daily) or placebo for 12 months in a cross‐over design. The primary end point was change of liver iron content measured by MRI. A total of 30 participants were enrolled in the trial. Treatment with esomeprazole resulted in a statistically significant reduction in liver iron content that was 0.55 mg Fe/g dw larger than after treatment with placebo (95%CI [0.05 to 1.06]; p = 0.03). Median baseline liver iron content at the start of esomeprazole was 4.99 versus 4.49 mg Fe/g dw at start of placebo. Mean delta liver iron content after esomeprazole treatment was −0.57 (SD 1.20) versus −0.11 mg Fe/g dw (SD 0.75) after placebo treatment. Esomeprazole was well tolerated, reported adverse events were mild and none of the patients withdrew from the study due to side effects. In summary, esomeprazole resulted in a significant reduction in liver iron content when compared to placebo in a heterogeneous group of patients with non‐transfusion‐dependent hereditary anemias. From an international perspective this result can have major implications given the fact that proton pump inhibitors may frequently be the only realistic therapy for many patients without access to or not tolerating iron chelators.
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Affiliation(s)
- Annelies van Vuren
- Center for Benign Haematology Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | | | - Saskia Schols
- Department of Hematology Radboud university medical center Nijmegen The Netherlands
| | - Anita Rijneveld
- Department of Hematology Erasmus Medical Center Cancer Institute Rotterdam The Netherlands
| | - Erfan Nur
- Department of Hematology Amsterdam University Centers, University of Amsterdam Amsterdam The Netherlands
- Department of Blood Cell Research Sanquin Research Amsterdam The Netherlands
| | - Dore Peereboom
- Contactgroep Pyruvaatkinasedeficiëntie Stichting Zeldzame Bloedziekten Medemblik The Netherlands
| | - Yves Gandon
- Department of Radiology CHU Rennes, University of Rennes Rennes France
| | - Paco Welsing
- Division of Internal Medicine and Dermatology University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Richard van Wijk
- Central Diagnostic Laboratory ‐ Research, Division of Laboratories Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Roger Schutgens
- Center for Benign Haematology Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Wouter van Solinge
- Central Diagnostic Laboratory ‐ Research, Division of Laboratories Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Joannes Marx
- University Medical Center Utrecht Utrecht The Netherlands
| | - Tim Leiner
- Department of Radiology Mayo Clinic Rochester Minnesota USA
- Department of Radiology University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Bart Biemond
- Department of Hematology Amsterdam University Centers, University of Amsterdam Amsterdam The Netherlands
| | - Eduard van Beers
- Center for Benign Haematology Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
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33
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Chueh HW, Hwang SM, Shim YJ, Lee JM, Park HS, Lee JH, Nam Y, Kim N, Jung HL, Choi HS. Korean clinical practice guidelines for the diagnosis of hereditary hemolytic anemia. Blood Res 2022; 57:86-94. [PMID: 35593002 PMCID: PMC9242826 DOI: 10.5045/br.2022.2021224] [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: 12/28/2021] [Revised: 02/03/2022] [Accepted: 02/28/2022] [Indexed: 01/19/2023] Open
Abstract
Although the prevalence of hereditary hemolytic anemia (HHA) is relatively low in Korea, it has been gradually increasing in recent decades due to increment in the proportions of hemoglobinopathies from immigrants of South East Asia, raising awareness of the disease among clinicians, and advances in diagnostic technology. As such, the red blood cell (RBC) Disorder Working Party (WP), previously called HHA WP, of the Korean Society of Hematology (KSH) developed the Korean Standard Operating Procedures (SOPs) for the diagnosis of HHA in 2007. These SOPs have been continuously revised and updated following advances in diagnostic technology [e.g., flow cytometric osmotic fragility test (FOFT) and eosin-5-maleimide (EMA) binding test], current methods for membrane protein or enzyme analysis [e.g., liquid chromatography-tandem mass spectrometry (LC-MS/MS), ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS), high-performance liquid chromatography (HPLC)], and molecular genetic tests using next-generation sequencing (NGS). However, the diagnosis and treatment of HHA remain challenging as they require considerable experience and understanding of the disease. Therefore, in this new Korean Clinical Practice Guidelines for the Diagnosis of HHA, on behalf of the RBC Disorder WP of KSH, updated guidelines to approach patients suspected of HHA are summarized. NGS is proposed to perform prior to membrane protein or enzyme analysis by LC-MS/MS, UPLC-MS/MS or HPLC techniques due to the availability of gene testing in more laboratories in Korea. We hope that this guideline will be helpful for clinicians in making diagnostic decisions for patients with HHA in Korea.
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Affiliation(s)
- Hee Won Chueh
- Department of Pediatrics, Dong-A University, College of Medicine, Busan, Korea
| | - Sang Mee Hwang
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Department of Pediatrics, Cheongju, Korea
| | - Ye Jee Shim
- Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Cheongju, Korea
| | - Jae Min Lee
- Yeungnam University Medical Center, Daegu, Department of Laboratory Medicine, Cheongju, Korea
| | - Hee Sue Park
- Chungbuk National University Hospital, Cheongju, Korea
| | - Joon Hee Lee
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Department of Pediatrics, Cheongju, Korea
| | - Youngwon Nam
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Department of Pediatrics, Cheongju, Korea
| | - Namhee Kim
- Dong-A University, College of Medicine, Busan, Department of Pediatrics, Seoul, Korea
| | - Hye Lim Jung
- Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyoung Soo Choi
- Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Abstract
AbstractThe druggable genome is limited by structural features that can be targeted by small molecules in disease-relevant proteins. While orthosteric and allosteric protein modulators have been well studied, they are limited to antagonistic/agonistic functions. This approach to protein modulation leaves many disease-relevant proteins as undruggable targets. Recently, protein-protein interaction modulation has emerged as a promising therapeutic field for previously undruggable protein targets. Molecular glues and heterobifunctional degraders such as PROTACs can facilitate protein interactions and bring the proteasome into proximity to induce targeted protein degradation. In this review, we discuss the function and rational design of molecular glues, heterobifunctional degraders, and hydrophobic tag degraders. We also review historic and novel molecular glues and targets and discuss the challenges and opportunities in this new therapeutic field.
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Lin S, Hua X, Li J, Li Y. Novel Compound Heterozygous PKLR Mutation Induced Pyruvate Kinase Deficiency With Persistent Pulmonary Hypertension in a Neonate: A Case Report. Front Cardiovasc Med 2022; 9:872172. [PMID: 35557523 PMCID: PMC9086540 DOI: 10.3389/fcvm.2022.872172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/04/2022] [Indexed: 01/19/2023] Open
Abstract
Background Pulmonary hypertension could be associated with pyruvate kinase deficiency (PKD). There are few reported cases of PPHN as the first clinical manifestation of PKD. Herein we report a rare case of PKD in which the patient exhibited persistent pulmonary hypertension in the neonate (PPHN), and genetic testing helped to rapidly identify an potential association. Case presentation The patient was a newborn boy who suffered from severe dyspnea, extreme anemia, skin pallor, and hypoxemia. Repeated echocardiography indicated persistent severe pulmonary hypertension with a calculated pulmonary artery pressure of 75 mmHg, and right ventricular hypertrophy. The administration of nitric oxide significantly reduced the pulmonary artery pressure. Whole-exome sequencing revealed a compound heterozygous mutation consisting of c.707T > G and c.826_827insAGGAGCATGGGG. PolyPhen_2 and MutationTaster indicated that both the c.707T > G (probability 0.999) and c.826_827insAGGAGCATGGGG (probability 0.998) mutations were disease causing. PROVEAN protein batch analysis indicated that the associated p.L236R region was deleterious (score −4.71) and damaging (SIFT prediction 0.00), and this was also the case for p.G275_V276insEEHG (deleterious score −12.00, SIFT prediction 0.00). Substantial structural changes in the transport domain of the protein were predicted using SWISS-MODEL, and indicated that both mutations led to an unstable protein structure. Thus, a novel compound heterozygous mutation of PKLR-induced PKD with PPHN was diagnosed. Conclusion The current study suggests that molecular genetic screening is useful for identifying PPHN, particularly in children with metabolic disorders. In patients exhibiting unexplained hyperbilirubinemia combined with severe pulmonary hypertension, PKD might be a potential possible alternative explanation. Genetic screening is helpful for identifying genetic causes of pulmonary hypertension, especially in patients with PPHN. This report expands the mutation spectrum of the PKLR gene, and contributes to the genotype-phenotype map of PKD.
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Al-Samkari H, Galactéros F, Glenthøj A, Rothman JA, Andres O, Grace RF, Morado-Arias M, Layton DM, Onodera K, Verhovsek M, Barcellini W, Chonat S, Judge MP, Zagadailov E, Xu R, Hawkins P, Beynon V, Gheuens S, van Beers EJ. Mitapivat versus Placebo for Pyruvate Kinase Deficiency. N Engl J Med 2022; 386:1432-1442. [PMID: 35417638 DOI: 10.1056/nejmoa2116634] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pyruvate kinase deficiency is a rare, hereditary, chronic condition that is associated with hemolytic anemia. In a phase 2 study, mitapivat, an oral, first-in-class activator of erythrocyte pyruvate kinase, increased the hemoglobin level in patients with pyruvate kinase deficiency. METHODS In this global, phase 3, randomized, placebo-controlled trial, we evaluated the efficacy and safety of mitapivat in adults with pyruvate kinase deficiency who were not receiving regular red-cell transfusions. The patients were assigned to receive either mitapivat (5 mg twice daily, with potential escalation to 20 or 50 mg twice daily) or placebo for 24 weeks. The primary end point was a hemoglobin response (an increase from baseline of ≥1.5 g per deciliter in the hemoglobin level) that was sustained at two or more scheduled assessments at weeks 16, 20, and 24. Secondary efficacy end points were the average change from baseline in the hemoglobin level, markers of hemolysis and hematopoiesis, and the change from baseline at week 24 in two pyruvate kinase deficiency-specific patient-reported outcome measures. RESULTS Sixteen of the 40 patients (40%) in the mitapivat group had a hemoglobin response, as compared with none of the 40 patients in the placebo group (adjusted difference, 39.3 percentage points; 95% confidence interval, 24.1 to 54.6; two-sided P<0.001). Patients who received mitapivat had a greater response than those who received placebo with respect to each secondary end point, including the average change from baseline in the hemoglobin level. The most common adverse events were nausea (in 7 patients [18%] in the mitapivat group and 9 patients [23%] in the placebo group) and headache (in 6 patients [15%] and 13 patients [33%], respectively). Adverse events of grade 3 or higher occurred in 10 patients (25%) who received mitapivat and 5 patients (13%) who received placebo. CONCLUSIONS In patients with pyruvate kinase deficiency, mitapivat significantly increased the hemoglobin level, decreased hemolysis, and improved patient-reported outcomes. No new safety signals were identified in the patients who received mitapivat. (Funded by Agios Pharmaceuticals; ACTIVATE ClinicalTrials.gov number, NCT03548220.).
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Affiliation(s)
- Hanny Al-Samkari
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Frédéric Galactéros
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Andreas Glenthøj
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Jennifer A Rothman
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Oliver Andres
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Rachael F Grace
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Marta Morado-Arias
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - D Mark Layton
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Koichi Onodera
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Madeleine Verhovsek
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Wilma Barcellini
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Satheesh Chonat
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Malia P Judge
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Erin Zagadailov
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Rengyi Xu
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Peter Hawkins
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Vanessa Beynon
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Sarah Gheuens
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Eduard J van Beers
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
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Concomitant Hereditary Spherocytosis and Pyruvate Kinase Deficiency in a Spanish Family with Chronic Hemolytic Anemia: Contribution of Laser Ektacytometry to Clinical Diagnosis. Cells 2022; 11:cells11071133. [PMID: 35406697 PMCID: PMC8997718 DOI: 10.3390/cells11071133] [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: 01/28/2022] [Revised: 02/22/2022] [Accepted: 03/23/2022] [Indexed: 01/19/2023] Open
Abstract
Background: Hereditary spherocytosis (HS) and pyruvate kinase deficiency (PKD) are the most common causes of hereditary chronic hemolytic anemia. Here, we describe clinical and genetic characteristics of a Spanish family with concomitant β-spectrin (SPTB) c.647G>A variant and pyruvate kinase (PKLR) c.1706G>A variant. Methods: A family of 11 members was studied. Hematological investigation, hemolysis tests, and specific red cell studies were performed in all family members, according to conventional procedures. An ektacytometric study was performed using the osmoscan module of the Lorca ektacytometer (MaxSis. RR Mechatronics). The presence of the SPTB and PKLR variants was confirmed by t-NGS. Results: The t-NGS genetic characterization of the 11 family members showed the presence of a heterozygous mutation for the β-spectrin (SPTB; c.647G>A) in seven members with HS, three of them co-inherited the PKLR variant c.1706G>A. In the remaining four members, no gene mutation was found. Ektacytometry allowed a clear diagnostic orientation of HS, independently from the PKLR variant. Conclusions: This family study allows concluding that the SPTB mutation, (c.647G>A) previously described as likely pathogenic (LP), should be classified as pathogenic (P), according to the recommendations for pathogenicity of the American College of Medical Genetics and the Association for Molecular Pathology. In addition, after 6 years of clinical follow-up of the patients with HS, it can be inferred that the chronic hemolytic anemia may be attributable to the SPTB mutation only, without influence of the concomitant PKLR. Moreover, only the family members with the SPTB mutation exhibited an ektacytometric profile characteristic of HS.
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38
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Vercellati C, Zaninoni A, Marcello AP, Fermo E, Fattizzo B, Giannotta JA, Bianchi P, Zanella A, Barcellini W. Changing trends of splenectomy in hereditary spherocytosis: The experience of a reference Centre in the last 40 years. Br J Haematol 2022; 198:912-915. [DOI: 10.1111/bjh.18106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Cristina Vercellati
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Anna Zaninoni
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Anna P. Marcello
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Elisa Fermo
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Bruno Fattizzo
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Juri A. Giannotta
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Paola Bianchi
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Alberto Zanella
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Wilma Barcellini
- Hematology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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39
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Chueh HW, Kim N. Molecular genetic testing enabled the diagnosis of otherwise undiagnosable cases of pyruvate kinase deficiency. Pediatr Hematol Oncol 2022; 39:166-173. [PMID: 34281465 DOI: 10.1080/08880018.2021.1950877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The gold standard for the diagnosis of pyruvate kinase (PK) deficiency, the most frequent red blood cell enzymopathy, is an enzymatic activity assay. However, this assay is rather unreliable in a clinical setting, often leading to misdiagnosis or missed diagnosis. This report presented the cases of two patients diagnosed with PK deficiency using molecular genetic testing, even though conventional laboratory tests, including the PK activity assay, failed to detect any abnormalities. Genetic analysis of the patients and their asymptomatic parents revealed the presence of variants in both alleles of the PKLR gene that were assessed as "likely pathogenic" or "pathogenic" in the form of compound heterozygotes. One of the mutations detected was common in both patients. Our results suggested that genetic testing might be required for the reliable diagnosis of suspected congenital hemolytic anemia cases displaying atypical presentation.
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Affiliation(s)
- Hee Won Chueh
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Namhee Kim
- Department of Laboratory Medicine, Donga-A University College of Medicine, Busan, Republic of Korea
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40
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Schwartz JD, Barcellini W, Grace RF, Bianchi P, Zanella A, López Lorenzo JL, Sevilla J, Shah AJ, Glader B, Nicoletti E, Navarro Ordoñez S, Segovia JC. Who should be eligible for gene therapy clinical trials in red blood cell pyruvate kinase deficiency (PKD)?: Toward an expanded definition of severe PKD. Am J Hematol 2022; 97:E120-E125. [PMID: 34989415 PMCID: PMC9305868 DOI: 10.1002/ajh.26458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 01/19/2023]
Affiliation(s)
| | - Wilma Barcellini
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit Milan Italy
| | - Rachel F. Grace
- Dana‐Farber/Boston Children's Cancer and Blood Disorders Center Harvard Medical School Boston Massachusetts USA
| | - Paola Bianchi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit Milan Italy
| | - Alberto Zanella
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit Milan Italy
| | - José Luis López Lorenzo
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz (IIS‐FJD), Hospital Universitario Fundación Jiménez Díaz Madrid Spain
| | - Julián Sevilla
- Hospital Infantil Universitario Niño Jesús (HIUNJ), Fundación para la Investigación Biomédica HIUNJ Madrid Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) Madrid Spain
| | - Ami J. Shah
- Lucile Packard Children's Hospital Stanford University School of Medicine Stanford California USA
| | - Bertil Glader
- Lucile Packard Children's Hospital Stanford University School of Medicine Stanford California USA
| | | | - Susana Navarro Ordoñez
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) Madrid Spain
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT) Madrid Spain
| | - José Carlos Segovia
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) Madrid Spain
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT) Madrid Spain
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41
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Fawaz N, Beshlawi I, Alqasim A, Zachariah M, Russo R, Andolfo I, Gambale A, Pathare A, Iolascon A. Novel PKLR missense mutation (A300P) causing pyruvate kinase deficiency in an Omani Kindred-PK deficiency masquerading as congenital dyserythropoietic anemia. Clin Case Rep 2022; 10:e05315. [PMID: 35154711 PMCID: PMC8819580 DOI: 10.1002/ccr3.5315] [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: 11/01/2021] [Revised: 12/28/2021] [Accepted: 01/02/2022] [Indexed: 01/19/2023] Open
Abstract
We report herein a child with transfusion-dependent chronic anemia, the cause of which was difficult to establish because of his transfusion dependency. The clinical and laboratory features suggested a chronic nonspherocytic hemolytic anemia (CNSHA) with bone marrow features suggestive of congenital dyserythropoietic anemia (CDA). DNA studies, however, revealed the underlying condition to be due to a novel mutation in the PKLR gene responsible for pyruvate kinase deficiency (PKD). Molecular investigations by a targeted next-generation sequencing (t-NGS) using a custom panel of 71 genes involved in the red blood cell (RBC) disorders revealed that the patient was homozygous for a novel missense mutation c.898G>C, p.Ala300Pro, whereas both his parents were heterozygous for the same mutation.
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Affiliation(s)
- Naglaa Fawaz
- Department of HematologyCollege of Medicine and Health SciencesSultan Qaboos UniversityMuscatOman
- Department of HematologySultan Qaboos University HospitalMuscatOman
| | - Ismail Beshlawi
- Department of HematologySultan Qaboos University HospitalMuscatOman
| | | | - Mathew Zachariah
- Department of HematologySultan Qaboos University HospitalMuscatOman
| | - Roberta Russo
- Dipartimento di Medicina Molecolare e Biotecnologie MedicheUniversità di Napoli Federico IINapoliItaly
- CEINGE Biotecnologie AvanzateNapoliItaly
| | - Immacolata Andolfo
- Dipartimento di Medicina Molecolare e Biotecnologie MedicheUniversità di Napoli Federico IINapoliItaly
- CEINGE Biotecnologie AvanzateNapoliItaly
| | - Antonella Gambale
- Dipartimento di Medicina Molecolare e Biotecnologie MedicheUniversità di Napoli Federico IINapoliItaly
- CEINGE Biotecnologie AvanzateNapoliItaly
| | - Anil Pathare
- Department of HematologySultan Qaboos University HospitalMuscatOman
| | - Achille Iolascon
- Dipartimento di Medicina Molecolare e Biotecnologie MedicheUniversità di Napoli Federico IINapoliItaly
- CEINGE Biotecnologie AvanzateNapoliItaly
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42
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Kim M, Lee SY, Kim N, Lee J, Kim DS, Park J, Cho YG. Case report: Compound heterozygosity in PKLR gene with a large exon deletion and a novel rare p.Gly536Asp variant as a cause of severe pyruvate kinase deficiency. Front Pediatr 2022; 10:1022980. [PMID: 36533240 PMCID: PMC9752143 DOI: 10.3389/fped.2022.1022980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/17/2022] [Indexed: 12/05/2022] Open
Abstract
Red cell pyruvate kinase (PK) deficiency is the most common cause of hereditary nonspherocytic hemolytic anemia and the most frequent enzyme abnormality of the glycolytic pathway. To the best of our knowledge, this is the first Korean PK deficiency study that analyzes copy number variation (CNV) using next-generation sequencing (NGS). A 7-year-old girl with jaundice was admitted for evaluation of a persistent hemolytic anemia. The proband appeared chronically ill, showing a yellowish skin color, icteric sclera, hepatomegaly, and splenomegaly on physical examination. Sequence variants and CNV generated from NGS data were estimated to determine if there was a potential genetic cause. As a result, compound heterozygosity in the PKLR gene for a large exon deletion between exon 3 and exon 9 accompanied with a novel rare p.Gly536Asp variant located on exon 10 was identified as a cause of severe PK deficiency in the proband. The PK activity of the proband had been measured at the time of day 1, 21, and 28 after receiving transfusion to indirectly assume the effect of the transfused blood, and the results were 100.9%, 73.0%, and 48.5%, compared with average of normal controls, respectively. Our report emphasizes the need to perform complete CNV analysis of NGS data and gene dosage assays such as multiplex ligation-dependent probe amplification to evaluate large deletions or duplications/insertions of the PKLR gene in patients with suspected PK deficiency.
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Affiliation(s)
- Minsun Kim
- Department of Pediatrics, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
| | - Seung Yeob Lee
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Namsu Kim
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Jaehyeon Lee
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Dal Sik Kim
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Joonhong Park
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Yong Gon Cho
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
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43
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Al-Samkari H, van Beers EJ. Mitapivat, a novel pyruvate kinase activator, for the treatment of hereditary hemolytic anemias. Ther Adv Hematol 2021; 12:20406207211066070. [PMID: 34987744 PMCID: PMC8721383 DOI: 10.1177/20406207211066070] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/27/2021] [Indexed: 01/19/2023] Open
Abstract
Mitapivat (AG-348) is a novel, first-in-class oral small molecule allosteric activator of the pyruvate kinase enzyme. Mitapivat has been shown to significantly upregulate both wild-type and numerous mutant forms of erythrocyte pyruvate kinase (PKR), increasing adenosine triphosphate (ATP) production and reducing levels of 2,3-diphosphoglycerate. Given this mechanism, mitapivat has been evaluated in clinical trials in a wide range of hereditary hemolytic anemias, including pyruvate kinase deficiency (PKD), sickle cell disease, and the thalassemias. The clinical development of mitapivat in adults with PKD is nearly complete, with the completion of two successful phase III clinical trials demonstrating its safety and efficacy. Given these findings, mitapivat has the potential to be the first approved therapeutic for PKD. Mitapivat has additionally been evaluated in a phase II trial of patients with alpha- and beta-thalassemia and a phase I trial of patients with sickle cell disease, with findings suggesting safety and efficacy in these more common hereditary anemias. Following these successful early-phase trials, two phase III trials of mitapivat in thalassemia and a phase II/III trial of mitapivat in sickle cell disease are beginning worldwide. Promising preclinical studies have additionally been done evaluating mitapivat in hereditary spherocytosis, suggesting potential efficacy in erythrocyte membranopathies as well. With convenient oral dosing and a safety profile comparable with placebo in adults with PKD, mitapivat is a promising new therapeutic for several hereditary hemolytic anemias, including those without any currently US Food and Drug Administration (FDA) or European Medicines Agency (EMA)-approved drug therapies. This review discusses the preclinical studies, pharmacology, and clinical trials of mitapivat.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 118, Office 112, Boston, MA 02114, USA
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44
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Sivasankaran M, Reddy VK, Kumar V, Munirathnam D. Hereditary Non-Spherocytic Hemolytic Anemia (HNSHA): Four Children with Rare Hereditary Red Cell Enzymopathies. Indian Pediatr 2021. [PMID: 34636333 PMCID: PMC8549597 DOI: 10.1007/s13312-021-2339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Meena Sivasankaran
- Department of Pediatric Haemato-Oncology and Bone Marrow Transplantation, Kanchi Kamakoti CHILD Trust Hopsital, Numgambakkam, Chennai, Tamil Nadu.
| | - Vamsi Krishna Reddy
- Department of Pediatrics, Kanchi Kamakoti CHILD Trust Hopsital, Numgambakkam, Chennai, Tamil Nadu
| | - Vimal Kumar
- Department of Pediatric Haemato-Oncology and Bone Marrow Transplantation, Kanchi Kamakoti CHILD Trust Hopsital, Numgambakkam, Chennai, Tamil Nadu
| | - Deenadayalan Munirathnam
- Department of Pediatric Haemato-Oncology and Bone Marrow Transplantation, Kanchi Kamakoti CHILD Trust Hopsital, Numgambakkam, Chennai, Tamil Nadu
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45
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Confounding factors in the diagnosis and clinical course of rare congenital hemolytic anemias. Orphanet J Rare Dis 2021; 16:415. [PMID: 34627331 PMCID: PMC8501562 DOI: 10.1186/s13023-021-02036-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/19/2021] [Indexed: 01/19/2023] Open
Abstract
Congenital hemolytic anemias (CHAs) comprise defects of the erythrocyte membrane proteins and of red blood cell enzymes metabolism, along with alterations of erythropoiesis. These rare and heterogeneous conditions may generate several difficulties from the diagnostic point of view. Membrane defects include hereditary spherocytosis and elliptocytosis, and the group of hereditary stomatocytosis; glucose-6-phosphate dehydrogenase and pyruvate kinase, are the most common enzyme deficiencies. Among ultra-rare forms, it is worth reminding other enzyme defects (glucosephosphate isomerase, phosphofructokinase, adenylate kinase, triosephosphate isomerase, phosphoglycerate kinase, hexokinase, and pyrimidine 5′-nucleotidase), and congenital dyserythropoietic anemias. Family history, clinical findings (anemia, hemolysis, splenomegaly, gallstones, and iron overload), red cells morphology, and biochemical tests are well recognized diagnostic tools. Molecular findings are increasingly used, particularly in recessive and de novo cases, and may be fundamental in unraveling the diagnosis. Notably, several confounders may further challenge the diagnostic workup, including concomitant blood loss, nutrients deficiency, alterations of hemolytic markers due to other causes (alloimmunization, infectious agents, rare metabolic disorders), coexistence of other hemolytic disorders (autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, etc.). Additional factors to be considered are the possible association with bone marrow, renal or hepatic diseases, other causes of iron overload (hereditary hemochromatosis, hemoglobinopathies, metabolic diseases), and the presence of extra-hematological signs/symptoms. In this review we provide some instructive clinical vignettes that highlight the difficulties and confounders encountered in the diagnosis and clinical management of CHAs.
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46
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Van Dooijeweert B, Broeks MH, Verhoeven-Duif NM, Van Beers EJ, Nieuwenhuis EES, Van Solinge WW, Bartels M, Jans JJ, Van Wijk R. Untargeted metabolic profiling in dried blood spots identifies disease fingerprint for pyruvate kinase deficiency. Haematologica 2021; 106:2720-2725. [PMID: 33054133 PMCID: PMC8485668 DOI: 10.3324/haematol.2020.266957] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Indexed: 01/19/2023] Open
Abstract
The diagnostic evaluation and clinical characterization of rare hereditary anemia (RHA) is to date still challenging. In particular, there is little knowledge on the broad metabolic impact of many of the molecular defects underlying RHA. In this study we explored the potential of untargeted metabolomics to diagnose a relatively common type of RHA: Pyruvate Kinase Deficiency (PKD). In total, 1903 unique metabolite features were identified in dried blood spot samples from 16 PKD patients and 32 healthy controls. A metabolic fingerprint was identified using a machine learning algorithm, and subsequently a binary classification model was designed. The model showed high performance characteristics (AUC 0.990, 95%CI 0.981-0.999) and an accurate class assignment was achieved for all newly added control (13) and patient samples (6), with the exception of one patient (accuracy 94%). Important metabolites in the metabolic fingerprint included glycolytic intermediates, polyamines and several acyl carnitines. In general, the application of untargeted metabolomics in dried blood spots is a novel functional tool that holds promise for diagnostic stratification and studies on disease pathophysiology in RHA.
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Affiliation(s)
- Birgit Van Dooijeweert
- Central Diagnostic Laboratory-Research, University Medical Center Utrecht, Utrecht, The Netherlands.; Department of Pediatric Hematology, University Medical Center Utrecht, Utrecht.
| | - Melissa H Broeks
- Section Metabolic Diagnostics, Department of Genetics, University Medical Center Utrecht, Utrecht
| | - Nanda M Verhoeven-Duif
- Section Metabolic Diagnostics, Department of Genetics, University Medical Center Utrecht, Utrecht
| | | | | | - Wouter W Van Solinge
- Central Diagnostic Laboratory-Research, University Medical Center Utrecht, Utrecht
| | - Marije Bartels
- Department of Pediatric Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.; Van Creveldkliniek, University Medical Center Utrecht, Utrecht
| | - Judith J Jans
- Section Metabolic Diagnostics, Department of Genetics, University Medical Center Utrecht, Utrecht
| | - Richard Van Wijk
- Central Diagnostic Laboratory-Research, University Medical Center Utrecht, Utrecht
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48
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Morado M, Villegas AM, de la Iglesia S, Martínez-Nieto J, Del Orbe Barreto R, Beneitez D, Salido E. [Consensus document for the diagnosis and treatment of pyruvate kinase deficiency]. Med Clin (Barc) 2021; 157:253.e1-253.e8. [PMID: 33431182 DOI: 10.1016/j.medcli.2020.10.018] [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: 06/17/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase (PK) deficiency is the second most frequent enzymopathy and the most common cause of chronic hereditary non-spherocytic haemolytic anaemia. Its global prevalence is underestimated due to low clinical suspicion of mild cases, associated with difficulties in the performance and interpretation of PK enzymatic activity assays. With the advent of next generation sequencing techniques, a better diagnostic approach is achieved. Treatment remains based on red blood cell transfusions and splenectomy, with special attention to iron overload, not only in transfusion-dependent patients. Nowadays, allogeneic hematopoietic stem cell transplantation is the only curative treatment, recommended only in selected cases of severely affected patients with an HLA-identical donor. Novel pharmacological and gene therapies are in clinical trials, with promising results. In this article, the Spanish Erythropathology Group reviews the current situation of PK deficiency, paying special attention to the usefulness of different diagnostic techniques and to actual and emerging treatments.
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Affiliation(s)
- Marta Morado
- Servicio de Hematología y Hemoterapia, Hospital Universitario La Paz, Madrid, España.
| | - Ana María Villegas
- Servicio de Hematología y Hemoterapia, Hospital Universitario Clínico San Carlos, Madrid, España
| | - Silvia de la Iglesia
- Servicio de Hematología y Hemoterapia, Hospital Universitario Doctor Negrín, Las Palmas de Gran Canaria, España
| | - Jorge Martínez-Nieto
- Servicio de Hematología y Hemoterapia, Hospital Universitario Clínico San Carlos, Madrid, España
| | - Rafael Del Orbe Barreto
- Servicio de Hematología y Hemoterapia, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
| | - David Beneitez
- Servicio de Hematología y Hemoterapia, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Eduardo Salido
- Servicio de Hematología y Hemoterapia, Hospital Universitario Virgen de la Arrixaca, Murcia, España
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49
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Preclinical studies of efficacy thresholds and tolerability of a clinically ready lentiviral vector for pyruvate kinase deficiency treatment. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2021; 22:350-359. [PMID: 34514027 PMCID: PMC8408550 DOI: 10.1016/j.omtm.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/23/2021] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase deficiency (PKD) is a rare autosomal recessive disorder caused by mutations in the PKLR gene. PKD is characterized by non-spherocytic hemolytic anemia of variable severity and may be fatal in some cases during early childhood. Although not considered the standard of care, allogeneic stem cell transplantation has been shown as a potentially curative treatment, limited by donor availability, toxicity, and incomplete engraftment. Preclinical studies were conducted to define conditions to enable consistent therapeutic reversal, which were based on our previous data on lentiviral gene therapy for PKD. Improvement of erythroid parameters was identified by the presence of 20%–30% healthy donor cells. A minimum vector copy number (VCN) of 0.2−0.3 was required to correct PKD when corrected cells were transplanted in a mouse model for PKD. Biodistribution and pharmacokinetics studies, with the aim of conducting a global gene therapy clinical trial for PKD patients (RP-L301-0119), demonstrated that genetically corrected cells do not confer additional side effects. Moreover, a clinically compatible transduction protocol with mobilized peripheral blood CD34+ cells was optimized, thus facilitating the efficient transduction on human cells capable of repopulating the hematopoiesis of immunodeficient mice. We established conditions for a curative lentiviral vector gene therapy protocol for PKD.
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Clinically relevant gene editing in hematopoietic stem cells for the treatment of pyruvate kinase deficiency. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2021; 22:237-248. [PMID: 34485608 PMCID: PMC8399088 DOI: 10.1016/j.omtm.2021.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase deficiency (PKD), an autosomal-recessive disorder, is the main cause of chronic non-spherocytic hemolytic anemia. PKD is caused by mutations in the pyruvate kinase, liver and red blood cell (PKLR) gene, which encodes for the erythroid pyruvate kinase protein (RPK). RPK is implicated in the last step of anaerobic glycolysis in red blood cells (RBCs), responsible for the maintenance of normal erythrocyte ATP levels. The only curative treatment for PKD is allogeneic hematopoietic stem and progenitor cell (HSPC) transplant, associated with a significant morbidity and mortality, especially relevant in PKD patients. Here, we address the correction of PKD through precise gene editing at the PKLR endogenous locus to keep the tight regulation of RPK enzyme during erythropoiesis. We combined CRISPR-Cas9 system and donor recombinant adeno-associated vector (rAAV) delivery to build an efficient, safe, and clinically applicable system to knock in therapeutic sequences at the translation start site of the RPK isoform in human hematopoietic progenitors. Edited human hematopoietic progenitors efficiently reconstituted human hematopoiesis in primary and secondary immunodeficient mice. Erythroid cells derived from edited PKD-HSPCs recovered normal ATP levels, demonstrating the restoration of RPK function in PKD erythropoiesis after gene editing. Our gene-editing strategy may represent a lifelong therapy to correct RPK functionality in RBCs for PKD patients.
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