1
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Liao R, Bresnick EH. Endogenous small molecule effectors in GATA transcription factor mechanisms governing biological and pathological processes. Exp Hematol 2024:104252. [PMID: 38876253 DOI: 10.1016/j.exphem.2024.104252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
Transcriptional mechanisms establish and maintain complex genetic and protein networks to control cell state transitions. The hematopoietic transcription factor GATA1 is a master regulator of erythropoiesis and megakaryopoiesis, and human GATA1genetic variants cause anemia and megakaryoblastic leukemia. Multiomic analyses revealed that GATA1 controls expression of transporters and metabolic enzymes that dictate intracellular levels of endogenous small molecules, including heme, metal ions, and sphingolipids. Besides its canonical function as a hemoglobin component, heme facilitates or antagonizes GATA1 function to regulate erythropoiesis via mechanisms dependent or independent of the heme-binding transcription factor BTB domain and CNC homology 1 (BACH1). GATA1 regulates the expression of genes encoding heme biosynthetic enzymes and BACH1. GATA1 maintains homeostasis of bioactive ceramides during erythroid differentiation by regulating genes encoding sphingolipid metabolic enzymes. Disrupting ceramide homeostasis impairs critical cytokine signaling and is detrimental to erythroid cells. During erythroid maturation, GATA1 induces a zinc transporter switch that favors export versus import, thus dictating the intracellular zinc level, erythroblast survival, and differentiation. In aggregate, these studies support an emerging paradigm in which GATA factor-dependent transcriptional mechanisms control the intracellular levels of endogenous small molecules and small molecule-dependent feedback loops that serve as vital effectors of transcription factor activity, genome function, and cell state transitions.
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Affiliation(s)
- Ruiqi Liao
- Wisconsin Blood Cancer Research Institute, Department of Cell and Regenerative Biology, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Emery H Bresnick
- Wisconsin Blood Cancer Research Institute, Department of Cell and Regenerative Biology, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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2
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Wise TJ, Ott ME, Joseph MS, Welsby IJ, Darrow CC, McMahon TJ. Modulation of the allosteric and vasoregulatory arms of erythrocytic oxygen transport. Front Physiol 2024; 15:1394650. [PMID: 38915775 PMCID: PMC11194670 DOI: 10.3389/fphys.2024.1394650] [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] [Received: 03/01/2024] [Accepted: 04/24/2024] [Indexed: 06/26/2024] Open
Abstract
Efficient distribution of oxygen (O2) to the tissues in mammals depends on the evolved ability of red blood cell (RBC) hemoglobin (Hb) to sense not only O2 levels, but metabolic cues such as pH, PCO2, and organic phosphates, and then dispense or take up oxygen accordingly. O2 delivery is the product of not only oxygen release from RBCs, but also blood flow, which itself is also governed by vasoactive molecular mediators exported by RBCs. These vascular signals, including ATP and S-nitrosothiols (SNOs) are produced and exported as a function of the oxygen and metabolic milieu, and then fine-tune peripheral metabolism through context-sensitive vasoregulation. Emerging and repurposed RBC-oriented therapeutics can modulate either or both of these allosteric and vasoregulatory activities, with a single molecule or other intervention influencing both arms of O2 transport in some cases. For example, organic phosphate repletion of stored RBCs boosts the negative allosteric effector 2,3 biphosphoglycerate (BPG) as well as the anti-adhesive molecule ATP. In sickle cell disease, aromatic aldehydes such as voxelotor can disfavor sickling by increasing O2 affinity, and in newer generations, these molecules have been coupled to vasoactive nitric oxide (NO)-releasing adducts. Activation of RBC pyruvate kinase also promotes a left shift in oxygen binding by consuming and lowering BPG, while increasing the ATP available for cell health and export on demand. Further translational and clinical investigation of these novel allosteric and/or vasoregulatory approaches to modulating O2 transport are expected to yield new insights and improve the ability to correct or compensate for anemia and other O2 delivery deficits.
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Affiliation(s)
- Thomas J. Wise
- Duke University School of Medicine, Durham, NC, United States
| | - Maura E. Ott
- Duke University School of Medicine, Durham, NC, United States
| | - Mahalah S. Joseph
- Duke University School of Medicine, Durham, NC, United States
- Florida International University School of Medicine, Miami, FL, United States
| | - Ian J. Welsby
- Duke University School of Medicine, Durham, NC, United States
| | - Cole C. Darrow
- Duke University School of Medicine, Durham, NC, United States
| | - Tim J. McMahon
- Duke University School of Medicine, Durham, NC, United States
- Durham VA Health Care System, Durham, NC, United States
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3
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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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4
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van Dijk MJ, Rab MAE, van Oirschot BA, Bos J, Derichs C, Rijneveld AW, Cnossen MH, Nur E, Biemond BJ, Bartels M, Jans JJM, van Solinge WW, Schutgens REG, van Wijk R, van Beers EJ. One-year safety and efficacy of mitapivat in sickle cell disease: follow-up results of a phase 2, open-label study. Blood Adv 2023; 7:7539-7550. [PMID: 37934880 PMCID: PMC10761354 DOI: 10.1182/bloodadvances.2023011477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 11/09/2023] Open
Abstract
Targeting the primary pathogenic event of sickle cell disease (SCD), the polymerization of sickle hemoglobin (HbS), may prevent downstream clinical events. Mitapivat, an oral pyruvate kinase (PK) activator, has therapeutic potential by increasing adenosine triphosphate (ATP) and decreasing 2,3-diphosphoglycerate (2,3-DPG), a glycolytic red blood cell (RBC) intermediate. In the previously reported 8-week dose-finding period of this phase 2, investigator-initiated, open-label study, mitapivat was well tolerated and showed efficacy in SCD. Here, the 1-year fixed-dose extension period is reported in which 9 of 10 included patients (90%) aged ≥16 years with SCD (HbSS, HbS/β0, or HbS/β+) continued with mitapivat. Mostly mild treatment-emergent adverse events (AEs) (most commonly, transaminase increase and headache) were still reported. Apart from the reported nontreatment-related serious AE (SAE) of a urinary tract infection in the dose-finding period, 1 nontreatment-related SAE occurred in the fixed-dose extension period in a patient who died of massive pulmonary embolism due to COVID-19. Importantly, sustained improvement in Hb level (mean increase, 1.1 ± 0.7 g/dL; P = .0014) was seen, which was accompanied by decreases in markers of hemolysis. In addition, the annualized rate of vaso-occlusive events reduced significantly from a historic baseline of 1.33 ± 1.32 to 0.64 ± 0.87 (P = .0489) when combining the dose-finding period and fixed-dose extension period. Cellularly, the ATP:2,3-DPG ratio and Hb-oxygen affinity significantly increased and RBC sickling (point of sickling) nonsignificantly reduced. Overall, this study demonstrated 1-year safety and efficacy of treatment with mitapivat in SCD, supporting further evaluation in ongoing phase 2/3 study (RISE UP, NCT05031780). This trial was registered at https://www.clinicaltrialsregister.eu/ as NL8517 and EudraCT 2019-003438-18.
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Affiliation(s)
- Myrthe J. van Dijk
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Minke A. E. Rab
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Brigitte A. van Oirschot
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jennifer Bos
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cleo Derichs
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anita W. Rijneveld
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - Bart J. Biemond
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije Bartels
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Judith J. M. Jans
- Section Metabolic Diagnostics, Department of Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter W. van Solinge
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E. G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard van Wijk
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eduard J. van Beers
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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5
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Xu JZ. Pyruvate kinase activators: targeting red cell metabolism in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:107-113. [PMID: 38066891 PMCID: PMC10727103 DOI: 10.1182/hematology.2023000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Hemoglobin S (HbS) polymerization, red blood cell (RBC) sickling, chronic anemia, and vaso-occlusion are core to sickle cell disease (SCD) pathophysiology. Pyruvate kinase (PK) activators are a novel class of drugs that target RBC metabolism by reducing the buildup of the glycolytic intermediate 2,3-diphosphoglycerate (2,3-DPG) and increasing production of adenosine triphosphate (ATP). Lower 2,3-DPG level is associated with an increase in oxygen affinity and reduction in HbS polymerization, while increased RBC ATP may improve RBC membrane integrity and survival. There are currently 3 PK activators in clinical development for SCD: mitapivat (AG-348), etavopivat (FT-4202), and the second-generation molecule AG-946. Preclinical and clinical data from these 3 molecules demonstrate the ability of PK activators to lower 2,3-DPG levels and increase ATP levels in animal models and patients with SCD, as well as influence a number of potential pathways in SCD, including hemoglobin oxygen affinity, RBC sickling, RBC deformability, RBC hydration, inflammation, oxidative stress, hypercoagulability, and adhesion. Furthermore, early-phase clinical trials of mitapivat and etavopivat have demonstrated the safety and tolerability of PK activators in patients with SCD, and phase 2/3 trials for both drugs are ongoing. Additional considerations for this novel therapeutic approach include the balance between increasing hemoglobin oxygen affinity and tissue oxygen delivery, the cost and accessibility of these drugs, and the potential of multimodal therapy with existing and novel therapies targeting different disease mechanisms in SCD.
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Affiliation(s)
- Julia Z. Xu
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
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6
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van Dijk MJ, de Wilde JRA, Bartels M, Kuo KHM, Glenthøj A, Rab MAE, van Beers EJ, van Wijk R. Activation of pyruvate kinase as therapeutic option for rare hemolytic anemias: Shedding new light on an old enzyme. Blood Rev 2023; 61:101103. [PMID: 37353463 DOI: 10.1016/j.blre.2023.101103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023]
Abstract
Novel developments in therapies for various hereditary hemolytic anemias reflect the pivotal role of pyruvate kinase (PK), a key enzyme of glycolysis, in red blood cell (RBC) health. Without PK catalyzing one of the final steps of the Embden-Meyerhof pathway, there is no net yield of adenosine triphosphate (ATP) during glycolysis, the sole source of energy production required for proper RBC function and survival. In hereditary hemolytic anemias, RBC health is compromised and therefore lifespan is shortened. Although our knowledge on glycolysis in general and PK function in particular is solid, recent advances in genetic, molecular, biochemical, and metabolic aspects of hereditary anemias have improved our understanding of these diseases. These advances provide a rationale for targeting PK as therapeutic option in hereditary hemolytic anemias other than PK deficiency. This review summarizes the knowledge, rationale, (pre)clinical trials, and future advances of PK activators for this important group of rare diseases.
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Affiliation(s)
- Myrthe J van Dijk
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jonathan R A de Wilde
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marije Bartels
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Andreas Glenthøj
- Danish Red Blood Center, Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Minke A E Rab
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Hematology, Erasmus Medical Center Rotterdam, the Netherlands
| | - Eduard J van Beers
- Center for Benign Hematology, Thrombosis and Hemostasis - Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Richard van Wijk
- Department of Central Diagnostic Laboratory - Research, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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7
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Piel FB, Rees DC, DeBaun MR, Nnodu O, Ranque B, Thompson AA, Ware RE, Abboud MR, Abraham A, Ambrose EE, Andemariam B, Colah R, Colombatti R, Conran N, Costa FF, Cronin RM, de Montalembert M, Elion J, Esrick E, Greenway AL, Idris IM, Issom DZ, Jain D, Jordan LC, Kaplan ZS, King AA, Lloyd-Puryear M, Oppong SA, Sharma A, Sung L, Tshilolo L, Wilkie DJ, Ohene-Frempong K. Defining global strategies to improve outcomes in sickle cell disease: a Lancet Haematology Commission. Lancet Haematol 2023; 10:e633-e686. [PMID: 37451304 DOI: 10.1016/s2352-3026(23)00096-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Frédéric B Piel
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - David C Rees
- Department of Paediatric Haematology, King's College London, King's College Hospital, London, UK
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence for Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Obiageli Nnodu
- Department of Haematology and Blood Transfusion, College of Health Sciences and Centre of Excellence for Sickle Cell Disease Research and Training, University of Abuja, Abuja, Nigeria
| | - Brigitte Ranque
- Department of Internal Medicine, Georges Pompidou European Hospital, Assistance Publique-Hopitaux de Paris Centre, University of Paris Cité, Paris, France
| | - Alexis A Thompson
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell E Ware
- Division of Hematology and Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, and Sickle Cell Program, American University of Beirut, Beirut, Lebanon
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Bugando Medical Centre, Mwanza, Tanzania
| | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health, Connecticut, USA
| | - Roshan Colah
- Department of Haematogenetics, Indian Council of Medical Research National Institute of Immunohaematology, Mumbai, India
| | - Raffaella Colombatti
- Pediatric Oncology Hematology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Nicola Conran
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Fernando F Costa
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Mariane de Montalembert
- Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris Centre, Paris, France
| | - Jacques Elion
- Paris Cité University and University of the Antilles, Inserm, BIGR, Paris, France
| | - Erica Esrick
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Anthea L Greenway
- Department Clinical Haematology, Royal Children's Hospital, Parkville and Department Haematology, Monash Health, Clayton, VIC, Australia
| | - Ibrahim M Idris
- Department of Hematology, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
| | - David-Zacharie Issom
- Department of Business Information Systems, School of Management, HES-SO University of Applied Sciences and Arts of Western Switzerland, Geneva, Switzerland
| | - Dipty Jain
- Department of Paediatrics, Government Medical College, Nagpur, India
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zane S Kaplan
- Department of Clinical Haematology, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Allison A King
- Departments of Pediatrics and Internal Medicine, Divisions of Pediatric Hematology and Oncology and Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - Michele Lloyd-Puryear
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Samuel A Oppong
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leon Tshilolo
- Institute of Biomedical Research/CEFA Monkole Hospital Centre and Official University of Mbuji-Mayi, Mbuji-Mayi, Democratic Republic of the Congo
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Kwaku Ohene-Frempong
- Division of Hematology, Children's Hospital of Philadelphia, Pennsylvania, USA; Sickle Cell Foundation of Ghana, Kumasi, Ghana
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8
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D’Alessandro A, Nouraie SM, Zhang Y, Cendali F, Gamboni F, Reisz JA, Zhang X, Bartsch KW, Galbraith MD, Gordeuk VR, Gladwin MT. In vivo evaluation of the effect of sickle cell hemoglobin S, C and therapeutic transfusion on erythrocyte metabolism and cardiorenal dysfunction. Am J Hematol 2023; 98:1017-1028. [PMID: 36971592 PMCID: PMC10272107 DOI: 10.1002/ajh.26923] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023]
Abstract
Despite a wealth of exploratory plasma metabolomics studies in sickle cell disease (SCD), no study to date has evaluate a large and well phenotyped cohort to compare the primary erythrocyte metabolome of hemoglobin SS, SC and transfused AA red blood cells (RBCs) in vivo. The current study evaluates the RBC metabolome of 587 subjects with sickle cell sickle cell disease (SCD) from the WALK-PHaSST clinical cohort. The set includes hemoglobin SS, hemoglobin SC SCD patients, with variable levels of HbA related to RBC transfusion events. Here we explore the modulating effects of genotype, age, sex, severity of hemolysis, and transfusion therapy on sickle RBC metabolism. Results show that RBCs from patients with Hb SS genotypes-compared to AA RBCs from recent transfusion events or SC RBCs-are characterized by significant alterations of RBC acylcarnitines, pyruvate, sphingosine 1-phosphate, creatinine, kynurenine and urate metabolism. Surprisingly, the RBC metabolism of SC RBCs is dramatically different from SS, with all glycolytic intermediates significantly elevated in SS RBCs, with the exception of pyruvate. This result suggests a metabolic blockade at the ATP-generating phosphoenolpyruvate to pyruvate step of glycolysis, which is catalyzed by redox-sensitive pyruvate kinase. Metabolomics, clinical and hematological data were collated in a novel online portal. In conclusion, we identified metabolic signatures of HbS RBCs that correlate with the degree of steady state hemolytic anemia, cardiovascular and renal dysfunction and mortality.
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Affiliation(s)
- Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
- Department of Medicine – Division of Hematology, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - S. Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pennsylvania, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pennsylvania, USA
| | - Francesca Cendali
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Fabia Gamboni
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Julie A. Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver – Anschutz Medical Campus, Aurora, CO, USA
| | - Xu Zhang
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kyle W. Bartsch
- Linda Crnic Institute for Down Syndrome, University of Colorado – Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew D. Galbraith
- Linda Crnic Institute for Down Syndrome, University of Colorado – Anschutz Medical Campus, Aurora, CO, USA
| | - Victor R. Gordeuk
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mark T Gladwin
- University of Maryland School of Medicine, University of Maryland, Baltimore, MD, USA
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9
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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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10
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D'Alessandro A, Nouraie SM, Zhang Y, Cendali F, Gamboni F, Reisz JA, Zhang X, Bartsch KW, Galbraith MD, Gordeuk VR, Gladwin MT. In vivo evaluation of the effect of sickle cell hemoglobin S, C and therapeutic transfusion on erythrocyte metabolism and cardiorenal dysfunction. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.13.528368. [PMID: 36824724 PMCID: PMC9948995 DOI: 10.1101/2023.02.13.528368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Despite a wealth of exploratory plasma metabolomics studies in sickle cell disease (SCD), no study to date has evaluate a large and well phenotyped cohort to compare the primary erythrocyte metabolome of hemoglobin SS, SC and transfused AA red blood cells (RBCs) in vivo . The current study evaluates the RBC metabolome of 587 subjects with sickle cell sickle cell disease (SCD) from the WALK-PHaSST clinical cohort. The set includes hemoglobin SS, hemoglobin SC SCD patients, with variable levels of HbA related to RBC transfusion events, and HbF related to hydroxyurea therapy. Here we explore the modulating effects of genotype, age, sex, severity of hemolysis, and hydroxyurea and transfusion therapy on sickle RBC metabolism. Data - collated in an online portal - show that the Hb SS genotype is associated with significant alterations of RBC acylcarnitines, pyruvate, sphingosine 1-phosphate, creatinine, kynurenine and urate metabolism. Surprisingly, the RBC metabolism of SC RBCs is dramatically different from SS, with all glycolytic intermediates significantly elevated in SS RBCs, with the exception of pyruvate. This result suggests a metabolic blockade at the ATP-generating phosphoenolpyruvate to pyruvate step of glycolysis, which is catalyzed by redox-sensitive pyruvate kinase. Increasing in vivo concentrations of HbA improved glycolytic flux and normalized the HbS erythrocyte metabolome. An unexpectedly limited metabolic effect of hydroxyurea and HbF was observed, possibly related to the modest induction of HbF in this cohort. The metabolic signature of HbS RBCs correlated with the degree of steady state hemolytic anemia, cardiovascular and renal dysfunction and mortality. Key points In vivo dysregulation of RBC metabolism by HbS is evaluated by metabolic profiling of 587 patients with variable HbA, HbC and HbF levels;RBC acyl-carnitines, urate, pyruvate metabolism, S1P, kynurenine relate to hemolysis and cardiorenal dysfunction, respond to transfusion.
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11
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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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12
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Quezado ZMN, Kamimura S, Smith M, Wang X, Heaven MR, Jana S, Vogel S, Zerfas P, Combs CA, Almeida LEF, Li Q, Quezado M, Horkayne-Szakaly I, Kosinski PA, Yu S, Kapadnis U, Kung C, Dang L, Wakim P, Eaton WA, Alayash AI, Thein SL. Mitapivat increases ATP and decreases oxidative stress and erythrocyte mitochondria retention in a SCD mouse model. Blood Cells Mol Dis 2022; 95:102660. [PMID: 35366607 DOI: 10.1016/j.bcmd.2022.102660] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/25/2022]
Abstract
Polymerization of deoxygenated sickle hemoglobin (HbS) leads to erythrocyte sickling. Enhancing activity of the erythrocyte glycolytic pathway has anti-sickling potential as this reduces 2,3-diphosphoglycerate (2,3-DPG) and increases ATP, factors that decrease HbS polymerization and improve erythrocyte membrane integrity. These factors can be modulated by mitapivat, which activates erythrocyte pyruvate kinase (PKR) and improves sickling kinetics in SCD patients. We investigated mechanisms by which mitapivat may impact SCD by examining its effects in the Townes SCD mouse model. Control (HbAA) and sickle (HbSS) mice were treated with mitapivat or vehicle. Surprisingly, HbSS had higher PKR protein, higher ATP, and lower 2,3-DPG levels, compared to HbAA mice, in contrast with humans with SCD, in whom 2,3-DPG is elevated compared to healthy subjects. Despite our inability to investigate 2,3-DPG-mediated sickling and hemoglobin effects, mitapivat yielded potential benefits in HbSS mice. Mitapivat further increased ATP without significantly changing 2,3-DPG or hemoglobin levels, and decreased levels of leukocytosis, erythrocyte oxidative stress, and the percentage of erythrocytes that retained mitochondria in HbSS mice. These data suggest that, even though Townes HbSS mice have increased PKR activity, further activation of PKR with mitapivat yields potentially beneficial effects that are independent of changes in sickling or hemoglobin levels.
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Affiliation(s)
- Zenaide M N Quezado
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA; Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Sayuri Kamimura
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Meghann Smith
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xunde Wang
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Michael R Heaven
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
| | - Sirsendu Jana
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
| | - Sebastian Vogel
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Patricia Zerfas
- Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, MD 20892, USA
| | - Christian A Combs
- Light Microscopy Core, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Luis E F Almeida
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Quan Li
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Martha Quezado
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Iren Horkayne-Szakaly
- Neuropathology and Ophthalmic Pathology, Joint Pathology Center, Defense Health Agency, Silver Spring, MD 20910, USA
| | | | - Shaoxia Yu
- Agios Pharmaceuticals Inc, Cambridge, MA 02139, USA
| | | | - Charles Kung
- Agios Pharmaceuticals Inc, Cambridge, MA 02139, USA
| | - Lenny Dang
- Agios Pharmaceuticals Inc, Cambridge, MA 02139, USA
| | - Paul Wakim
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - William A Eaton
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Abdu I Alayash
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration (FDA), Silver Spring, MD 20993, USA
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
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13
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Woodard KJ, Doerfler PA, Mayberry KD, Sharma A, Levine R, Yen J, Valentine V, Palmer LE, Valentine M, Weiss MJ. Limitations of mouse models for sickle cell disease conferred by their human globin transgene configurations. Dis Model Mech 2022; 15:275817. [PMID: 35793591 PMCID: PMC9277148 DOI: 10.1242/dmm.049463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/25/2022] [Indexed: 12/22/2022] Open
Abstract
We characterized the human β-like globin transgenes in two mouse models of sickle cell disease (SCD) and tested a genome-editing strategy to induce red blood cell fetal hemoglobin (HbF; α2γ2). Berkeley SCD mice contain four to 22 randomly arranged, fragmented copies of three human transgenes (HBA1, HBG2-HBG1-HBD-HBBS and a mini-locus control region) integrated into a single site of mouse chromosome 1. Cas9 disruption of the BCL11A repressor binding motif in the γ-globin gene (HBG1 and HBG2; HBG) promoters of Berkeley mouse hematopoietic stem cells (HSCs) caused extensive death from multiple double-strand DNA breaks. Long-range sequencing of Townes SCD mice verified that the endogenous Hbb genes were replaced by single-copy segments of human HBG1 and HBBS including proximal but not some distal gene-regulatory elements. Townes mouse HSCs were viable after Cas9 disruption of the HBG1 BCL11A binding motif but failed to induce HbF to therapeutic levels, contrasting with human HSCs. Our findings provide practical information on the genomic structures of two common mouse SCD models, illustrate their limitations for analyzing therapies to induce HbF and confirm the importance of distal DNA elements in human globin regulation. This article has an associated First Person interview with the first author of the paper. Editor's choice: This study describes the genomic structures of two common sickle cell disease mouse models, illustrates their limitations for analyzing some genetic therapies and confirms the importance of distal DNA elements in human globin gene regulation.
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Affiliation(s)
- Kaitly J Woodard
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.,Integrated Biomedical Sciences Program, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Phillip A Doerfler
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Kalin D Mayberry
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Rachel Levine
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Jonathan Yen
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Virginia Valentine
- Cytogenetics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Lance E Palmer
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Marc Valentine
- Cytogenetics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Mitchell J Weiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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14
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Revisiting anemia in sickle cell disease and finding the balance with therapeutic approaches. Blood 2022; 139:3030-3039. [PMID: 35587865 DOI: 10.1182/blood.2021013873] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/05/2021] [Indexed: 11/20/2022] Open
Abstract
Chronic hemolytic anemia and intermittent acute pain episodes are the 2 hallmark characteristics of sickle cell disease (SCD). Anemia in SCD not only signals a reduction of red cell mass and oxygen delivery, but also ongoing red cell breakdown and release of cell-free hemoglobin, which together contribute to a number of pathophysiological responses and play a key role in the pathogenesis of cumulative multiorgan damage. However, although anemia is clearly associated with many detrimental outcomes, it may also have an advantage in SCD in lowering risks of potential viscosity-related complications. Until recently, clinical drug development for SCD has predominantly targeted a reduction in the frequency of vaso-occlusive crises as an endpoint, but increasingly, more attention is being directed toward addressing the contribution of chronic anemia to poor outcomes in SCD. This article aims to explore the complex pathophysiology and mechanisms of anemia in SCD, as well as the need to balance the benefits of raising hemoglobin levels with the potential risks of increasing blood viscosity, in the context of the current therapeutic landscape for anemia in SCD.
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15
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Schroeder P, Fulzele K, Forsyth S, Ribadeneira MD, Guichard S, Wilker E, Marshall CG, Drake A, Fessler R, Konstantinidis DG, Seu KG, Kalfa TA. Etavopivat, a Pyruvate Kinase Activator in Red Blood Cells, for the Treatment of Sickle Cell Disease. J Pharmacol Exp Ther 2022; 380:210-219. [PMID: 35031585 DOI: 10.1124/jpet.121.000743] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022] Open
Abstract
Etavopivat is an investigational, oral, small molecule activator of erythrocyte pyruvate kinase (PKR) in development for the treatment of sickle cell disease (SCD) and other hemoglobinopathies. PKR activation is proposed to ameliorate the sickling of SCD red blood cells (RBC) through multiple mechanisms, including reduction of 2,3-diphosphoglycerate (2,3-DPG), which consequently increases hemoglobin (Hb)-oxygen affinity; increased binding of oxygen reduces HbS polymerization and sickling. In addition, PKR activation increases adenosine triphosphate (ATP) produced via glycolytic flux, which helps preserve membrane integrity and RBC deformability. We evaluated the pharmacodynamic response to etavopivat in non-human primates (NHP) and in healthy human subjects, and the effects in RBC from patients with SCD after ex vivo treatment with etavopivat. A single dose of etavopivat decreased 2,3-DPG in NHP and healthy subjects. Hb-oxygen affinity was significantly increased in healthy subjects after 24 hours. Following daily dosing of etavopivat over 5 consecutive days in NHP, ATP was increased by 38% from baseline. Etavopivat increased Hb-oxygen affinity and reduced sickling in RBC collected from SCD patients with either HbSS or HbSC disease. Collectively, these results demonstrate the ability of etavopivat to decrease 2,3-DPG and increase ATP, resulting in increased Hb-oxygen affinity and improved sickle RBC function. Etavopivat is currently being evaluated in clinical trials for the treatment of SCD. ClinicalTrials.gov identifier: NCT03815695 Significance Statement Etavopivat-a small molecule activator of the glycolytic enzyme erythrocyte pyruvate kinase -decreased 2,3-diphosphoglycerate in red blood cells (RBC) from non-human primates and healthy subjects and significantly increased hemoglobin (Hb)-oxygen affinity in healthy subjects. Using ex vivo RBC from donors with sickle cell disease (SCD) (HbSS or HbSC genotype), etavopivat increased Hb-oxygen affinity and reduced sickling under deoxygenation. Etavopivat shows promise as a treatment for SCD, that potentially might reduce vaso-occlusion and improve anemia.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Rose Fessler
- Cincinnati Children's Hospital Medical Center, United States
| | | | - Katie G Seu
- Cincinnati Children's Hospital Medical Center, United States
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16
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Forsyth S, Schroeder P, Geib J, Vrishabhendra L, Konstantinidis DG, LaSalvia K, Ribadeneira MD, Wu E, Kelly P, Kalfa TA. Safety, Pharmacokinetics, and Pharmacodynamics of Etavopivat (FT-4202), an Allosteric Activator of Pyruvate Kinase-R, in Healthy Adults: A Randomized, Placebo-Controlled, Double-Blind, First-in-Human Phase 1 Trial. Clin Pharmacol Drug Dev 2022; 11:654-665. [PMID: 35019238 PMCID: PMC9306898 DOI: 10.1002/cpdd.1058] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/21/2021] [Indexed: 11/14/2022]
Abstract
Etavopivat (FT‐4202) is an orally administered, small‐molecule allosteric activator of erythrocyte pyruvate kinase‐R (PKR) in clinical development for the treatment of sickle cell disease and other hemoglobin disorders. This randomized, placebo‐controlled, double‐blind, first‐in‐human combination single‐ascending dose and multiple‐ascending dose phase 1 trial (NCT03815695) evaluated the safety and pharmacokinetics/pharmacodynamics of etavopivat in 90 healthy adult subjects. In 4 single‐ascending dose cohorts, 8 participants were randomized 3:1 to a single oral dose of either etavopivat (n = 6) or placebo (n = 2). In four 14‐day multiple‐ascending dose cohorts, 12 participants were randomized 3:1 to 14 days of etavopivat (n = 9) or placebo (n = 3). In these studies, most treatment‐emergent adverse events were of mild severity (grade 1) and none led to study discontinuation. Etavopivat exhibited a linear and time‐independent pharmacokinetic profile (at doses ≤400 mg) and elicited the expected pharmacodynamic effects of PKR activation (decreased 2,3‐diphosphoglycerate and increased adenosine triphosphate) and evidence of improved hemoglobin‐oxygen affinity. In addition, pharmacodynamic responses were durable with effects continuing for 48 to 72 hours after the last dose, thereby supporting once‐daily dosing. Food appeared to have no clinically meaningful effects on etavopivat exposure, thus facilitating administration with or without food. In conclusion, the evaluation of etavopivat in healthy subjects demonstrated proof of mechanism (PKR activation) without significant adverse events. This study also allowed for the selection of dose levels, projected to have an acceptable safety profile and provide therapeutic benefit, for evaluation in future trials in patients with sickle cell disease.
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Affiliation(s)
| | | | - James Geib
- Forma Therapeutics, Inc., Watertown, Massachusetts, USA
| | | | | | - Kari LaSalvia
- Medpace Clinical Pharmacology Unit, Cincinnati, Ohio, USA
| | | | - Eric Wu
- Forma Therapeutics, Inc., Watertown, Massachusetts, USA
| | - Patrick Kelly
- Forma Therapeutics, Inc., Watertown, Massachusetts, USA
| | - Theodosia A Kalfa
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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17
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McMahon TJ, Darrow CC, Hoehn BA, Zhu H. Generation and Export of Red Blood Cell ATP in Health and Disease. Front Physiol 2021; 12:754638. [PMID: 34803737 PMCID: PMC8602689 DOI: 10.3389/fphys.2021.754638] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/05/2021] [Indexed: 12/16/2022] Open
Abstract
Metabolic homeostasis in animals depends critically on evolved mechanisms by which red blood cell (RBC) hemoglobin (Hb) senses oxygen (O2) need and responds accordingly. The entwined regulation of ATP production and antioxidant systems within the RBC also exploits Hb-based O2-sensitivity to respond to various physiologic and pathophysiologic stresses. O2 offloading, for example, promotes glycolysis in order to generate both 2,3-DPG (a negative allosteric effector of Hb O2 binding) and ATP. Alternatively, generation of the nicotinamide adenine dinucleotide phosphate (NADPH) critical for reducing systems is favored under the oxidizing conditions of O2 abundance. Dynamic control of ATP not only ensures the functional activity of ion pumps and cellular flexibility, but also contributes to the availability of vasoregulatory ATP that can be exported when necessary, for example in hypoxia or upon RBC deformation in microvessels. RBC ATP export in response to hypoxia or deformation dilates blood vessels in order to promote efficient O2 delivery. The ability of RBCs to adapt to the metabolic environment via differential control of these metabolites is impaired in the face of enzymopathies [pyruvate kinase deficiency; glucose-6-phosphate dehydrogenase (G6PD) deficiency], blood banking, diabetes mellitus, COVID-19 or sepsis, and sickle cell disease. The emerging availability of therapies capable of augmenting RBC ATP, including newly established uses of allosteric effectors and metabolite-specific additive solutions for RBC transfusates, raises the prospect of clinical interventions to optimize or correct RBC function via these metabolite delivery mechanisms.
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Affiliation(s)
- Timothy J McMahon
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham VA and Duke University Medical Centers, Durham, NC, United States
| | - Cole C Darrow
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham VA and Duke University Medical Centers, Durham, NC, United States
| | - Brooke A Hoehn
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham VA and Duke University Medical Centers, Durham, NC, United States
| | - Hongmei Zhu
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Durham VA and Duke University Medical Centers, Durham, NC, United States
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