Treatment of iron overload in myelodysplastic syndromes and other bone marrow failure syndromes

Abstract

Iron is essential to maintain cellular homeostasis, such as hemoglobin synthesis, mitochondrial respiratory chain formation, DNA replication, DNA demethylation, and histone demethylation. In addition, iron acts as a catalyst to produce reactive oxygen species, including hydroxyl radicals, which induce 8-OHdG production and DNA double strand breaks. Hence, the total body iron level should be strictly regulated. Recently, hepatic hepcidin was found to inhibit iron absorption from the gastrointestinal tract, and hepcidin production is reduced by erythroid factors, such as growth differentiation factor 15 (GDF15) and erythroferrone. Systemic iron kinetics seem to be regulated by cooperation among the liver, gastrointestinal tract, and hematopoietic tissues. However, this cooperation could be disturbed in bone marrow failure syndrome (BMFS). In some anemic disorders, such as β-thalassemia, and some categories of MDS, GDF15 or erythroferrone were overproduced and promoted iron absorption. Frequent blood transfusions rapidly increase iron accumulation in the body and eventually result in irreversible organ damage, such as heart failure. Therefore, the introduction of an early intervention to improve iron overload in BMFS is necessary. In recent years, oral chelators have been introduced for clinical use. Erythropoiesis-stimulating agents and thrombopoietin receptor agonists could also improve refractory anemia or BMFS and improve iron overload.