Fetal Hemoglobin Synthesis Research Articles

Pomalidomide and lenalidomide regulate erythropoiesis and fetal hemoglobin production in human CD34+ cells

Sickle-cell disease (SCD) and beta thalassemia constitute worldwide public health problems. New therapies, including hydroxyurea, have attempted to augment the synthesis of fetal hemoglobin (HbF) and improve current treatment. Lenalidomide and pomalidomide are members of a class of immunomodulators used as anticancer agents. Because clinical trials have demonstrated that lenalidomide reduces or eliminates the need for transfusions in some patients with disrupted blood cell production, we investigated the effects of lenalidomide and pomalidomide on erythropoiesis and hemoglobin synthesis. We used an in vitro erythropoiesis model derived from human CD34+ progenitor cells from normal and SCD donors. We found that both compounds slowed erythroid maturation, increased proliferation of immature erythroid cells, and regulated hemoglobin transcription, resulting in potent induction of HbF without the cytotoxicity associated with other HbF inducers. When combined with hydroxyurea, pomalidomide and, to a lesser extent, lenalidomide were found to have synergistic effects on HbF upregulation. Our results elucidate what we believe to be a new mechanism of action of pomalidomide and lenalidomide and support the hypothesis that pomalidomide, used alone or in combination with hydroxyurea, may improve erythropoiesis and increase the ratio of fetal to adult hemoglobin. These findings support the evaluation of pomalidomide as an innovative new therapy for beta-hemoglobinopathies.

Modulation of Arginase Pathway by Chloroquine and Its Congener May Underlie the Enhanced Cell Commitment towards Erythroid Differentiation.

Arginase is a nitric oxide synthase-alternative pathway enzyme for L-arginine breakdown leading to biosynthesis of urea and L-ornithine. Evidence suggests that reduction of arginine bioavailability for NO production secondary to increased plasma arginase levels in sickle cell disease, may contribute to severe pathophysiological derangements and increase mortality. Recently, we showed that Chloroquine (CQ), an anti-malarial and anti-rheumatoid drug, displays a linear competitive mode of inhibition on sickle erythrocyte arginase (Iyamu et al., Brit J. Haematol, 2007: in press). Utilizing the K562 cell line as a model system in our present study, we obtained evidence of the anti-proliferative and differentiation effects of CQ and its analog, Hydroxychloroquine (OHCQ) at pharmacologically attainable concentrations (5–20μM). Specifically, CQ (IC50= 8.0 ±1.2 μM) and OHCQ (IC50 =17.0 ± 2.4 μM) inhibited K562 cell proliferation in a dose-dependent manner. This inhibitory effect was accompanied by enhanced commitment towards erythroid maturation as assessed by hemoglobinization (Iyamu et al., Exp Hematol, 2003); this was linked to a dose-dependent inhibition of arginase activity. To assess the role of the arginine-polyamine pathway in the induction of differentiation of K562 cells by CQ or OHCQ, cells were treated with 10 μM CQ or 20 μM OHCQ in the presence or absence of spermine (5μM) or spermidine (5 μM). Our results indicate that spermine and spermidine (intermediate products of the arginine polyamine pathway) partially reverted the effects of CQ and OHCQ on arginase activity. But this reversal did not affect the commitment of K562 cells towards erythroid maturation. We also show that CQ and OHCQ enhanced fetal hemoglobin (Hb F) synthesis by 3.4 and 3.2-fold (vs control), and maximally stimulated intracellular cGMP levels (as determined by immunosorbent assay) by 6.6- and 3.0-fold at 6hrs and 3hrs respectively. The induction of these macromolecules by CQ or OHCQ correlated with arginase inhibition. Again, the partial reversal of arginase activity by spermine or spermidine could not reduce the Hb F induction by CQ or OHCQ. This observation suggests that the commitment of cells towards erythroid maturation precedes the effects of spermine or spermidine on arginase activity. We further investigated the effects of 8-Bromo-cAMP (cAMP analog) on arginase activity in lipopolysaccharide (LPS)-stimulated K562 cells. The inhibitory effect of CQ on arginase was reversed in LPS-stimulated cells but this reversal of arginase activity was not observed in Bromo-cAMP-LPS- treated cells. Moreover, the moderate increase of arginase activity in LPS-treated cells in the presence of CQ failed to reduce the CQ-dependent enhancement of total hemoglobin and Hb F production. Indeed, the combination of 8-Bromo-cAMP with CQ in LPS-treated cells resulted in a significant inhibition (>35%) of arginase activity. This inhibitory effect was associated with a 3.9-fold increase of Hb F synthesis (vs CQ alone) as well as enhancement of total Hb production. This surprising observation demonstrates the possible involvement of the arginase pathway as well as additional, but yet unidentified mechanism(s). In conclusion, these observations that CQ and OHCQ may inhibit the initial step of the arginine-polyamine pathway, resulting in the enhancement of erythroid differentiation may provide a paradigm for targeted therapy of hemoglobinopathies.

A Humanized Cooley's Anemia Mouse Model.

Cooley's Anemia (CA) is a heterogeneous group of inherited disorders all marked by the complete absence of adult β-globin chains in red blood cells (RBCs). Newborns with CA are healthy because of the high level of fetal hemoglobin (HbF) present at birth. As HbF levels decline during the first year of life, the absence of functional adult β-globin genes results in a severe anemia that necessitates the initiation of regular blood transfusions for the remainder of life. CA has been difficult to study in murine models due to the lack of a human fetal hemoglobin equivalent in the mouse. This study reports a novel preclinical animal model of CA that survives solely on human fetal hemoglobin at birth and is blood transfusion dependent for life upon completion of the hemoglobin switch after birth. These humanized CA mice were generated by targeted gene replacement in embryonic stem cells of the adult mouse α-globin genes with human α-globin and the adult mouse β-globin genes with a delayed switching γδβ0-globin gene cassette. The nonfunctional human β0-globin knock-in allele contains a single G to A nucleotide mutation in the first base of intervening sequence 1. Both wild-type and hereditary persistence of fetal hemoglobin (HPFH) promoter mutations were tested in the human γ-globin knock-in allele. Heterozygous knock-in mice exhibit β thalassemia intermedia. Newborn homozygous knock-in mice express 100% human hemoglobin in their RBCs, suffer from ineffective erythropoiesis, survive from one to ten days after birth, and are blood transfusion dependent for adult life. This is the first CA mouse model that recapitulates the temporal onset of the disease in human patients. This CA disease model is useful for the study of the regulation of globin gene expression, synthesis, and switching; development of transfusion and iron chelation therapies; induction of fetal hemoglobin synthesis; and the testing of novel genetic and cell-based therapies for the correction of thalassemia.

Hypoxia alters progression of the erythroid program

Hypoxia can induce erythropoiesis through regulated increase of erythropoietin (Epo) production. We investigated the direct influence of oxygen tension (pO(2)) in the physiologic range (2-8%) on erythroid progenitor cell differentiation using cultures of adult human hematopoietic progenitor cells exposed to decreasing (20% to 2%) pO(2) and independent of variation in Epo levels. Decreases in hemoglobin (Hb)-containing cells were observed at the end of the culture period with decreasing pO(2). This is due, in part, to a reduction in cell growth and, at 2% O(2), a marked increase in cell toxicity. Analysis of the kinetics of cell differentiation showed an increase in the proportion of cells with glycophorin-A expression and Hb accumulation at physiologic pO(2). Cells were characterized by an early induction of gamma-globin expression and a delay and reduction in peak levels of beta-globin expression. Overall, fetal Hb and gamma-globin expression were increased at physiologic pO(2), but these increases were reduced at 2% O(2) as cultures become cytotoxic. At reduced pO(2), induction of Epo-receptor (Epo-R) by Epo was decreased and delayed, analogous to the delay in beta-globin induction. The oxygen-dependent reduction of Epo-R can account for the associated cytotoxicity at 2% O(2). Epo induction of erythroid transcription factors, EKLF, GATA-1, and SCL/Tal-1, was also delayed and decreased at reduced pO(2), consistent with lower levels of Epo-R and resultant Epo signaling. These changes in Epo-R and globin gene expression raise the possibility that the early increase of gamma-globin is a consequence of reduced Epo signaling and a delay in induction of erythroid transcription factors.

The Thalassemias and Related Disorders

The thalassemias, sickle cell disease, and other hemoglobinopathies represent a major group of inherited disorders of hemoglobin synthesis. The abnormal hemoglobins were reviewed in the July 2006 issue of Baylor University Medical Center Proceedings. Because of immigration patterns and population flow, these disorders are becoming increasingly more prevalent in the USA. In this article, the clinical aspects of the more common thalassemia syndromes are reviewed. For most symptomatic patients with thalassemia, there is no definite cure; only supportive management of the anemia is possible. A very limited number of patients with thalassemia may be cured by bone marrow transplantation from HLA-identical donors. Other tentative approaches to management include stimulation of fetal hemoglobin synthesis and attempts at somatic cell gene therapy. Prevention of disease transmission by carrier screening programs along with prenatal diagnosis remain of paramount importance in the reduction of these diseases worldwide.

Therapeutic Options for Patients with Severe β-Thalassemia: The Need for Globin Gene Therapy

Therapeutic Options for Patients with Severe β-Thalassemia: The Need for Globin Gene Therapy

The Role of Nitric Oxide in γ-Globin Induction by Hydroxyurea.

Hydroxyurea (HU) has been shown to induce fetal hemoglobin (HbF) synthesis through activation of the soluble guanosine cyclase/cyclic guanosine monophosphate signaling pathway. The release of NO from HU by heme iron is thought to be involved in this mechanism of HbF induction. Studies completed in sickle cell patients confirmed increased serum NO levels after oral HU therapy but NO generation in red blood cells and the effect on γ-gene transcription have not been extensively investigated. Therefore, we performed studies to quantify NO generated by HU in K562 cells and normal erythroid progenitors as a mechanism for γ-globin activation. NO levels were measured after drug treatments using the Nitric Oxide Assay Kit (Calbiochem) and γ-globin mRNA was measured using quantitative PCR. HU (100μM) increased NO 1.4 to 1.8-fold at 24–72 hrs in K562 cells compared to a 2.0 to 2.5-fold increase in NO produced by the known NO donor, deta-nonoate (DE; 400μM). NO levels were also measured in erythroid progenitors grown in liquid cultures; a 1.6-fold increase in NO was produced by 30μM HU after 48 hrs with comparable increases produced by 200μM DE. To understand the effects of HU on normal NO synthesis from L-arginine through the action of NO synthase (NOS), we performed studies with the NOS inhibitor, NG-Monomethyl-L-arginine (L-NMMA). Interestingly, HU increased NO levels 2.5-fold at 24 hrs when combined L-NMMA compared a 1.4-fold increase produced by HU alone; this pattern persisted up to 72 hrs. Parallel with these findings γ-globin activation by HU was augmented approximately 25% by L-NMMA; DE combined with L-NMMA did not produce the same effect. These data suggest a novel mechanism for NOS regulation by HU compared to DE. Subsequent studies were completed to determine if HbF synthesis could be augmented by combining NO donors since they have different mechanisms of action. HbF levels in K562 cells were measured by ELISA (Bethyl Laboratories) and normalized by total hemoglobin and protein. Treatment with HU or DE increased HbF 3.6-fold and 4.6-fold respectively; when HU was combined with DE an additive 7.6-fold increase in HbF was produced. These data confirm that HU treatment lead to NO generation in K562 cells and normal erythroid progenitors which plays a role in its mechanism of γ-globin activation. HU combined with DE had an additive effect on HbF synthesis. These findings are relevant to current research efforts to develop novel HbF inducers for therapy in sickle cell patients.

New Approaches to the Regulation of Erythropoiesis and Hematoglobin Synthesis in β-Hemoglobinopathies: Studies with the Immunomodulatory Drug CC-4047.

Sickle cell disease (SCA) and β-thalassemia constitute worldwide public health problems and new therapies are needed. Inhibition of hemoglobin S (HbS) polymerization is a major target for therapeutic approaches in SCA. New experimental therapies including hydroxyurea (HU) have attempted to augment the synthesis of fetal hemoglobin (HbF) and improve upon current treatment. Clinical trial results have demonstrated that lenalidomide (Revlimid®), recently approved by the FDA, reduces or even eliminates the need for red blood cell transfusions in some anemic myelodysplastic patients. We have examined whether CC-4047, another IMiDs® immunomodulatory drug currently under evaluation for the treatment of hematological cancers could regulate erythropoiesis and hemoglobin synthesis. For this purpose, we used an in vitro culture model to differentiate human erythroid progenitors from bone marrow or peripheral blood CD34+ cells. We demonstrate that CC-4047 is a potent inducer of HbF that synergizes with HU, the sole drug approved for SCA, during erythroid differentiation of CD34 progenitors isolated from healthy donors and patients with SCA. In addition CC-4047 modulates erythropoiesis, slowing erythroid maturation and increased proliferation of immature erythroid cells. Unlike other inducers of HbF such as HU, 5-aza-cytidine and butyrate, CC-4047 is not cytotoxic. The percentage of F-cells are increased by 2 to 3 fold with pan-cellular expression of HbF and an increase of Fetal/Adult hemoglobin ratio that are relevant for SCA. Gene expression profiling of erythroid differentiated cells shows that CC-4047 regulates specific erythroid transcription factors and genes that participate in hemoglobin synthesis, and genes involved in cell cycle and cellular differentiation. CC-4047 controls globin gene expression during erythroid differentiation by increasing the rate of γ-globin and ε-globin transcription and by inducing sustained expression of fetal and embryonic hemoglobin synthesis.Our results support the hypothesis that CC-4047, alone or in combination with certain current approved therapies comprising HU, can restore effective erythropoiesis and increase the ratio of fetal to adult hemoglobin. Moreover, CC-4047 has demonstrated anti-inflammatory and immunomodulatory effect in vivo that could help to limit the inflammatory state in sickle cell patients. In conclusion, administration of CC-4047 may represent an innovative new therapy for β-hemoglobinopathies.

Novel valproic acid derivatives with hemoglobin F inducing activity

Pharmacological induction of hemoglobin F expression may be a promising approach for the treatment of beta-thalassemia and sickle cell disease. Valproic acid, a drug frequently used for the treatment of seizure disorders, has been shown to enhance fetal hemoglobin synthesis in erythroid cells. However, this effect is only modest and requires relative high concentrations. Therefore, the drug appears not to be applicable for the treatment of beta-globin chain disorders. Here, we describe the identification of novel valproic acid derivatives with potent hemoglobin F inducing activities at concentrations that presumably can be obtained in vivo.

Understanding mechanisms of γ‐globin gene regulation to develop strategies for pharmacological fetal hemoglobin induction

The developmental regulation of gamma-globin gene expression has shaped research efforts to establish therapeutic modalities for individuals affected with sickle cell disease (SCD). Fetal hemoglobin (Hb F) synthesis is high at birth, followed by a decline to adult levels by 10 months of age. The expression of gamma-globin is controlled by a developmentally regulated transcriptional program that is recapitulated during normal erythropoiesis in the adult bone marrow. It is known that naturally occurring mutations in the gamma-gene promoters cause persistent Hb F synthesis after birth, which ameliorates symptoms in SCD by inhibiting hemoglobin S polymerization and vaso-occlusion. Several pharmacological agents have been identified over the past 2 decades that reactivate gamma-gene transcription through different cellular systems. We will review the progress made in our understanding of molecular mechanisms that control gamma-globin expression and insights gained from Hb F-inducing agents that act through signal transduction pathways.

Effect of 5-aza-2′-deoxycytidine (Dacogen) on covalent histone modifications of chromatin associated with the ɛ-, γ-, and β-globin promoters in Papio anubis

Treatment with the DNA demethylating drug 5-aza-2'-deoxycytidine (Dacogen; DAC) increased fetal hemoglobin and F cells to therapeutically significant levels in patients with sickle cell disease. To gain more insight into the mechanism of action of this drug and to increase our understanding of the relationship between DNA methylation and chromatin structure, we have determined the effect of DAC on covalent histone modifications of chromatin associated with the epsilon, gamma-, and beta-globin promoters in purified bone marrow erythroid cells of four baboons (P. anubis) pre- and posttreatment. Fetal hemoglobin increased from 6.45%+/-1.75% in pretreatment samples to 62.1%+/-7.94% following DAC. DNA methylation of three CpG sites within the epsilon-globin promoter and 5 CpG sites within the gamma-globin promoter decreased more than 50% following DAC treatment. Levels of RNA polymerase II, acetyl-histone H3, acetyl-histone H4, dimethyl-histone H3 (lys4), dimethyl-histone H3 (lys36), and dimethyl-histone H3 (lys79) associated with the epsilon-, gamma-, and beta-globin promoters were determined by chromatin immunoprecipitation of formaldehyde-fixed chromatin followed by real-time PCR. Dacogen treatment increased the association of RNA polymerase II, acetyl-histone H3, and acetyl-histone H4 with the gamma-globin promoter but did not significantly affect the association of dimethyl-histone H3 (lys4), dimethyl-histone H3 (lys36), and dimethyl-histone H3 (lys79) with the epsilon-, gamma-, and beta-globin gene promoters. These experiments illustrate the usefulness of the baboon model to investigate the mechanism of pharmacologic reactivation of fetal hemoglobin synthesis at the molecular level.

Infusion of Autologous Retrodifferentiated Stem Cells into Patients with Beta-Thalassemia

Beta-thalassemia is a genetic, red blood cell disorder affecting the beta-globin chain of the adult hemoglobin gene. This results in excess accumulation of unpaired alpha-chain gene products leading to reduced red blood cell life span and the development of severe anemia. Current treatment of this disease involves regular blood transfusion and adjunct chelation therapy to lower blood transfusion–induced iron overload. Fetal hemoglobin switching agents have been proposed to treat genetic blood disorders, such as sickle cell anemia and beta-thalassemia, in an effort to compensate for the dysfunctional form of the beta-globin chain in adult hemoglobin. The rationale behind this approach is to pair the excess normal alpha-globin chain with the alternative fetal gamma-chain to promote red blood cell survival and ameliorate the anemia. Reprogramming of differentiation in intact, mature, adult white blood cells in response to inclusion of monoclonal antibody CR3/43 has been described. This form of retrograde development has been termed “retrodifferentiation”, with the ability to re-express a variety of stem cell markers in a heterogeneous population of white blood cells. This form of reprogramming, or reontogeny, to a more pluripotent stem cell state ought to recapitulate early hematopoiesis and facilitate expression of a fetal and/or adult program of hemoglobin synthesis or regeneration on infusion and subsequent redifferentiation. Herein, the outcome of infusion of autologous retrodifferentiated stem cells (RSC) into 21 patients with beta-thalassemia is described. Over 6 months, Infusion of 3-h autologous RSC subjected to hematopoietic-conducive conditions into patients with beta-thalassemia reduced mean blood transfusion requirement, increased mean fetal hemoglobin synthesis, and significantly lowered mean serum ferritin. This was always accompanied by an increase in mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) in such patients. No adverse side effects in response to the infusion of autologous RSC were noted.This novel clinical procedure may profoundly modify the devastating course of many genetic disorders in an autologous setting, thus paving the way to harnessing pluripotency from differentiated cells to regenerate transiently an otherwise genetically degenerate tissue such as thalassemic blood.

Expression of Fetal Hemoglobin among Adult Human Erythroblasts Is Associated with an Altered Expression Pattern for the Transcription Factor c-Myb.

The c-Myb transcription factor plays a central role in regulating growth and differentiation during definitive erythropoiesis. In addition, c-Myb expression has been previously linked to GATA-1 expression and hereditary persistence of fetal hemoglobin. Here we examined a potential role for c-Myb in signaled expression of fetal hemoglobin (HbF) among primary adult human erythroblasts. Initial experiments were performed to determine the expression pattern of c-Myb under conditions of low fetal hemoglobin production (CD34 cells cultured over 14 days in media supplemented with erythropoietin (EPO) alone). Quantitative PCR performed on cells sampled on days 2, 5, 8, 11, and 14 demonstrated highly regulated c-Myb expression. A dramatic increase (>30 fold) in c-Myb mRNA was measured between days 5 and 8 as the committed progenitor cells differentiated to the proerythroblast stage. That increase was followed by a 3-fold reduction in c-Myb during terminal differentiation. Western blotting of nuclear extracts obtained on days 7 and 14 in EPO cultures corroborated with the quantitative PCR analyses. Electrophoretic mobility shift assays performed using day 7 and day 14 nuclear extracts showed a shifted major band with a c-Myb consensus probe. That major band was competed by unlabeled c-Myb probe on both days. Moreover, day 14 extracts repeatedly revealed two additional bands that were not competed suggesting the possibility of other complexes binding to the Myb motif or changes in c-Myb conformation during terminal differentiation. Chromatin immunoprecipitation assays also revealed preliminary evidence for Myb binding directly to beta globin locus. When compared to low HbF culture conditions (EPO; HbF <1%), cells grown in high HbF conditions (erythropoietin + stem cell factor + TGF-beta (EST); HbF>35%) demonstrated a distinct pattern of c-Myb expression. Relative to the low HbF conditions, high HbF expressing cells had reduced c-Myb levels on day 7 followed by increased levels on day 14. These results suggest that c-Myb possesses highly regulated patterns of expression and DNA binding during erythroid maturation. In addition, the association of changes in c-Myb expression patterns with HbF production suggests that this growth-related transcription factor may help regulate fetal hemoglobin synthesis in patients with beta-hemoglobinopathies.

Lenalidomide and Novel Immunomodulatory Drugs (IMiDs®): A New Approach to the Regulation of Erythropoiesis and Hemoglobin Synthesis in Anemia.

Clinical trial results have demonstrated that lenalidomide (Revlimid®) reduces or even eliminates the need for red blood cell transfusions in some anemic myelodysplastic patients. We have examined whether lenalidomide and Actimid™, members of a new class of immunomodulatory drugs (IMiDs®), which are currently under evaluation for the treatment of hematological cancers could regulate erythropoiesis and hemoglobin synthesis. For this purpose, we used an in vitro culture model to differentiate human erythroid progenitors from bone marrow or peripheral blood CD34+ cells. We demonstrate that lenalidomide and AztimidTM modulate erythropoiesis and increase proliferation of immature erythroid cells. In addition to the regulation of erythroid differentiation, lenalidomide and ActimidTM are potent inducers of fetal hemoglobin. Unlike other inducers of fetal hemoglobin such as 5-aza-cytidine that are cytotoxic, IMiDs® promoted survival of erythroblast cultured with known cytotoxic drug. Gene expression profiling of erythroid differentiated cells showed that IMiDs® regulate specific erythroid transcription factors and genes that participate in hemoglobin synthesis, and genes invoved in cell cycle and cellular differentiation. Globin gene expression is controlled by IMiDs® during erythroid differentiation by inducing fetal hemoglobin synthesis. Our results support the hypothesis that IMiDs® restore effective erythropoiesis in myelodysplastic patients and protect erythroid cells from the cytotoxic effect of chemotherapeutic agents. In conclusion, IMiDs® may represent an interesting new therapy for cancer-related anemia and β-hemoglobinopathies.

Thalassemia: The Continued Challenge

This overview describes the history of transfusion therapy and consequent iron overload in thalassemia. It emphasizes the importance of measurement of hepatic iron and reviews the history of chelation therapy. It briefly describes the discoveries of the genetic basis of thalassemia and the application of that knowledge in prenatal diagnosis. The review goes on to emphasize pharmaceutical efforts to induce fetal hemoglobin synthesis in thalassemic red cells and ends with a discussion of oral iron chelators, stem cell transplant, and the status of gene therapy.

Modulation of erythrocyte arginase activity in sickle cell disease patients during hydroxyurea therapy

An elevated erythrocyte arginase activity with a corresponding decrease in nitric oxide (NO) level has been implicated in the pathophysiology of sickle cell disease (SCD). Recent studies have shown that hydroxyurea (HU) increases the production of NO, which increases the soluble guanylate cyclase activity and fetal haemoglobin (HbF) synthesis. To study the effects of HU on the arginase and nitric oxide synthase (NOS) activities in SCD patients, we compared levels of arginase activity and NO metabolites in red blood cells and plasma, respectively, from 23 patients with SCD (HbSS) receiving HU therapy, with those of 12 SCD patients not receiving HU treatment. Patients on HU therapy showed significantly lower arginase activity than that of HbSS patients not on HU therapy (1.36+/-0.2 U/10(8) cells vs. 3.31+/-0.29 U/10(8) cells). NOS activity was higher in patients on HU therapy than in untreated patients (0.72+/-0.4 nmol/ml/min vs. 0.35+/-0.15 nmol/ml/min, P<0.05). Among the HU-treated patients, the decreased level of arginase activity correlated (r=0.71) with HbF level as well as the mean corpuscular haemoglobin content. These data suggest that one of the beneficial effects of HU in vivo may involve the regulation of arginase activity and a concomitant induction of NOS activity, which may lead to an increased production of NO. The outcome of this study may lead to the development of improved NO-based treatments for SCD.

Hydroxamic Acids Derivatives Induce γ Globin Gene Expression in Vivo.

We have previously shown that four hydroxamic acids: butyric and propionic hydroxamic acids, subericbishydroxamic acid (SBHA) and suberoylanilide hydroxamic acid (SAHA) are potent inhibitors of histone deacetylase and strong inducers of fetal hemoglobin expression in vitro (Exp Hematol. 31:197, 2003). In the present study we tested their effect on fetal hemoglobin synthesis in vivo. Transgenic mice carrying the human μLCR Aγ construct continue to express the human γ gene in the adult stage of development ( γ/α mRNA ratio ~ 5%, Blood. 77:1326, 1991). These mice were crossed to mice heterozygous for a thalassemia gene due to β globin gene deletion (PNAS. 92:11608, 1995). The β thalassemia/μLCR Aγ mice represent an appropriate moderately anemic animal model for testing the effects of Hb F inducers. Compounds were administered subcutaneously with a mini-osmotic pump continuously for 7days in a high and a low concentration. Concentrations were: for butyric hydroxamic acid: 500mg/kg/day/100mg/kg/day; for propionic hydroxamic acid: 500mg/kg/day/100mg/kg/day; for SAHA: 100mg/kg/day/20mg/kg/day; and for SBHA: 200mg/kg/day/40mg/kg/day. Two test groups were studied. In group 1, 70μL mice blood was drawn every other day up to 20 days; in group 2, 70μL mice blood was drawn only on days 0 and 21. Reticulocytes and F reticulocytes were measured using flow cytometry, while γ globin gene expression was quantitated by RNase protection assay. Butyric and propionate hydroxamic acids increased reticulocytes by 70.52% (from 13.96% to 23.81%) and 172.52% (from 10.34% to 28.20%) respectively. There was only small increase in reticulocytes in the mice treated with SAHA (from 13.33% to 15.36%), SBHA (from 14.24% to 16.27%) and the PBS control (11.06% to 14.11%). All the compounds increased the level of γ mRNA: butyric hydroxamate by 53.07%; propionic hydroxamate by 40.05%; SAHA by 49.87%, and SBHA by 34.05%. These results suggest first that all the hydroxamic acid derivatives we used increase fetal hemoglobin in vivo in the thalassemia animal model; second butyric and propionic hydroxanic acids are in addition inducers of in vivo erythropoiesis.

The Venezuelan Type of Nondeletional Hereditary Persistence of Fetal Hemoglobin Is Due C →T Mutation at Nucleotide -211 of the Aγ Globin Gene.

Hereditary Persistence of Fetal Hemoglobin (HPFH) is a clinically benign condition characterized by continuous synthesis of fetal hemoglobin (Hb F) in adult life without major related hematological changes. The nondeletional HPFH is characterized by hemoglobin F level between 5% and 30%, in heterozygotes state. This condition has been observed among Blacks, Italians, Greeks, English and Chinese. Two different forms are known, characterized by the type of chain involve, either Gγ or Aγ. Several point mutations in the promoter region of the Aγ globin gene have been identified in ndHPFH: −202, −198, −196, −195, −117, −114, deletion 4pb (−222 −225) and −158.The propositus is a 36 year old black female with a moderate increased level of Hb F, also her sister and her sibling had the same condition. She was discovered during studies due to the presence of splenomegaly and gastroesophageal reflux. The Hbs A, A2 and F were eluted and quantified by cation exchange high-performance liquid chromatography (HPLC-CE), using Beta Tal short program, Variant BioRad (Hercules, California, USA). DNA was isolated from peripheral blood leukocytes by a salting-out extraction procedure. The Aγ and Gγ promoters globins gene were amplified independently by PCR and the presence of the HPFH mutation was determined by denaturing gradient gel electrophoresis technique (DGGE) as previously described Gottardi et al., (1992). The Aγ promoter globin gene was sequenced in three members of the family using the BigDyeTM Terminator Cycler Sequencing Kit and the ABI PRISMTM 310 Genetic Analyzer (PE Applied Biosystems, Foster City, CQ, USA).Her hematological studies revealed Hb: 14.2 g/dl, Hcto: 41.1 %, MCV: 94.4 fl, MCHC: 34.5 fl, Hb A: 81.9 %, Hb A2: 2.1 % and Hb F: 6.3 %. The sibling hematological finding was Hb: 13.1 g/dl, Hcto: 41.8 %, MCV: 83.7 fl, MCHC: 31.3 fl, Hb A: 83.2 %, Hb A2: 3.2 % and Hb F: 5.1. The sister was Hb: 14.3 g/dl, Hcto: 46.4 %, MCV: 105.9 fl, MCHC: 30.8 fl, Hb A: 83.7 %, Hb A2: 3.3 % and Hb F: 2.7 %. No spleen enlargement was seen in the other two affected members of the family. The DGGE results in the Aγ promoter, suggested the presence of a non-deletion form of HPFH in heterozygotes state. The Aγ promoter region revealed the presence of a substitution C→T at position −211. This mutation does not modify any restriction site.To our knowledge the −211 (C→T) mutation in the Aγ promoter have not been reported previously. Since modulation of g-globin gene expression in adults could provide a therapeutic intervention in hemoglobinopathy, the study of the molecular mechanisms generating HPFH is medically relevant.

Novel Immunomodulatory Drugs (IMiDs®): A Potential, New Therapy for β-Hemoglobinopathies.

Sickle cell anemia (SCA) and β-thalassemia constitute a public health problem worldwide and new therapies are needed 1. Inhibition of hemoglobin S (HbS) polymerization is a major target for therapeutic approaches in SCA. New experimental therapies including hydroxyurea (HU) have attempted to augment the synthesis of fetal hemoglobin (HbF) and improve upon current treatment 2. We examined whether immunomodulatory analogs of thalidomide (IMiDs®) which have effects on hematopoiesis and are currently under evaluation for the treatment of hematological cancers could stimulate erythropoiesis and hemoglobin synthesis 3. Clinical trial results have demonstrated that Thalidomide and Revlimid™ reduce or even eliminate the need for red blood cell transfusions in some anemic myelodysplastic patients 4,5. We demonstrate here that CC-4047 (Actimid™) and CC-5013 (Revlimid™) are potent inducers of HbF in vitro and synergize with hydroxyurea during erythroid differentiation of CD34 progenitors isolated from human donors. In addition, we show by gene microarray profiling of CD34 differentiated cells that IMiDs® regulate specific erythroid genes that participate in hemoglobin synthesis. These results support that IMiDs®, alone or in combination with current approved therapies, can be a new approach to augment HbF synthesis, and have the potential to provide an innovative therapy for the β-hemoglobinopathies and other anemias.

The role of fetal hemoglobin–enhancing agents in thalassemia

Augmentation of fetal hemoglobin (HbF) synthesis can reduce the severity of beta-thalassemia by improving the imbalance between alpha- and non-alpha-globin chains. However, previous clinical trials of pharmacologic induction of HbF in thalassemia produced inconsistent results. Striking responses in HbF and total hemoglobin synthesis were occasionally observed, but in most patients, the increase in gamma-globin synthesis was inadequate to influence the clinical course of thalassemia. A small number of patients treated with azacytidine demonstrated a consistent response, but the development of this drug was abandoned due to concerns over toxicity. Decitabine, an analog of azacytidine, is a more potent inhibitor of DNA methyltransferase, and may be less toxic in clinical use. Trials in sickle cell anemia have confirmed that decitabine is effective in patients refractory to hydroxyurea. The clinical trials of decitabine in thalassemia must carefully evaluate the dose and route of administration, and address concerns about long-term side effects.