Refractory Iron Deficiency Anemia Research Articles

Activation of Intestinal HIF2α Ameliorates Iron-Refractory Anemia.

In clinics, hepcidin levels are elevated in various anemia-related conditions, particularly in iron-refractory anemia and in high inflammatory states that suppress iron absorption, which remains an urgent unmet medical need. To identify effective treatment options for various types of iron-refractory anemia, the potential effect of hypoxia and pharmacologically-mimetic drug FG-4592 (Roxadustat) are evaluated, a hypoxia-inducible factor (HIF)-prolyl hydroxylase (PHD) inhibitor, on mouse models of iron-refractory iron-deficiency anemia (IRIDA), anemia of inflammation and 5-fluorouracil-induced chemotherapy-related anemia. The potent protective effects of both hypoxia and FG-4592 on IRIDA as well as other 2 tested mouse cohorts are found. Mechanistically, it is demonstrated that hypoxia or FG-4592 could stabilize duodenal Hif2α, leading to the activation of Fpn transcription regardless of hepcidin levels, which in turn results in increased intestinal iron absorption and the amelioration of hepcidin-activated anemias. Moreover, duodenal Hif2α overexpression fully rescues phenotypes of Tmprss6 knockout mice, and Hif2α knockout in the gut significantly delays the recovery from 5-fluorouracil-induced anemia, which can not be rescued by FG-4592 treatment. Taken together, the findings of this study provide compelling evidence that targeting intestinal hypoxia-related pathways can serve as a potential therapeutic strategy for treating a broad spectrum of anemia, especially iron refractory anemia.

Rker-216 Reversed Microcytic Anemia in a Mouse Model of Iron Refractory Iron Deficiency Anemia

Background Iron refractory iron deficiency anemia (IRIDA) is an inherited disease caused by TMPRSS6 mutations that increase serum hepcidin and result in microcytic anemia from iron malabsorption. As hepcidin promotes ferroportin (Fpn) degradation to limit iron absorption, its production in anemia should be decreased to make up body iron deficits. In contrast to typical iron deficiency anemia that can be improved by oral iron supplementation or intravenous (IV) iron infusion, IRIDA patients tend to have no response to iron supplements and only transiently respond to iron infusion, resulting in lifelong anemia. Hepcidin is mainly regulated by the bone morphogenetic protein (BMP) pathway, in which BMP ligands activate transcription factors SMAD1/5/9 by binding to the BMP receptors, including ALK2. We previously showed that RKER-216 (m216), a research ALK2 neutralizing antibody, improved iron availability in mice with anemia of inflammation resulting from high hepcidin. Here, we explored m216 pharmacology in an IRIDA mouse model. Aim To examine 1) mechanism of action (MOA), 2) efficacy of IV iron infusion and m216-mediated iron absorption, and 3) dose response of m216 in resolving microcytic anemia in Tmprss6 knockout (KO) mice. Methods TMPRSS6 KO mice at 8-11 weeks (wk) were subcutaneously dosed with isotype control or m216 at 1 or 3 mg/kg in all studies. Mice were given a single dose for 6, 24 or 96 h in MOA and twice weekly for 9 or 21 d for efficacy studies. For IV iron, KO mice were given a single dose of iron dextran at 100 mg/kg and evaluated on day 9. Results TMPRSS6 KO mice at 8 wk had high serum hepcidin, low transferrin saturation (TSAT), and microcytic anemia as indicated by low mean corpuscular volume (MCV) and hemoglobin (Hb), key features in IRIDA. Liver SMAD1/5/9 phosphorylation, hepcidin ( Hamp) mRNA, and serum hepcidin levels were decreased similarly in KO mice dosed with 1 or 3 mg/kg of m216 for 6 h, compared to isotype controls. KO mice given both dose levels for 24 h decreased serum hepcidin by 88% and increased TSAT by 4-fold, compared to isotype mice, but only mice receiving 3 mg/kg had sustained effects by 96 h. These data suggest that m216 inhibited SMAD signaling to lower serum hepcidin, allowing more iron absorption to increase TSAT. To explore the relevance of m216 to current therapy, we compared the result of IV iron or 1 mg/kg of m216 in KO mice for 9 d. Compared to controls, liver iron, serum hepcidin, and TSAT were increased in mice given IV iron whereas mice receiving m216 exhibited reduced hepcidin with increased duodenal Fpn and TSAT, confirming target engagement. Although TSAT was higher in mice dosed with m216 compared to IV iron, anemia improved similarly (1-2 g/dl in Hb; 2 fl in MCV) in these two groups. These data suggest that despite high hepcidin, IV iron improved anemia via increased TSAT; however, the relationship between TSAT and anemia recovery is not always linear. We next examined KO mice dosed with m216 at 1 or 3 mg/kg for 3 wk. Hb and MCV improved from 9.2 g/dl and 26.2 fl in isotype controls to 11.5 g/dl and 33.7 fl in 1 mg/kg-m216 mice and further improved to 14.1 g/dl and 39.8 fl in the 3 mg/kg-m216 cohort, respectively, showing a dose proportional mitigation in improving microcytic anemia compared to isotype controls. In fact, Hb and MCV of the 3 mg/kg-m216 cohort were restored to the levels of WT mice, indicating that microcytic anemia was fully resolved in this group. Conclusion These data suggest that m216 inhibited the BMP pathway to increase iron absorption via hepcidin suppression and was able to provide similar effects as iron infusion in reversing microcytic anemia in a mouse model of IRIDA.

The role of hepcidin and an oral iron absorption test in identifying the root cause of iron-restricted anemia.

Traditional iron parameters often fail to distinguish the cause of iron-restricted anemia in patients without an obvious underlying cause. We evaluated whether an oral iron absorption test (OIAT) and hepcidin measurement could be useful diagnostic tests in these patients. We retrospectively analyzed data extracted from medical records of all patients who underwent an OIAT and hepcidin measurement, noting subsequent clinical diagnosis. Δ iron >15 µmol/L during the OIAT and hepcidin level below the median (or suppressed ≤0.5 nM) were considered appropriate. Thirty-nine adult patients were included in the study. Sixteen patients with adequate OIAT had suppressed hepcidin levels indicative of classical iron-deficiency anemia (IDA); 59% of patients had abnormal OIAT. In this group, most patients with low hepcidin levels had anemia associated with abnormalities in the gastrointestinal tract, whereas 83.3% patients with high hepcidin levels had iron-refractory iron deficiency anemia (IRIDA), confirmed by genetic testing. Finally, transferrin/log ferritin ratio accurately identified patients with suppressed hepcidin: AUC 0.98 [95% CI: 0.95-1.02], P < 0.001. OIAT differentiates between classical IDA and other types of anemia caused by abnormalities in iron absorption or systemic iron availability. Additionally, elevated hepcidin in patients with oral iron malabsorption could indicate IRIDA.

Genomics of iron refractory iron deficiency anemia phenotype reveals a spectrum of novel pathogenic biallelic and monoallelic TMPRSS6 variants and rare overlapping disorders

The study highlights genomic findings in a series of 13 IRIDA phenotype cases. All had microcytic hypochromic anemia with suboptimal oral iron response to two different oral iron preparations at 4–6 weeks and low-normal ferritin, low transferrin saturation, and inappropriately high hepcidin. Targeted NGS on a 26-gene iron panel revealed pathogenic TMPRSS6 variants in 5/13 (38 %) cases. In addition, 2 (15 %) cases revealed rare SMAD4 and TBXAS1 gene variants that can present with refractory anemia but were consistent with diagnosis of hereditary hemorrhagic telangiectasia and Ghosal hematodiaphyseal dysplasia respectively.

Matriptase-2 regulates iron homeostasis primarily by setting the basal levels of hepatic hepcidin expression through a nonproteolytic mechanism

Matriptase-2 (MT2), encoded by TMPRSS6, is a membrane-anchored serine protease. It plays a key role in iron homeostasis by suppressing the iron-regulatory hormone, hepcidin. Lack of functional MT2 results in an inappropriately high hepcidin and iron-refractory iron-deficiency anemia. Mt2 cleaves multiple components of the hepcidin-induction pathway in vitro. It is inhibited by the membrane-anchored serine protease inhibitor, Hai-2. Earlier in vivo studies show that Mt2 can suppress hepcidin expression independently of its proteolytic activity. In this study, our data indicate that hepatic Mt2 was a limiting factor in suppressing hepcidin. Studies in Tmprss6-/- mice revealed that increases in the dietary iron to ∼0.5% were sufficient to overcome the high hepcidin barrier and to correct the iron-deficiency anemia. Interestingly, the increased iron in Tmprss6-/- mice was able to further upregulate hepcidin expression to a similar magnitude as in wild-type mice. These results suggest that lack of Mt2 does not impact the iron induction of hepcidin. Additional studies of wild-type Mt2 and the proteolytic-dead form, fMt2S762A, indicated that the function of Mt2 is to lower the basal levels of hepcidin expression in a manner that primarily relies on its nonproteolytic role. This idea is supported by the studies in mice with the hepatocyte-specific ablation of Hai-2, which showed a marginal impact on iron homeostasis and no significant effects on iron regulation of hepcidin. Together, these observations suggest that the function of Mt2 is to set the basal levels of hepcidin expression and that this process is primarily accomplished through a nonproteolytic mechanism.

Myelin oligodendrocyte glycoprotein antibody-associated disease as a novel presentation of central nervous system autoimmunity in a pediatric patient with Wiskott-Aldrich syndrome

BackgroundWiskott-Aldrich syndrome (WAS) is an X-linked primary immunodeficiency caused by mutations in the WAS gene that leads to increased susceptibility to infections, thrombocytopenia, eczema, malignancies, and autoimmunity. Central nervous system (CNS) autoimmune manifestations are uncommon.Case PresentationWe describe the case of a five-year-old boy with refractory thrombocytopenia and iron deficiency anemia who developed relapsing bilateral optic neuritis. Myelin oligodendrocyte glycoprotein antibody (MOG-IgG) via serum fluorescence-activated cell sorting assay was positive (titer 1:100), confirming a diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). At age six, molecular panel testing for genes associated with primary immunodeficiency identified a missense WAS gene variant. He was subsequently found to have decreased WAS protein expression, consistent with a diagnosis of WAS.ConclusionsThis case expands the reported spectrum of CNS autoimmunity associated with WAS and may help to inform long-term therapeutic options.

A stepwise diagnostic approach for undiagnosed Anemia in children: A model for low-middle income country

BackgroundReaching a precise diagnosis in rare inherited anemia is extremely difficult and challenging, especially in areas with limited use of genetic studies, which makes undiagnosed anemia a unique clinical entity in tertiary hematology centers. In this study, we aim at plotting a stepwise diagnostic approach in children with undiagnosed anemia while identifying indications for genetic testing. Patients and methodsA one-year cross-sectional study involved 44 children and adolescents with undiagnosed anemia after undergoing an initial routine panel of investigations. They were classified based on mean corpuscular volume (MCV) into 3 groups: microcytic (n = 19), normocytic (n = 14) and macrocytic (n = 11). An algorithm that included four levels of investigations was devised for each category. ResultsAfter applying a systematic diagnostic approach, 33 patients (75 %) were diagnosed of whom 7 (15 %) had combined diagnoses, while 11 (25 %) patients remained undiagnosed. Based on the first, second, third and fourth levels of investigations, patients were diagnosed, respectively, as follows: of the 11 patients, 7 were microcytic, 3 normocytic and 1 macrocytic; of the 7 patients, 2 were microcytic, 2 normocytic, and 3 macrocytic; of 10 patients, 5 were microcytic, 4 normocytic and 1 macrocytic; finally, of the 16 patients, 8 were microcytic, 6 normocytic and 2 macrocytic. Numbers recorded appear higher than the actual number of the patients because some of them were diagnosed by more than one level of investigation. The diagnoses obtained in the microcytic group showed hemoglobinopathies, iron refractory iron deficiency anemia (IRIDA), membrane defects, sideroblastic anemia, hypo-transferrinemia, a combined diagnosis of sickle cell trait and pyropoikilocytosis. The diagnoses also showed a combined diagnosis of hereditary spherocytosis (HS) and alpha thalassemia minor, and a combined diagnosis of iron deficiency anemia and beta thalassemia minor, while 15 % remained undiagnosed. In the normocytic group, the diagnosis revealed autosomal recessive (AR) HS, vitamin B12 deficiency, pyruvate kinase deficiency (PKD), congenital dyserythropoietic anemia (CDA) type I, Diamond Blackfan anemia and beta thalassemia major. In addition, it showed a combined diagnosis of AR HS and CDA type II, a combined diagnosis of AR HS and PKD, and a combined diagnosis of dehydrated stomatocytosis (DHS) and G6PD carrier, meanwhile 20 % remained undiagnosed. Finally, the macrocytic group was diagnosed by vitamin B12 deficiency, sideroblastic anemia, PKD, a combined diagnosis of PKD and G6PD deficiency carrier, while 45 % remained undiagnosed. ConclusionConducting a stepwise approach with different levels of investigations may help reach the diagnosis of difficult anemia without having to resort to unnecessary investigations. Combined diagnosis is an important cause of undiagnosed anemia, especially in countries with high frequency of consanguinity. The remaining 25 % of the patients continued to be undiagnosed, requiring more sophisticated investigations.

Anastomotic Ulcers: Current Understanding of the Pathogenesis and Management.

Anastomotic ulceration following intestinal resection is an under- recognized problem in pediatrics. We discuss the relevant literature regarding this condition. Anastomotic Ulceration following intestinal resection is a potentially life threatening cause of refractory anemia. Evaluation should include correction of micronutrient deficiencies and endoscopic evaluation by upper and lower endoscopy and small intestinal endoscopy if necessary. Initial treatment by medical therapy may consist of anti-inflammatory agents as well as antibiotics to treat small intestinal bacterial overgrowth. Surgical resection should be considered if refractory to treatment. Anastomotic ulcers in pediatric patients with small bowel resection should be considered as a cause of refractory iron deficiency anemia. Endoscopic evaluation should be undertaken to look for evidence of anastomotic ulcers. Surgical resection should be considered if medical therapy fails.

Refractory Iron Deficiency Anemia Secondary to Angiodysplasia-Related Gastrointestinal Bleeding Successfully Treated With Bevacizumab

Refractory Iron Deficiency Anemia Secondary to Angiodysplasia-Related Gastrointestinal Bleeding Successfully Treated With Bevacizumab

A Rationally Designed Complex Replenishes the Transferrin Iron Pool Directly and with High Specificity.

Many forms of anemia are caused or complicated by pathologic restriction of iron (Fe). Chronic inflammation and certain genetic mutations decrease the activity of ferroportin, the only Fe-exporter protein, so that endogenously recycled or nutritionally absorbed Fe cannot be exported to the extracellular Fe carrier protein transferrin for delivery to the bone marrow. Diminished ferroportin activity renders anemia correction challenging as Fe administered intravenously or through nutritional supplementation is trafficked through the ferroportin-transferrin axis. Utilizing judicious application of coordination chemistry principles, we designed an Fe complex (Fe-BBG) with solution thermodynamics and Fe dissociation kinetics optimized to replenish the transferrin-Fe pool rapidly, directly, and with precision. Fe-BBG is unreactive under conditions designed to force redox cycling and production of reactive oxygen species. The BBG ligand has a low affinity for divalent metal ions and does not compete for binding of other endogenously present ions including Cu and Zn. Treatment with Fe-BBG confers anemia correction in a mouse model of iron-refractory iron-deficiency anemia. Repeated exposure to Fe-BBG did not cause adverse clinical chemistry changes or trigger the expression of genes related to oxidative stress or inflammation. Fe-BBG represents the first entry in a promising new class of transferrin-targeted Fe replacement drugs.

GUT-BIOME MODULATION WITH HUMAN MILK OLIGOSACCHARIDE (HMO) BASED SYNBIOTIC FOR A COMPLETE AND DEEP REMISSION IN CROHN’S DISEASE: A CASE STUDY

Abstract BACKGROUND Gut microbiome plays a crucial role in modulation of inflammatory and immune pathways. Diverse bacterial species from gut microbiota feed on specific prebiotics (non-digestible dietary fibers) producing metabolites, such as short chain fatty acids (SCFA). These metabolites beneficially affect the intestinal mucosa with their role in metabolic and immunologic homeostasis, and gut barrier integrity. Recently gut-biome modulation and use of metabolites gained interest as potential targets for therapeutic development, for instance in Inflammatory Bowel Disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC). HYPOTHESIS Nourishing the gut-biome thru synbiotic formulation can enhance the interspecies synergy with production of metabolites and improved gut barrier integrity more naturally. This is a superior and holistic approach to reduce gut-inflammation. METHODS (CLINICAL CASE) An 11 year old male with refractory iron deficiency anemia, fecal calprotectin at 1375 µg/g, on video capsule endoscopy showed discrete linear and serpiginous ulcers with surrounding erythema in duodenum and proximal jejunum. Biopsy of colon showed multiple granulomas in terminal ileum and entire colon suggesting CD (Inflammatory phenotype). Exclusive Enteral Nutrition (EEN) with polymeric formula proved unsustainable. To nourish the gut-biome and its ecosystem a synbiotic formulation (Gastrosyn) that has a blend of specific prebiotics with HMO and complimentary probiotic blend with strains of Lactobacilli and Bifidobacterium was administered and followed for 20 weeks. Formulation also contained powerful antioxidant for synergistic effect in reducing inflammation. RESULTS After 4 weeks on synbiotic, fecal calprotectin dropped to 665ug/g which further dropped to 110 ug/g by week 12. Complete and deep remission was observed by 15 weeks as analyzed by endoscopy/colonoscopy (images), histology and lab tests results repeated several times (Calprotectin 65ug/g by week 15). Anemia also improved significantly, and patient continued to tolerate solid foods with no relapse even after 1year. CONCLUSIONS Synbiotics utilizing prebiotics that are specific to probiotic strains used is crucial for successful engraftment and biome modulation as established in recent literature. HMO based Synbiotic formulation has proven to nurture the ecosystem, and foster interspecies interactions, cross feeding, and generation of metabolites (SCFAs), providing a holistic and superior approach for remission in IBD.

TMPRSS6 as a Therapeutic Target for Disorders of Erythropoiesis and Iron Homeostasis.

TMPRSS6 is a serine protease highly expressed in the liver. Its role in iron regulation was first reported in 2008 when mutations in TMPRSS6 were shown to be the cause of iron-refractory iron deficiency anemia (IRIDA) in humans and in mouse models. TMPRSS6 functions as a negative regulator of the expression of the systemic iron-regulatory hormone hepcidin. Over the last decade and a half, growing understanding of TMPRSS6 biology and mechanism of action has enabled development of new therapeutic approaches for patients with diseases of erythropoiesis and iron homeostasis.ClinicalTrials.gov identifier NCT03165864.

Helicobacter pylori eradication rates using clarithromycin and levofloxacin-based regimens in patients with previous COVID-19 treatment: a randomized clinical trial

BackgroundHelicobacter pylori (H. pylori) is affecting half of the globe. It is considered a main causative organism of chronic gastritis, peptic ulcer disease, and different gastric maliganacies. It has been also correlated to extraintestinal diseases, including refractory iron deficiency anaemia, vitamin B12 deficiency, and immune thrombocytopenic purpura. The misuse of antibiotics during the coronavirus diseases 2019 (COVID-19) pandemic time can affect H. pylori eradication rates. Our aim was to compare the efficacy of clarithromycin versus levofloxacin-based regimens for H. pylori treatment in naïve patients after the COVID-19 pandemic misuse of antibiotics.MethodsA total of 270 naïve H. pylori infected patients with previous treatment for COVID-19 more than 3 months before enrolment were recruited. Patients were randomized to receive either clarithromycin, esomeprazole, and amoxicillin, or levofloxacin, esomeprazole, and amoxicillin.ResultsA total of 270 naïve H. pylori infected patients with previous treatment for COVID-19 more than 3 months before enrolment were included, 135 in each arm. In total, 19 patients in the clarithromycin group and 18 patients in the levofloxacin group stopped treatment after 2–4 days because of side effects or were lost for follow-up. Finally, 116 subjects in the clarithromycin group and 117 in the levofloxacin group were assessed. The eradication rates in intention to treat (ITT) and per protocol (PP) analyses were: group I, 55.56% and 64.66%; and Group II, 64.44% and 74.36% respectively (p = 0.11).ConclusionAs COVID-19 pandemic has moved forward fast, high resistance rates of H. pylori to both clarithromycin and levofloxacin were developed after less than two years from the start of the pandemic. Molecular & genetic testing is highly recommended to identify antimicrobial resistance patterns. Strategies to prevent antibiotic misuse in the treatment of COVID-19 are needed to prevent more antibiotic resistance.Trial Registration: The trial was registered on Clinicaltrials.gov NCT05035186. Date of registration is 2-09-2021.

The global prevalence and ethnic heterogeneity of iron-refractory iron deficiency anaemia

BackgroundIron-refractory iron deficiency anaemia (IRIDA) is an autosomal recessive iron deficiency anaemia caused by mutations in the TMPRSS6 gene. Iron deficiency anaemia is common, whereas IRIDA is rare. The prevalence of IRIDA is unclear. This study aimed to estimate the carrier frequency and genetic prevalence of IRIDA using Genome Aggregation Database (gnomAD) data.MethodsThe pathogenicity of TMPRSS6 variants was interpreted according to the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology (AMP) standards and guidelines. The minor allele frequency (MAF) of TMPRSS6 gene disease-causing variants in 141,456 unique individuals was examined to estimate the global prevalence of IRIDA in seven ethnicities: African/African American (afr), American Admixed/Latino (amr), Ashkenazi Jewish (asj), East Asian (eas), Finnish (fin), Non-Finnish European (nfe) and South Asian (sas). The global and population-specific carrier frequencies and genetic prevalence of IRIDA were calculated using the Hardy–Weinberg equation.ResultsIn total, 86 pathogenic/likely pathogenic variants (PV/LPV) were identified according to ACMG/AMP guideline. The global carrier frequency and genetic prevalence of IRIDA were 2.02 per thousand and 1.02 per million, respectively.ConclusionsThe prevalence of IRIDA is greater than previous estimates.

Diagnosis and treatment of anemia by malnutrition in the elderly

Recently, nutritional anemia has been increasing, particularly refractory iron-deficiency anemia, which has become more common not only among older adults but also among relatively young people. Coexisting conditions such as chronic inflammatory disease, gastrointestinal disease, and chronic kidney disease can all complicate diagnosis and treatment. In many cases, appropriate treatment can improve anemia. Same as iron, copper, and zinc are proven to be absorbed from the transporter in the upper gastrointestinal mucosa, but potential zinc and copper deficiencies are increasingly being reported in cases of iron deficiency. Serum zinc deficiency is more common in cases of severe iron-deficiency anemia. This paper provides an overview of refractory iron-deficiency anemia and discusses the molecular groups involved in iron dynamics, zinc, and copper metabolism.

Helicobacter pylori-Associated Iron Deficiency Anemia in Childhood and Adolescence-Pathogenesis and Clinical Management Strategy.

Many epidemiological studies and meta-analyses show that persistent Helicobacter pylori infection in the gastric mucosa can lead to iron deficiency or iron deficiency anemia (IDA), particularly in certain populations of children and adolescents. Moreover, it has been demonstrated that H. pylori infection can lead to and be closely associated with recurrent and/or refractory iron deficiency and IDA. However, the pathogenesis and specific risk factors leading to this clinical outcome in H. pylori-infected children remain poorly understood. In general, most of pediatric patients with H. pylori-associated IDA do not show evidence of overt blood loss due to gastrointestinal hemorrhagic lesions. In adult populations, H. pylori atrophic gastritis is reported to cause impaired iron absorption due to impaired gastric acid secretion, which, subsequently, results in IDA. However, significant gastric atrophy, and the resultant substantial reduction in gastric acid secretion, has not been shown in H. pylori-infected children. Recently, it has been hypothesized that competition between H. pylori and humans for iron availability in the upper gastrointestinal tract could lead to IDA. Many genes, including those encoding major outer membrane proteins (OMPs), are known to be involved in iron-uptake mechanisms in H. pylori. Recent studies have been published that describe H. pylori virulence factors, including specific OMP genes that may be associated with the pathogenesis of IDA. Daily iron demand substantively increases in children as they begin pubertal development starting with the associated growth spurt, and this important physiological mechanism may play a synergistic role for the microorganisms as a host pathogenetic factor of IDA. Like in the most recent pediatric guidelines, a test-and-treat strategy in H. pylori infection should be considered, especially for children and adolescents in whom IDA is recurrent or refractory to iron supplementation and other definitive causes have not been identified. This review will focus on providing the evidence that supports a clear biological plausibility for H. pylori infection and iron deficiency, as well as IDA.

Improvement in Refractory Iron Deficiency Anemia after Successful Eradication of H-Pylori

Background: Helicobacter pylori has caused gastritis leading to bleeding and iron deficiency anemia. H-pylori eradication results in better response to oral iron treatment. Aim: To determine the frequency of improvement in refractory iron deficiency anemia after successful eradication of H-pylori. Study design: Descriptive, case series. Methodology: Patients (n=89) of refractory iron deficiency anemia, 15-55 years of either gender were included. After this taking relevant history, urea breath test was done for H-Pylori. After this, 10 days of PPI, bismuth, tetracycline and nitromidazole was given to the positive patients. Improvement in iron deficiency anemia was noted after 3 months of H-pylori eradication therapy. SPSS v.26 analyzed the data. Mean and standard deviation were calculated for age, duration of iron deficiency anemia and BMI. Stratification of improvement in refractory iron deficiency anemia was done with respect to age, gender and BMI. Post stratification Chi-Squire test was applied with P-value ≤0.05 was taken as significant. Results: Mean age was 35.90 ± 9.89 years. Improvement in refractory iron deficiency anemia after eradication of h pylori was found in 54 (60.67%) patients, whereas there was no improvement in 35 (39.33%) patients. Practical Implication: This study provided the local stats of the problem and helped the clinicians to design a protocol for eradication of H pylori in these particular patients thus improving refractory IDA. Conclusion: It was concluded that frequency of improvement in refractory iron deficiency anemia after eradication of H-pylori was very high. Keywords: H-Pylori, Eradication and Refractory Iron Deficiency Anemia.

Preliminary Results of a Phase-2 Clinical Trial of the ALK-2 Inhibitor Ker-047 for Treatment of Iron Refractory Iron Deficiency Anemia

Background: Iron refractory iron deficiency anemia (IRIDA) is a rare autosomal recessive disorder, caused by a genetic defect in TMPRSS6. This results in increased signaling through the bone morphogenic protein (BMP)/sons of mothers against decapentaplegic (SMAD) pathway, leading to disproportionally high levels of hepcidin relative to body iron status. Hepcidin reduces iron transport to the plasma by degrading the cellular iron exporter ferroportin, resulting in systemic iron deficiency and microcytic anemia. Symptomatic interventions such as intravenous iron administration results in iron sequestration in the reticular endothelial system (RES) and generally only a partial response of hemoglobin concentrations. Further, the potential long-term adverse effects of chronic intravenous iron therapy and associated elevated RES-iron levels are unknown in these patients. Blood transfusion can be administered in cases of severe symptomatic anemia but is generally avoided due to transfusion-related risks. Currently, there is an unmet need for more effective, safe, convenient, and direct-acting treatments for IRIDA. Given the central role of aberrant BMP/SMAD signaling in hepcidin production, selective inhibition of the BMP receptor ALK2 to reduce hepcidin represents a rational approach to target a precipitating factor of IRIDA. Preclinical studies in the TMPRSS6 siRNA knockdown mouse model of IRIDA demonstrated that treatment with a selective ALK2 inhibitor reduced hepcidin, increased serum iron, and ameliorated anemia. KER-047 is a novel, oral, investigational, small-molecule kinase inhibitor with potent and selective inhibitory activity against the ALK2 receptor. In a Phase 1 clinical trial, single-ascending and multiple-ascending doses of KER-047 administered to healthy participants resulted in robust decreases from baseline in hepcidin levels, increases in serum iron and transferrin saturation (TSAT), decreases in serum ferritin, and increases in reticulocyte hemoglobin content (Ret-He). Based on these observations, KER-047 was advanced to Phase 2 clinical trials. Aims: The primary objective of this ongoing Phase 2 clinical trial is to evaluate the safety and tolerability of ascending doses of KER-047 in participants with IRIDA. Secondary objectives include evaluation of pharmacokinetic (PK) and pharmacodynamic (PD) parameters. Methods: This is a 2-part open label, dose escalation and dose expansion trial. Part 1 (dose escalation) consists of up to 4 ascending dose cohorts starting with 25 mg q.d. Part 2 will be the dose expansion phase with safety as the primary focus. Patients diagnosed with IRIDA may enroll in all cohorts in Parts 1 and 2. Key inclusion criteria include diagnosis of IRIDA based on a homozygous or compound heterozygous TMPRSS6 genotype, a TSAT <15%, a ferritin level 50-700 µg/L and hemoglobin <13.8 g/dL (males) or <12.7g/dL (females) and signed informed consent. Patients are excluded if they have received IV iron treatment within 28 days prior to trial entry. Participants will be treated once daily with KER-047 for a 2-week period, followed by a 2-week washout period. Data are analyzed by using descriptive statistics. Results: At the time of this abstract submission, one participant had enrolled in the first dose-expansion cohort (KER-047 25mg q.d.). This participant reported intermittent dizziness, however no serious adverse events were observed during treatment. Hemoglobin concentration and mean corpuscular volume remained stable. Ret-He increased by day 5 of treatment. Ferritin levels decreased during treatment and returned to baseline levels after the 2-week treatment period. TSAT/hepcidin ratio, which is characteristically below reference intervals in IRIDA patients, was slightly increased but returned to baseline levels after 2-weeks treatment. Conclusion: Data are preliminary and limited to a single participant thus far in whom KER-047 25mg q.d. was well tolerated. Changes in red cell and iron parameters at this low dose support development of KER-047 as an agent to potentially address an underlying cause of IRIDA. At the time of this abstract submission, two additional patients are scheduled for screening to complete the first dose cohort. We anticipate data from the total of three patients in time for the presentation to further characterize safety of KER-047 and substantiate effects on iron metabolism. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Investigations into the Mechanisms and Clinical Implications of Modulation of Hepcidin Levels By Luspatercept in TD MDS and TD b-Thalassemia

Introduction: Multiple blood transfusions lead to significant iron overload in transfusion dependent (TD) thalassemia (TDT) and TD-MDS. This excess iron is deposited in various organs leading to end organ damage, morbidity, and mortality. Iron overload patients are treated with iron chelation therapy (ICT) owing to lack of effective physiological iron removal mechanisms. Furthermore, chronic transfusions lead to paradoxical changes in hepcidin, the master regulator of iron homeostasis. While hepcidin is upregulated under conditions of increased intracellular and extracellular iron concentrations through BMP6 and IL6 dependent signaling; it is downregulated during expanded erythropoiesis through Erythroferrone (ERFE) to increase iron availability for developing erythron. Increased levels of hepcidin sequesters iron within organs leading to inefficiency of iron chelation therapy in TD-MDS and TDT patients. Luspatercept is a modified activin receptor fusion protein (modified ActRIIB-Fc) that sequesters certain members of TGF-b superfamily ligands, thus enhancing late-stage erythroid-maturation. Luspatercept is approved for TDT and TD-MDS patient populations-based on significant reduction in transfusion burden in two independent phase 3 trails (BELIEVE and MEDALIST, respectively). Here, we evaluated modulation of hepcidin levels with luspatercept treatment and its clinical implications in anemias due to elevated levels of hepcidin including TD-MDS and TDT patients. Methods: Luspatercept was administered sub-cutaneously every three weeks. Hepcidin and ERFE levels were measured in serum or plasma samples from BELIEVE (NCT02604433) and MEDALIST (NCT02631070) trial patients using specific ELISA and or chemiluminescence assay kits at week 25 following treatment. The regulation of hepcidin by luspatercept, BMP6 and IL6 in HepG2 cell-line model was determined by ELISA (in conditioned media) and q-PCR at increasing doses and time points. Results: Serum hepcidin levels at baseline across both arms in MEDALIST and BELIEVE were 80.65 ng/ml and 43.1 ng/ml respectively. These were significantly higher than normal healthy individuals (range of 5-10 ng/ml; P < 0.001), reported previously (Ilkovska etal JIMB 2016). Patients treated with luspatercept in both TDT and TD-MDS showed significant reduction in serum levels of hepcidin by 49% and 53% respectively (P<0.001) at week 25 compared to baseline. Hepcidin levels in the placebo group in TD-MDS patients demonstrated an increase of 119% (P<0.001) and a decrease of 12% in TDT patients (P=0.004) at the same time point. In addition, ERFE protein levels in serum, were elevated in response to Luspatercept treatment in both TD-MDS (30%) and TDT (51%) (P<0.001) in comparison to the placebo arms of decrease of 28% in TD-MDS and an increase of 2% in TDT. In HepG2 cells, treatment with recombinant BMP6 and IL6 increased hepcidin protein expression in a dose dependent manner. Luspatercept treatment inhibited this increase in hepcidin expression mediated by BMP6 and IL6. Time course analyses (2, 6, 24 and 72 hours), revealed that luspatercept inhibited hepcidin transcription and secretion levels starting at 24 hours. Conclusions: Luspatercept treatment reduced transfusion burden and iron loading rate due to improved erythropoiesis and release of ERFE by maturing erythroblasts consequently leading to reductions in elevated hepcidin levels in both TD-MDS and TDT patients. Our data provides a mechanistic rationale for downregulation of hepcidin levels with luspatercept treatment. Interestingly, cell-based assay data suggest that luspatercept directly modulates hepcidin transcription suggesting that in diseased conditions with abnormally higher levels of hepcidin and TGFβ family ligands, luspatercept might also modulate hepcidin transcription by sequestering TGFβ family ligands implicated in hepcidin synthesis. We postulate that decreased hepcidin levels results in release of excess iron into peripheral blood, making it available for effective chelation. These observations implicate sequencing of luspatercept, and ICT for effective management of iron overload in these TD patients. Furthermore, the data provide a mechanistic rationale for evaluating luspatercept in hepcidin dependent anemia of inflammation and iron refractory iron deficiency anemia (IRIDA) disease indications.

Celiac Disease: a review

Celiac Disease (CD) is an immune-mediated enteropathy in response to the ingestion of gluten in genetically predisposed individuals, causing a malabsorptive syndrome. This review aims to conceptualize CD, describe its pathophysiology, highlight its epidemiology, detail associated clinical presentations, outline the diagnostic approach, and explain the treatment. To achieve this, works in English, Portuguese, and Spanish from the last five years were sought in the following databases: PubMed, LILACS, and SciELO, using the following keywords: “doença celíaca” and “celiac disease.” The search resulted in 175 articles, with 40 works chosen after screening and evaluation. The results revealed that CD affects approximately 1% of the global population, can be diagnosed at any age, but with more typical symptoms in children and atypical symptoms in adults. The pathogenesis involves the genetic factor HLA DQ2/DQ8, gluten ingestion, the formation of tissue transglutaminase antibodies, and an inflammatory reaction that damages the duodenum, impairing its absorptive function. Typical symptoms include chronic diarrhea, abdominal distension, weight loss, poor growth, and vitamin deficiencies. Atypical symptoms include dermatitis herpetiformis, refractory iron-deficiency anemia, delayed puberty, infertility, and neurological diseases. Diagnosis involves a suspected clinical picture, serologies for autoantibodies, genetic testing, and duodenal biopsy. Treatment is lifelong adherence to a gluten-free diet. Despite being well-characterized, CD remains underdiagnosed, and additional studies are needed.