Stimulation Of Erythropoiesis Research Articles

Understanding iron homeostasis in MDS: the role of erythroferrone.

Myelodysplastic neoplasms (MDS) are a heterogenous group of clonal stem cell disorders characterized by dysplasia and cytopenia in one or more cell lineages. Anemia is a very common symptom that is often treated with blood transfusions and/or erythropoiesis stimulating factors. Iron overload results from a combination of these factors together with the disease-associated ineffective erythropoiesis, that is seen especially in MDS cases with SF3B1 mutations. A growing body of research has shown that erythroferrone is an important regulator of hepcidin, the master regulator of systemic iron homeostasis. Consequently, it is of interest to understand how this molecule contributes to regulating the iron balance in MDS patients. This short review evaluates our current understanding of erythroferrone in general, but more specifically in MDS and seeks to place in context how the current knowledge could be utilized for prognostication and therapy.

Significance of erythropoesis correction in preoperative preparation in the surgical treatment of patients with colorectal cancer

Background. Anemic syndrome, which accompanies the development of pathology in patients with colorectal cancer, can cause serious early postoperative complications. The question of how preoperative preparation activities influence the state of the intestinal structures and the clinical situation in general is relevant. Of particular importance in this situation is the correction of anemic syndrome before surgery, using hematopoietic stimulants. Objective. The purpose of the study is to analyze the dynamics of erythropoiesis and changes in tissue and cell ultrastructure in intraoperative colon biopsy specimens after stimulation of erythropoiesis in preoperative preparation in the surgical treatment of patients with colorectal cancer. Methods. The study of red bone marrow and the wall of the large intestine using transmission electron microscopy. Results. Most patients with colorectal cancer are characterized by the development of signs of ineffective erythropoiesis with a moderate slowdown in the differentiation of erythroblasts and a delay in the release of mature erythrocytes into the systemic circulation. Stimulation of erythropoiesis with the help of epoetin leads to an increase in the functional activity of the central macrophages of the erythropoietic islets of the red bone marrow and the enhancement of their intercellular association with maturing erythroid cells. This is accompanied by the formation of a large number of full-fledged erythrocytes, an increase in the numerical density of cells of the erythroid series and the normalization of their ultrastructure. Conclusion. Stimulation of erythropoiesis with the help of epoetin in the preoperative period causes the inhibition of endothelial dysfunction due to the restriction of dystrophic and destructive changes in endothelial cell organelles, stabilization of their membranes, prevention of arteriole spasm, erythrocyte stasis and erythrocyte phenomena. As a result, the phenomena of infiltration, perivascular and interstitial edema in the composition of the membranes of the intestinal wall are much less pronounced than in the group of patients without preoperative activation of erythropoiesis.

Targeting hypoxia-inducible factors: therapeutic opportunities and challenges.

Hypoxia-inducible factors (HIFs) are highly conserved transcription factors that are crucial for adaptation of metazoans to limited oxygen availability. Recently, HIF activation and inhibition have emerged as therapeutic targets in various human diseases. Pharmacologically desirable effects of HIF activation include erythropoiesis stimulation, cellular metabolism optimization during hypoxia and adaptive responses during ischaemia and inflammation. By contrast, HIF inhibition has been explored as a therapy for various cancers, retinal neovascularization and pulmonary hypertension. This Review discusses the biochemical mechanisms that control HIF stabilization and the molecular strategies that can be exploited pharmacologically to activate or inhibit HIFs. In addition, we examine medical conditions that benefit from targeting HIFs, the potential side effects of HIF activation or inhibition and future challenges in this field.

Preclinical and Clinical Evidence for Erythroid-Stimulating Activity of RVU120 CDK8/19 Inhibitor in AML and MDS

Introduction: RVU120 is an orally bioavailable small molecule inhibitor targeting mediator complex kinases CDK8 and its paralog CDK19. Preclinical results indicated that treatment with RVU120 could reduce the viability of AML cells, in particular those positive for NPM1 and DNMT3A mutations. Further studies also indicated that RVU120 induces erythroid differentiation of malignant stem cells isolated from AML and MDS patients, likely by the induction of STAT5-GATA1-dependent transcription. The first signs of clinical efficacy have been observed in the ongoing Phase 1 dose escalation study of RVU120 in AML and HR-MDS patients. The presented work provides the preclinical rationale and growing clinical evidence that in addition to previously reported blast reduction, RVU120 has also strong erythropoiesis stimulating activity that may be useful as a potential therapeutic strategy for MDS. Methods: RVU120-induced erythroid differentiation was studied in primary malignant stem cells from MDS patients and in a stem cell model derived from cord blood cells transformed by TLS-ERG fusion. Erythroid differentiation was tracked by flow cytometry, chromatin status, and transcriptomic changes using RNAseq, ATACseq and ChIPseq. CLI120-001 study (NCT04021368) is a phase 1 dose escalation study of RVU120 in patients with relapsed/refractory AML and HR-MDS which is currently ongoing. Flow cytometry for erythroid differentiation markers, NGS myeloid panel and bulk RNAseq were performed in all patients enrolled after September 2021. Results: At the time of the abstract submission, within 24 evaluable patients' erythroid improvement was reported in 1 patient with HR-MDS, 3 patients with AML MRC, and 1 patient with AML secondary to MF. Interestingly, in these cases, erythroid improvement was observed independently of significant blast reduction, at doses from 25 mg to 135 mg every other day in 3 weeks cycles. Transient induction of erythroid differentiation markers CD71 and/or CD235a was confirmed in 3 additional transfusion-dependent patients treated with RVU120. Bulk RNA-seq confirmed broad transcriptomic changes in BM of selected patients after treatment compared to the pre-dose baseline levels. Robust induction of genes involved in erythroblast differentiation and hemoglobin metabolism genes was confirmed in 2 AML-MRC and 2 AML patients. These changes correlated with the repression of major pro-inflammatory pathways, including hallmark interferon gamma and TNF/NFKB response genes and repression of TGFβ pathway genes. Molecular and flow cytometry changes observed in patients were consistent with the erythroid commitment and sequential induction of erythroid differentiation markers in cultured CD34+ malignant stem cells isolated from MDS and AML-MRC patients treated with RVU120 and other chemically non-related CDK8 inhibitors. Conclusions: The presented results provide clinical and preclinical evidence for RVU120 as a candidate for a novel erythroid stimulating agent. Treatment with RVU120 could be a promising addition to the current treatment options for patients with lower-risk MDS who are transfusion-dependent and failing first-line therapies.

Effect of Carbamylated Erythropoietin in a Chronic Model of TNBS-Induced Colitis.

Inflammatory bowel disease (IBD) is a public health issue with a growing prevalence, which can be divided into two phenotypes, namely Crohn's disease (CD) and ulcerative colitis (UC). Currently, used therapy is based only on symptomatic and/or palliative pharmacological approaches. These treatments seek to induce and maintain remission of the disease and ameliorate its secondary effects; however, they do not modify or reverse the underlying pathogenic mechanism. Therefore, it is essential to investigate new potential treatments. Carbamylated erythropoietin (cEPO) results from the modification of the Erythropoietin (EPO) molecule, reducing cardiovascular-related side effects from the natural erythropoiesis stimulation. cEPO has been studied throughout several animal models, which demonstrated an anti-inflammatory effect by decreasing the production of several pro-inflammatory cytokines. This study aimed to evaluate the efficacy and safety of cEPO in a chronic TNBS-induced colitis model in rodents. Experimental colitis was induced by weekly intrarectal (IR) administrations of 1% TNBS for 5 weeks in female CD-1 mice. Then, the mice were treated with 500 IU/kg/day or 1000 IU/kg/day of cEPO through intraperitoneal injections for 14 days. cEPO significantly reduced the concentration of alkaline phosphatase (ALP), fecal hemoglobin, tumor necrosis factor (TNF)-α, and interleukin (IL)-10. Also, it demonstrated a beneficial influence on the extra-intestinal manifestations, with the absence of significant side effects of its use. Considering the positive results from cEPO in this experiment, it may arise as a new possible pharmacological approach for the future management of IBD.

Serum Erythroferrone in End Stage Renal Disease Patients: Relation to Iron Status, Anaemia and Erythropoiesis Stimulating Agents

Abstract Background Anaemia is a hallmark of chronic kidney disease (CKD), where erythropoietin deficiency and reduced iron availability by the negative iron regulator, hepcidin, are principal causes of the anaemia. Erythroferrone (ERFE), a hormone synthesized by erythroblasts, is a hepcidin inhibitor and increases iron absorption and mobilization, resulting in erythropoiesis stimulation. Thus, ERFE could be considered as one of potential clinical biomarkers for assessing erythropoiesis. Moreover, it has been found that ERFE is produced in response to erythropoietic stimulating agent (ESA) in CKD and thus could have a role in cure from anaemia in those patients. However, few studies focused on understanding the role of this hormone in the regulation of iron homeostasis. Aim of the Work To study the correlation between ERFE level and iron parameters and its response to iron/ESA in end stage renal disease (ESRD) patients with iron deficiency anaemia. Study design and methods A case-control study was carried out on 40 ESRD patients (GFR < 15 ml/min/1.73 mm3) with evidence of iron deficiency anaemia. Patients were further subdivided into 2 subgroups, where subgroup I included patients who received both iron and ESA (Erythropoietin) (n = 28) and subgroup II patients who were treated with iron only (n = 12). Ten age & sex matched normal healthy subjects were included in the study as a control group. The studied parameters (ERFE, Hb, HCT%, MCV, MCH, serum iron, TSAT% and TIBC) were measured at baseline and then revaluated three months later after iron/ESA therapy. Erythroferrone was measured (baseline and post iron/ESA treatment) by ELISA. Results The present study was conducted on 40 ESRD patients with male to female ratio 1:1.5. Their mean age was 51.03±11.22 years and mean dry weight 73.4±13.08 Kg. The commonest risk factor was hypertension (32.5%). Treatment with iron ± EPO results in significant increase of Hb and serum iron in both patients' subgroups (p ˂ 0.001). Baseline and post treatment ERFE levels were higher in patients’ groups than in the control group with significant statistical difference (p = 0.016 & 0.023 respectively). The highest level was in those patients treated with both iron and EPO (212.31±106.33 ng/L at baseline & 520.00±255.26 post treatment). Positive correlation of ERFE level with both Hb and serum Iron (p-value <0.05) was detected. Conclusion Managing anaemia in ESRD patients remain a significant unmet challenge in those patients. Insight into iron homeostasis is important in order to develop new diagnostic as well as therapeutic modalities. Our study proved that ERFE is associated with iron/EPO therapy and positively correlated with hemoglobin and serum iron levels. Thus, ERFE could play a key role in the assessment of erythropoietic activity, as well as, in the treatment process among those patients in status of iron deficiency or iron overload.

Hematological parameters of pig blood following the use of essential oils

Purpose. To study the morphological and biochemical parameters of the pig blood fed with essential oils as part of the protein-vitamin-mineral supplement “Efiprot” in a dose of 150 and 200 g per 1 ton of compound feed. Methods. In the research general scientific methods were used: zootechnical (experiments on animals), physiological (blood tests), statistical (biometric materials), analytical. Results. The use of a new feed component in the rations of experimental groups of pigs leads to an increase in the number of erythrocytes by 2.4-2.8%, leukocytes in the blood of animals of the experimental groups relative to the control indicator – by 1.37-4.94% (Р < 0.001). The leukocyte blood formula of all animals remained at the physiological level, but in the third group, an increase in basophils by 30.64% was observed, as well as a slight increase in eosinophils in both groups – by 9.28-6.55%. According to the research results, the number of platelets was higher in the second and third groups of animals by 1.31-2.9% (P < 0.01). The total protein content increased in the second group by 3.27% (Р < 0.001) and the third one – by 8.62% (Р < 0.001) relative to the control. Indicators of hemoglobin content in one erythrocyte in the experimental groups exceeded the control by 7.82 (Р < 0.001)-12.65% (Р < 0.001). Therefore, according to the results of laboratory studies, the number of albumins increased in both groups by 12.15 (Р < 0.001)-17.15% (Р < 0.001) relative to the control, and the level of bilirubin in the blood of pigs had a slight increase only in the third group – by 7, 41% (P < 0.01). The amount of glucose in the second and third groups increased by 8.84 (Р < 0.001)-6.81% (Р < 0.001). Conclusions. Complex feeding of the protein-vitamin-mineral supplement “Efiprot” with essential oils causes: stimulation of erythropoiesis (increase in the number of erythrocytes) in the blood of pigs and respiratory function of the blood (increase in hemoglobin level); activation of cellular immunity (increase in the number of leukocytes within the physiological norm).

#2560 HEMOGLOBIN VARIABILITY AND ADVERSE CLINICAL EVENTS IN PATIENTS WITH NON-DIALYSIS-DEPENDENT CHRONIC KIDNEY DISEASE AND ANEMIA IN CONTINUOUS CARE

Abstract Background and Aims Anemia management in non-dialysis dependent chronic kidney disease (NDD-CKD) patients has attracted attention with the introduction of new treatment options, such as prolyl hydroxylase domain enzyme inhibitors (HIF-PHI). However, studies reporting comprehensive information on anemia management in NDD-CKD patients are limited. While previous studies reported increased risks of adverse clinical events associated with hemoglobin (Hb) fluctuation in hemodialysis patients, limited information is available in NDD-CKD patients. Method A retrospective cohort study was performed using a Japanese nationwide electronic medical record-based hospital database. Patients with stage ≥3a NDD-CKD, aged ≥18 years, and at least one recorded Hb <11 g/dL between January 1st 2013 and April 30th 2021 were included. Patients already receiving any anemia treatment (erythropoiesis stimulating agent (ESA), iron, or HIF-PHI) were excluded. Hb levels were collected at the index date (the date of the first recorded Hb <11 g/dL) and during the follow-up period. Clinical events included all-cause death, cardiovascular (CV) events (myocardial infarction, unstable angina pectoris, stroke, or hospitalization for heart failure), dialysis introduction, and red-blood-cell transfusion. Time-dependent Cox proportional hazard models, adjusted by clinically relevant variables were applied to assess the risk of clinical events associated with transitioning Hb fluctuation patterns, categorized into six groups: within the target Hb range (11–13 g/dL); consistently below the target (low); consistently above the target (high); low-amplitude fluctuation around the upper limit of the target (LAH); low-amplitude fluctuation around the lower limit of the target (LAL); and, high amplitude fluctuation across the target (HA). Results Of 162,170 patients with CKD, 26,626 (16.4%) NDD-CKD patients with Hb <11 g/dL were identified (median follow-up length, 1.9 years). The mean age was 75.9 years, and 37.8% were female. In overall patients, the mean (±SD) Hb levels at index and at 3, 6, and 12 months of follow up were 9.9±1.2 g/dL, 10.6±1.5 g/dL, 10.8±1.6 g/dL, and 10.9±1.6 g/dL, respectively. The proportion of patients with Hb <10 g/dL at index and at 12 months were 34.3% and 23.9%, respectively. In the subgroup of patients treated with ESA or HIF-PHI (n = 8,876), the mean Hb (±SD) levels had increased from 9.3±1.3 g/dL to 10.3±1.5 g/dL at 3 months, 10.5±1.5 g/dL at 6 months, and 10.6±1.5 g/dL at 12 months after treatment initiation. In this subgroup, the proportion of patients with Hb <10 g/dL had decreased from 70.0% to 30.1% at 12 months. Fig. 1 shows the Hb levels and proportions of patients with Hb <10 g/dL by treatment type. During the follow-up period, 5,991 (22.5%) deaths, 3,545 (13.3%) CV events, 4,231 (15.9%) dialysis introductions, and 5,561 (20.9%) red-blood-cell transfusions were observed. The risks of clinical events were significantly higher in the low and LAL Hb groups than in the target Hb group (Fig. 2). The hazard ratios (95% CIs) for death, CV events, dialysis introduction, and red-blood-cell transfusion in the low Hb group, compared to the target Hb group were 1.35 (1.20–1.52), 1.90 (1.58–2.27), 1.75 (1.39–2.20), and 2.80 (2.28–3.43), respectively, and in the LAL Hb group were 1.28 (1.14–1.43), 1.71 (1.43–2.04), 1.85 (1.48–2.33), and 1.64 (1.33–2.02), respectively. In HA Hb group, significantly higher risks for dialysis introduction and red-blood-cell transfusion were observed. Conclusion This study reports comprehensive information on anemia management in NDD-CKD patients in clinical practice. Despite treatment for Hb correction, 20–30% of patients persistently remained at low Hb levels. The increased risk of adverse clinical events associated with Hb fluctuations suggest that stable Hb control within the target range is important to reduce the risk of mortality and morbidity in patients with NDD-CKD and anemia.

A single approach to targeting transferrin receptor 2 corrects iron and erythropoietic defects in murine models of anemia of inflammation and chronic kidney disease

Anemia is a common complication of systemic inflammation. Proinflammatory cytokines both decrease erythroblast sensitivity to erythropoietin (EPO) and increase the levels of the hepatic hormone hepcidin, sequestering iron in stores and causing functional iron deficiency. Anemia of chronic kidney disease (CKD) is a peculiar form of anemia of inflammation, characterized by impaired EPO production paralleling progressive kidney damage. Traditional therapy based on increased EPO (often in combination with iron) may have off-target effects due to EPO interaction with its non-erythroid receptors. Transferrin Receptor 2 (Tfr2) is a mediator of the iron-erythropoiesis crosstalk. Its deletion in the liver hampers hepcidin production, increasing iron absorption, whereas its deletion in the hematopoietic compartment increases erythroid EPO sensitivity and red blood cell production. Here, we show that selective hematopoietic Tfr2 deletion ameliorates anemia in mice with sterile inflammation in the presence of normal kidney function, promoting EPO responsiveness and erythropoiesis without increasing serum EPO levels. In mice with CKD, characterized by absolute rather than functional iron deficiency, Tfr2 hematopoietic deletion had a similar effect on erythropoiesis but anemia improvement was transient because of limited iron availability. Also, increasing iron levels by downregulating only hepatic Tfr2 had a minor effect on anemia. However, simultaneous deletion of hematopoietic and hepatic Tfr2, stimulating erythropoiesis and increased iron supply, was sufficient to ameliorate anemia for the entire protocol. Thus, our results suggest that combined targeting of hematopoietic and hepatic Tfr2 may be a therapeutic option to balance erythropoiesis stimulation and iron increase, without affecting EPO levels.

The Interplay Of The Angiotensin Receptor Blockers And Haematological Abnormalities: Insights And Implications.

Antihypertensive medications known as angiotensin receptor blockers (ARBs) have become increasingly popular for treating conditions beyond hypertension. The reason for this widespread use is mainly due to its reno-protective and cardioprotective properties in patients with congestive heart failure and diabetes mellitus. There have been conflicting studies on the relationship between ARBs and haematological abnormalities. Using the supplied search terms, we carried out a thorough search for relevant papers written in English and published before January 2024. All of the studies that met the selection criteria were searched for on PubMed, Cochrane Library, and Google Scholar. Based on the examined data from the searched literature, it has been demonstrated that angiotensin II is essential for the stimulation of erythropoiesis and inhibition of it by drugs such as ARBs can lower haematocrit levels, leading to anaemia. Accordingly, dose reduction or stopping the administration of ARBs could be a choice to correct anaemia. However, such a decision is based on the clinical situation and the requirements for other management options.

Potential new application points of SGLT2 inhibitors in patients with heart failure in combination with diabetes mellitus, non-alcoholic fatty liver disease and anemia (literature review)

Chronic heart failure is a global cardiac problem. The last decade can rightly be called a breakthrough in the treatment of this nosology, due to the emergence of a new group of drugs – SGLT2 inhibitors (gliflozins), which, both in patients with initial heart failure with different ejection fraction, and in the presence of risk factors for its development, have a persistent positive impact on the number of hospitalizations for heart failure. A number of pleiotropic effects of SGLT2 inhibitors are also attractive to the clinician, which include moderate weight loss, a decrease in body fat in visceral fat depots, a decrease in the level of hepatic transaminases in the blood, stimulation of erythropoiesis, which organically complements the strategy of complex cardiorenometabolic protection and emphasizes the unique role of this class drugs in modern cardiology. In the near future, we will have to learn the results of the ongoing multiple studies of gliflozin, which is highly likely to open new historical horizons in the treatment of patients with cardiovascular diseases, including various categories of patients with acute and chronic heart failure.

Inhibition of Hypoxia Inducible Factor Prolyl Hydroxylase By FG-4592 (Roxadustat) Increases Erythropoietic Stimulation in a Mouse Model of Sickle Cell Disease

Sickle cell disease (SCD) is a devastating monogenic disorder caused by a mutation in the β-globin gene, leading to production of mutant hemoglobin S (HbS). Abnormal polymerization of deoxygenated HbS causes sickling of red blood cells (RBCs), resulting in painful vaso-occlusive crises and chronic hemolytic anemia. Etiologies of chronic anemia in SCD are multifactorial, including intravascular and extravascular hemolysis, inadequate erythropoietin (EPO) production, and abnormal iron homeostasis (Xu and Thein, Blood 2022). Hydroxyurea (HU) is the standard-of-care drug therapy for SCD and primarily reduces HbS polymerization through induction of fetal Hb (HbF) expression. However, it only modestly improves anemia and does not address other causes of anemia in SCD. Additionally, lower Hb levels in SCD are associated with chronic kidney disease (CKD), stroke, and pulmonary hypertension, arguing for the need for additional therapies targeting anemia in SCD. Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are a class of drugs developed for treatment of anemia in CKD and end-stage renal disease. HIF-PHIs stimulate erythropoiesis by inhibiting prolyl hydroxylase and von Hippel-Lindau (VHL)-mediated degradation of HIF-α, leading to increased hypoxic signaling and promotion of HIF-induced EPO expression in the kidneys and liver. Stimulation of erythropoiesis also increases production of erythroferrone, the main regulator of hepcidin, and suppression of hepcidin levels by HIF-PHIs may improve iron mobilization. Furthermore, HIF-PHIs can induce HbF expression in erythroblasts derived from CD34+ hematopoietic stem and progenitor cells (HSPCs) (Hsieh et al.,Blood 2007, Feng et al., ASH abstract 2021), suggesting multiple potential therapeutic benefits in SCD. Therefore, we characterized the effect of the HIF-PHI FG-4592 (roxadustat), on HbF induction in CD34+ HSPCs and on hematologic markers, EPO and hepcidin expression in a mouse model of SCD. CD34+ HSPCs from 3 donors were differentiated in vitro to erythroblasts with vehicle, 20 μM of FG-4592, or 50 μM of HU. Flow cytometric analysis on Day 9 showed that FG-4592 treatment increased % F-cells by 1.47-fold (±0.45), compared to a 2.21-fold (±0.89) increase with HU (Fig. 1). We then transplanted lethally irradiated (1000 rads) male 6-8-week-old C57BL/6J mice with bone marrow from transgenic sickle cell mice (Hb SS; Townes model, Jackson Laboratory). Twelve weeks after transplantation, mice with >80% engraftment of the donor HbSS phenotype, determined by Hb electrophoresis, were used for subsequent experiments. Vehicle, 25 mg/kg FG-4592, or 50 mg/kg FG-4592 was administered three times weekly through intraperitoneal injection for 8 weeks. All mice underwent retro-orbital bleeding at baseline (48 h pretreatment), 2, 4, 6, and 8 weeks of treatment for hematological evaluation, including Hb, hematocrit, and reticulocyte % (Fig. 1). At the end of 8 weeks, livers, kidneys, and plasma were collected. Hb and hematocrit levels increased in the 50 mg/kg FG-4592 group compared to the other groups at 4 weeks but decreased by 8 weeks for all groups. Reticulocyte % also decreased in all groups at the 4- and 8-week timepoints. Red cell distribution width (RDW) and platelet count up-trended while mean corpuscular volume (MCV) and mean corpuscular Hb (MCH) down-trended over the 8 weeks, suggestive of an evolving iron deficiency contributing to worsening anemia. Quantitative PCR detected a 182% increase in liver EPO transcript and a 68% increase in kidney EPO transcript in the 50 mg/kg FG-4592 treated group, compared to vehicle. No changes in liver hepcidin transcription were observed in any group. ELISA analysis detected increased plasma EPO and decreased plasma hepcidin levels with increasing doses of FG-4592. None of these trends, except increases in RDW, were statistically significant. Our study is the first to characterize the effect of HIF-PHI drugs in a mouse model of SCD. Preliminary data confirm an effect of FG-4592 on HbF induction and suggest that FG-4592 may increase EPO expression and decrease hepcidin levels in SCD mice. These results highlight the potential of prolyl hydroxylase inhibition as a novel therapeutic approach for chronic anemia in SCD. Future directions include testing higher doses of FG-4592 to induce a stronger erythropoietic effect and monitoring additional markers of iron homeostasis in our mouse model of SCD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Luspatercept in Combination with Recombinant-Erythropoietin in MDS RS Patients: Stimulating Early and Late Erythropoiesis

Myelodysplastic syndrome with ring sideroblasts (MDS RS) and SF3B1 mutation is generally marked by severe anemia, limited response to recombinant erythropoietin (rEPO) and consequent transfusion burden. Recently, luspatercept, a TGF-beta-pathway inhibitor, was shown beneficial in approximately 1/3 of patients by reactivating late-stage erythropoiesis. Since rEPO mainly acts on early-stage erythropoiesis, we hypothesized a possible role of combination therapy in this subset of patients. Seven patients with MDS RS treated with luspatercept in combination with rEPO at two tertiary hematologic centers in Milan, Italy were retrospectively evaluated. Luspatercept was administered according to current data sheet (1 to 1.75mg/kg every 3 weeks). Endogenous (e)EPO was evaluated before rEPO start, and patients with values < 200 IU/L received subcutaneous epoetin alpha 40,000 U/week, while those with higher values received 80,000 U/week. Hematologic data and number of RBC transfusions were collected at each cycle of luspatercept, and hematologic improvement (HI) was assessed according to the revised International Working Group (IWG) 2018. All 7 patients were males, with a median age of 83 years old (70-90). According to IPSS-R, three patients were classified as intermediate risk, while the others were lower risk. At the time of luspatercept start all patients were anemic with median Hb values of 7.3 g/dL (6.1-9.9), while median neutrophil (3.1x103/mm3, 0.8-4.9) and platelet (200x103/mm3,43-282) counts were normal. The median number of RBC units transfused in the last 8 weeks before luspatercept was 8 (3-11). Figure 1 details the timing and doses of luspatercept and rEPO treatment. In total, 5 patients received rEPO as add-on treatment due to non- or loss of response to luspatercept. Median eEPO values in these subjects were 250 (99-445) IU/L. Overall, three patients (Case 1, 2 and 3) achieved HI, and one of them became transfusion independent. Specifically, Case 1 achieved minimal HI with luspatercept after cycles 2 and 6, and lost response; rEPO was added at cycle 12 with HI after cycle 14. Case 2 initially reached HI after cycle 4 but showed several oscillations of pre-transfusion Hb (7 to 9 g/dL). At cycle 13 rEPO was added obtaining HI after cycle 20. Case 3 achieved HI after 2 cycles of luspatercept but lost response after cycle 10; rEPO was added at cycle 14 and he became transfusion independent. Patient 6 had rEPO as a pre-existing therapy and experienced a minimal HI after luspatercept start; rEPO had not been stopped to avoid a drop of pre-transfusion Hb. The other patients did not respond to luspatercept, nor to combination with rEPO, which was added at cycles 14 and 7 (Case 4 and Case 5), or already ongoing at luspatercept start in Case 7. Notably, no treatment emerging adverse events were registered with the combination. In conclusion, despite the small number of cases, these data show for the first time that combination therapy of luspatercept plus rEPO is feasible and beneficial in about one third of subjects. Concomitant stimulation of early and late-stage erythropoiesis may be an interesting strategy that requires further investigation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The effect of SGLT-2i administration on red blood cell distribution width in patients with heart failure and type 2 diabetes mellitus: A randomized study.

BackgroundRecent studies suggest that the pivotal mechanism of sodium glucose co-transporter-2 inhibitors (SGLT-2i) favorable action in patients with heart failure (HF) and type 2 diabetes mellitus (DM) is the stimulation of erythropoiesis via an early increase in erythropoietin (EPO) production which leads to hematocrit rise. Red blood cell distribution width (RDW) is a simple hematological parameter which reflects the heterogeneity of the red blood cell size (anisocytosis). Since, EPO has been also implicated in the pathophysiology of RDW increase, the current mechanistic study examined the effect of SGLT-2i administration on red blood cells size (RDW) in patients with HF and DM.MethodsThe present was a prospective single-center study. Patients (N=110) were randomly assigned to dapagliflozin (10 mg a day on top of antidiabetic treatment) or the control group. Inclusion criteria were: (a) age > 18 years, (b) history of type 2 DM and hospitalization for HF exacerbation within 6 months. The evaluation of patients (at baseline, 6 and 12 months) included clinical assessment, laboratory blood tests, and echocardiography. Data were modeled using mixed linear models with dependent variable the RDW index. In order to find factors independently associated with prognosis (1-year death or HF rehospitalization), multiple logistic regression was conducted with death or HF rehospitalization as dependent variable.ResultsAn RDW increase both after 6 and after 12 months was observed in the SGLT-2i (dapagliflozin) group (p < 0.001 for all time comparisons), whereas RDW didn't change significantly in the control group. The increase in RDW was positively correlated with EPO, while negatively correlated with ferritin and folic acid (p < 0.005 for all). Baseline RDW was significantly associated with 1-year death or rehospitalization, after adjusting for group (SGLT-2i vs. control), age, gender, smoking and BMI at baseline.ConclusionRDW increased with time in patients with HF and DM who received SGLT-2i (dapagliflozin). The increased RDW rates in these patients may stem from the induction of hemopoiesis from dapagliflozin. Baseline RDW was found to be independently associated with outcome in patients with HF and DM.

Darbepoetin alfa injection versus epoetin alfa injection for treating anemia of Chinese hemodialysis patients with chronic kidney failure: A randomized, open-label, parallel-group, non-inferiority Phase III trail.

BackgroundErythropoietin is a glycoprotein that mainly regulates erythropoiesis. In patients with chronic renal failure with anemia, darbepoetin alfa can stimulate erythropoiesis, correct anemia, and maintain hemoglobin levels. This study was designed to demonstrate the efficacy and safety of darbepoetin alfa injections as being not inferior to epoetin alfa injections (Recombinant Human Erythropoietin injection, rHuEPO) when maintaining hemoglobin (Hb) levels within the target range (10.0–12.0 g/dL) for the treatment of renal anemia.MethodsNinety‐five patients were enrolled in this study from April 15, 2013 to April 10, 2014 at 25 sites. In this study, patients (n = 95) aged 18–70 years were randomized into a once per week intravenous darbepoetin alfa group (n = 56) and a twice or three times per week intravenous epoetin alfa group (n = 39) for 28 weeks, who had anemia with hemoglobin levels between 6 g/dL and 10 g/dL due to chronic kidney disease (CKD) and were undergoing hemodialysis or hemofiltration with ESA‐naive (erythropoiesis stimulating agent‐naive). The primary efficacy profile was the mean Hb level (the non‐inferiority margin was −1.0 g/dL, week 21–28); the secondary efficacy profiles were the Hb increase rate (week 0–4), the target Hb achievement cumulative rate and time, the change trends of the Hb levels, and the target Hb maintenance ratio. Adverse events (AEs) were observed and compared, and the efficacy and safety were analyzed between the two treatment groups. Additionally, the frequencies of dose adjustments between the darbepoetin alfa and epoetin alfa groups were compared during the treatment period. SAS® software version 9.2 was used to perform all statistical analyses. Descriptive statistics were used for all efficacy, safety, and demographic variable analyses, including for the primary efficacy indicators.ResultsThe mean Hb level was 11.3 g/dL in the darbepoetin alfa group and 10.7 g/dL in the epoetin alfa group, respectively; the difference of the lower limits of the 95% confidence intervals (CI) between the two groups was 0.1 g/dL (>−1.0 g/dL), and non‐inferiority was proven; the Hb levels started to increase in the first four weeks at a similar increase rate; no obvious differences were observed between the groups in the target Hb achievement cumulative rates, and the Hb levels as well as the target Hb level maintenance rate changed over time. The incidence of AEs was 62.5% in the darbepoetin alfa group and 76.9% in the epoetin alfa group. All the adverse events observed in the study were those commonly associated with hemodialysis.ConclusionDarbepoetin alfa intravenously once per week can effectively increase Hb levels and maintain the target Hb levels well, which makes it not inferior to epoetin alfa intravenously twice or three times per week. Darbepoetin alfa shows an efficacy and safety comparable to epoetin alfa for the treatment of renal anemia.

Определение кобальта в образцах плазмы крови методом масс-спектрометрии с индуктивно-связанной плазмой после перорального приема содержащих кобальт биологически активных добавок к пище

Salts of inorganic cobalt (Со) prevent the degradation of the alpha subunit of the hypoxia-inducible factor (HIF), imitating the state of hypoxia in the body and increasing the production of the endogenous hormone erythropoietin (EPO), and are used as doping substances that increase blood oxygen capacity and endurance, which give competitive advantages in sports. Currently, a large number of dietary supplements, including Co-containing ones, are offered on free sale. Their uncontrolled intake can affect not only the professional career of athletes, but also their health, due to the fact that this trace element and its salts are the strongest inorganic poisons and carcinogens. Despite this, their availability on the pharmaceutical market, a noticeable effect of erythropoiesis stimulation and a convenient oral form of administration lead to the need for their detection in modern doping control. The purpose of this research was to develop an approach to differentiate cobalt from vitamin B12, present in the body in its natural state, from the intake of cobalt salts by quantifying and comparing blood levels of vitamin B12 and total cobalt. Methods. The study involved 9 healthy volunteers (women and men) aged 25 to 45 years, leading an active lifestyle. Three of them took 2500 μg/day of cobalamin for 20 days (comparison group), three - dietary supplement containing cobalt asparaginate (100 μg/day in terms of pure cobalt), and the rest - dietary supplements with cobalt sulfate heptahydrate (100 μg/day in terms of pure cobalt) (administration groups) at the same time after meals. Blood samples were taken at baseline and on days 5, 9, 14 and 20. The concentrations of total cobalt in blood plasma samples of volunteers were measured by inductively coupled plasma mass-spectrometry (ICP-MS), the levels of cobalamin were determined on a Cobas 6000 immunochemical analyzer using the Elecsys Vitamin B12 II Assay ELISA kits. Results. It was found that oral intake of of cobalamin at a therapeutic dose significantly exceeding the recommended daily intake (3 μg), there was a regular slight increase in the blood concentration of total cobalt (1.1 times). At the same time intake of dietary supplements containing cobalt in the form of sulfate or asparaginate (about 100 μg per day in terms of pure cobalt) was accompanied by 4-6.7 fold increase in the concentration of total cobalt while unchanged vitamin B12 plasma concentration was observed. The detection of such changes can reliably indicate the use of prohibited salts and, of course, will be in demand for anti-doping control. Conclusion. Long-term monitoring of vitamin B12 and total cobalt levels, similar to hematological module of the Athlete Biological Passport program, will unambiguously detect possible abuse of cobalt salts and can be an additional evidence of the presence of these doping substances to other analytical methods, such as a combination of liquid chromatography and ICP-MS (LC-ICP-MS).

Interaction between sodium-glucose co-transporter 2 and the sympathetic nervous system.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have taken centre stage in research and therapeutic efforts to modulate hard clinical outcomes in patients with heightened cardiovascular and renal risk profiles. Sympathetic nervous system (SNS) activation is a prominent feature across several cardiovascular and renal disease states. This review reflects on the remarkable clinical impact of SGLT2 inhibitors on cardiorenal outcomes, and navigates the evidence for a proposed clinically relevant interaction between SGLT2 and the SNS. SGLT2 inhibitors exert several pleiotropic effects beyond glucose-lowering. These include, but are not limited to, diuresis and natriuresis, blood pressure lowering, reduction in inflammation and oxidative stress, stimulation of erythropoiesis, and improvement in cardiac energetics. Treatment with SGLT2 inhibitors is associated with significant improvement in cardiorenal outcomes irrespective of diabetes status. In addition, evidence from preclinical studies points to a strong signal of a bidirectional temporal association between SGLT2 inhibition and reduction in SNS activation. Ongoing preclinical and clinical trials aimed at unravelling the proposed interaction between SGLT and SNS will enhance our understanding of their individual and/or collective contributions to cardiovascular disease progression and guide future targeted therapeutic interventions.

Erythropoiesis Stimulating Agents (ESAS) in Supportive Care of Low-Risk Myelodysplastic Syndromes: Recamds Registry FINAL Results

Erythropoiesis stimulating agents (ESAs) are the frontline treatment in low-risk anemic MDS patients and an employment of this therapy in the earlier stage of the disease can delay the need for RBC transfusion, hypothetically by slowing the disease course. It's matter of debate whether the clinical response is a result of proliferation and maturation of the dysplastic clone or stimulation of residual normal erythropoiesis by ESAs.Macrocytosis is one of the cytological hallmarks of dyserithropoiesis in MDS: an analysis of the erythropoietic response to ESAs therapy in a cohort of anemic non trasfusion-dependent MDS patients, enrolled in a retrospective register, RECAMDS, subgroup of Italian register, was performed.183 patients, treated with standard-dose ESAs, have been retrospectively analyzed. Data analysis was performed, according to IWG 2006 criteria, at the baseline, after 3 and 6 months of continuous treatment, with a subanalysis of the patients according to WHO and R-IPSS risk stratification. ESAs were started at mean Hb concentration of 9.31 g/dl, mean serum EPO concentration: 51 mU/L, after a mean time from diagnosis of 6 months (r.1-118).ORR was 83.6% (153/183), no difference among WHO and IPSS subgroups was found: 132/183 (72.1%) achieved response after 3 months of treatment, while other 21/183 (11.2%) after 6 months. 19 patients with stable disease(non-responders, according to IWG criteria), in which treatment was continued, achieved response after 9 months. In the macrocytic-responders group 83.2% exhibits again macrocytosis after 3 months, while 16.8% become normocytic. In the normocytic-responders group 89.8% exhibits again normocytosis, while 10.2% become macrocytic: in these patients, after 3 months, there was a contemporary worsening in neutropenia and thrombocytopenia, with transfusion-dependence, regarded as first signs of progression of disease. Non-responders were 30/183 (16.3%): in the macrocytic non-responders group 89% exhibit again macrocytosis after 3 months, while 11% become normocytic; in the normocytic group 76% exhibits again macrocytosis, while 24% become normocytic.These preliminary data can suggest that, in the majority of MDS patients responsive to ESAs, the increase of Hb concentration occurs mainly stimulating erythroid production in MDS clones; in the minority of patients probably it happens recruiting residual polyclonal erythropoiesis.It is interesting to note that stimulating effects of ESAs last even when the expression of dysplasia progresses. [Display omitted] DisclosuresMartinelli: Roche: Consultancy; Stemline Therapeutics: Consultancy; Abbvie: Consultancy; Jazz Pharmaceuticals: Consultancy; Celgene /BMS: Consultancy, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau; Incyte: Consultancy; Daichii Sankyo: Consultancy; Astellas: Consultancy, Speakers Bureau.

Luspatercept Redistributes Body Iron to the Liver in Transfusion-Dependent-Thalassemia (TDT) during Erythropoietic Response

Luspatercept Redistributes Body Iron to the Liver in Transfusion-Dependent-Thalassemia (TDT) during Erythropoietic Response

Female Hyperandrogenism in Elite Sports and the Athletic Triad.

Essential hyperandrogenism seems to be overrepresented in female elite athletes. This applies to mild forms such as polycystic ovary syndrome, as well as rare differences/disorders of sex development (DSD). The reason is likely a selection bias since there is increasing evidence that androgens are beneficial for athletic performance by potent anabolic effects on muscle mass and bone mass, and stimulation of erythropoiesis. XY DSD may cause a greatly increased production of testosterone in the male range, that is, 10 to 20 times higher than the normal female range. The established regulations concerning the eligibility of female athletes with severe hyperandrogenism to compete in the female classification remain controversial. The most common cause of menstrual disorders in female athletes, however, is probably an acquired functional hypothalamic disturbance due to energy deficiency in relation to energy expenditure, which could lead to low bone mineral density and increased risk of injury. This condition is particularly common in endurance and esthetic sports, where a lean body composition is considered an advantage for physical performance. It is important to carefully evaluate endocrine disturbances and menstrual disorders in athletes since the management should be specific according to the underlying cause.