ALBERT

Description: Inappropriately low expression of the key iron regulator hepcidin (HAMP) causes iron overload in untransfused patients affected by β-thalassemia intermedia and Hamp modulation provides improvement of the thalassemic phenotype of the Hbbth3/+ mouse. HAMP expression is activated by iron through the bone morphogenetic protein (BMP)–son of mothers against decapentaplegic signaling pathway and inhibited by ineffective erythropoiesis through an unknown “erythroid regulator.” The BMP pathway is inactivated by the serine protease TMPRSS6 that cleaves the BMP coreceptor hemojuvelin. Here, we show that homozygous loss of Tmprss6 in Hbbth3/+ mice improves anemia and reduces ineffective erythropoiesis, splenomegaly, and iron loading. All these effects are mediated by Hamp up-regulation, which inhibits iron absorption and recycling. Because Hbbth3/+ mice lacking Tmprss6 show residual ineffective erythropoiesis, our results indicate that Tmprss6 is essential for Hamp inhibition by the erythroid regulator. We also obtained partial correction of the phenotype in Tmprss6 haploinsufficient Hbbth3/+ male but not female mice and showed that the observed sex difference reflects an unequal balance between iron and erythropoiesis-mediated Hamp regulation. Our study indicates that preventing iron overload improves β-thalassemia and strengthens the essential role of Tmprss6 for Hamp suppression, providing a proof of concept that Tmprss6 manipulation can offer a novel therapeutic option in this condition.

Description: Introduction Anemia is a common and invalidating complication of chronic kidney disease (CKD) mainly due to the impaired erythropoietin (EPO) production that parallels the progression of kidney failure. The current treatment, based on erythropoiesis-stimulating agents (ESA), is far from optimal, because of potential off-target side effects. The same holds true for HIF-stabilizers tested in phase 3 clinical trials. For this reason, the identification of agents that selectively boost erythropoiesis would be of great benefit. Transferrin Receptor 2 (TFR2) is a protein expressed in hepatocytes, where it modulates iron homeostasis activating hepcidin production, and in erythroid cells, where it acts as a partner of erythropoietin (EPO) receptor decreasing EPO signaling. Tfr2 deletion in the liver causes iron overload due to low hepcidin levels, while its deletion in erythroid compartment enhances erythropoiesis through increased EPO sensitivity. Aim The study aims at exploring whether erythroid TFR2 is a potential therapeutic target in anemia of CKD, characterized by reduced EPO production and function. Methods CKD was induced by feeding animals an adenine-rich diet for 8 weeks. The protocol was applied to both wild-type animals, to set-up the system, and to mice with genetic bone marrow Tfr2 deletion (Tfr2BMKO). Complete blood count (CBC) and serum urea were evaluated every 2 weeks during the entire protocol. At the end of the 8 weeks animals were sacrificed and a complete phenotypic analysis of hematological parameters, renal damage and iron homeostasis was performed. Results Wild-type mice fed the adenine diet showed renal damage and inflammation, anemia and iron restriction, recapitulating the main features of human CKD. Renal damage and iron restriction were similar between Tfr2BMKO and control mice, excluding a differential effect of the diet on the two genotypes. Tfr2BMKO mice maintained higher red blood cell count relative to controls for the entire timespan. Hemoglobin levels were higher in Tfr2BMKO mice for 6 weeks, while reached levels of controls at 8 weeks. Based on these findings we conclude that BM Tfr2deletion, increasing EPO sensitivity of erythroid cells, improves erythropoiesis and anemia until iron levels remains adequate. Conclusions We confirm that the adenine-induced murine model of CKD can be a suitable tool for the study of the pathophysiology of renal anemia and for the identification and validation of novel potential therapeutic approaches. More importantly, our results suggest that targeting Tfr2 could become a novel approach to ameliorate anemia of CKD. Given the TFR2 restricted expression, its inactivation would enhance EPO responsiveness selectively in erythroid cells, minimizing the risk of side effects. Targeting erythroid Tfr2 might be considered a novel "erythropoiesis-stimulating approach", likely applicable to other forms of anemia due to insufficient EPO stimulation and response. Disclosures Camaschella: Celgene: Consultancy; Vifor Iron Core: Consultancy; Novartis: Consultancy.

Description: Iron, an essential element in mammals, is absorbed by duodenal enterocytes, enters the circulation through the iron exporter ferroportin, (FPN), circulates bound to transferrin and is uptaken through Transferrin Receptor 1. If in excess, iron is stored in macrophages and hepatocytes and released when needed. To maintain systemic iron homeostasis and to avoid the formation of "non transferrin bound iron" (NTBI), a highly reactive form which causes organ damage, the liver synthetizes hepcidin that, binding FPN, blocks iron export to the circulation. Hepcidin integrates signals from body iron, erythropoiesis and inflammatory cytokines. Defective hepcidin production causes iron overload and organ failure in Hereditary Hemochromatosis and Thalassemia; hepcidin excess leads to anemia in Iron Refractory iron Deficiency Anemia (IRIDA) and Anemia of Inflammation (AI). In hepatocytes hepcidin is under the control of the BMP-SMAD pathway, which is activated in a paracrine manner by BMP2 and BMP6 produced by liver sinusoidal endothelial cells. BMP2 maintains hepcidin basal levels, while BMP6 controls its expression in response to iron. The two ligands have different affinity for BMP type I receptors ALK2 and ALK3, suggesting two distinct branches of the hepcidin activation pathway. This possibility is consistent with the non-redundant function of BMP2 and BMP6, the different iron phenotype of hepatocyte-conditional ALK2 and ALK3 KO mice and the residual ability of BMP6 to activate hepcidin in hemochromatosis mice. Moreover ALK2, but not ALK3, is inhibited by the immunophilin FKBP12 in the absence of ligands. The BMP pathway activation depends upon the coreceptor hemojuvelin (HJV), the MHC class I protein HFE and the second transferrin receptor (TFR2). Mutations of all these proteins lead to decreased hepcidin expression in hemochromatosis. Hepcidin expression is inhibited in iron deficiency, hypoxia and when erythropoiesis is increased. Inhibitors are the liver transmembrane serine protease TMPRSS6, whose genetic inactivation causes IRIDA, and the erythroid hormone erythroferrone (ERFE), which is released by erythropoietin-stimulated erythroblasts. The mechanism of hepcidin inhibition by ERFE is unclear; still to allow ERFE function the BMP-SMAD pathway has not to be hyperactive. Intriguingly, both iron deficiency and erythropoiesis require epigenetic modifications at the hepcidin locus with HDAC3-dependent reversible loss of H3K9ac and H3K4me3. Hepcidin also acts as an antimicrobial peptide since its expression, increased by proinflammatory cytokines, such as IL6 through JAK2-STAT3 signaling, restricts iron availability for microbial growth. This first-line of defense against infections negatively influences erythropoiesis since chronic hepcidin activation causes AI. Despite persistent JAK2-STAT3 activation, inhibition of the BMP-SMAD pathway reduces hepcidin activation in AI experimental rodent models, suggesting that hepcidin activation in inflammation requires a functional BMP-SMAD pathway. Independently from hepcidin, inflammation also reduces FPN mRNA levels, favoring macrophage iron sequestration. The identification of hepcidin-ferroportin axis molecular players has translational implications. In primary and secondary iron overload hepcidin agonists (hepcidin peptides or mimics, agents that inhibit the hepcidin inhibitor TMPRSS6 and likely the ALK2-inhibitor FKBP12) and ferroportin inhibitors are potentially useful to prevent iron overload and/or to favor iron redistribution to macrophages. In case of AI, hepcidin antagonists (including anti-hepcidin, anti-HJV and anti-BMP6 monoclonal antibodies, L-enantiomeric oligonucleotides targeting hepcidin, siRNA against hepcidin, non-anticoagulant heparins, the ALK2 inhibitor momelotinib) might improve erythropoiesis increasing iron availability. The effect of some agents that have now entered the clinical phase will become apparent in the coming years. Disclosures Camaschella: vifor Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Description: Inherited microcytic-hypochromic anemias in rodents and zebrafish suggest the existence of corresponding human disorders. The zebrafish mutant shiraz has severe anemia and is embryonically lethal because of glutaredoxin 5 (GRLX5) deletion, insufficient biogenesis of mitochondrial iron-sulfur (Fe/S) clusters, and deregulated iron-regulatory protein 1 (IRP1) activity. This leads to stabilization of transferrin receptor 1 (TfR) RNA, repression of ferritin, and ALA-synthase 2 (ALAS2) translation with impaired heme synthesis. We report the first case of GLRX5 deficiency in a middle-aged anemic male with iron overload and a low number of ringed sideroblasts. Anemia was worsened by blood transfusions but partially reversed by iron chelation. The patient had a homozygous (c.294A〉G) mutation that interferes with intron 1 splicing and drastically reduces GLRX5 RNA. As in shiraz, aconitase and H-ferritin levels were low and TfR level was high in the patient's cells, compatible with increased IRP1 binding. Based on the biochemical and clinical phenotype, we hypothesize that IRP2, less degraded by low heme, contributes to the repression of the erythroblasts ferritin and ALAS2, increasing mitochondrial iron. Iron chelation, redistributing iron to the cytosol, might relieve IRP2 excess, improving heme synthesis and anemia. GLRX5 function is highly conserved, but at variance with zebrafish, its defect in humans leads to anemia and iron overload.

Description: β-thalassemias are genetic disorders characterized by anemia, ineffective erythropoiesis, and iron overload. Current treatment of severe cases is based on blood transfusion and iron chelation or allogeneic bone marrow (BM) transplantation. Novel approaches are explored for nontransfusion-dependent patients (thalassemia intermedia) who develop anemia and iron overload. Here, we investigated the erythropoietin (EPO) receptor partner, transferrin receptor 2 (TFR2), as a novel potential therapeutic target. We generated a murine model of thalassemia intermedia specifically lacking BM Tfr2: because their erythroid cells are more susceptible to EPO stimulation, mice show improved erythropoiesis and red blood cell morphology as well as partial correction of anemia and iron overload. The beneficial effects become attenuated over time, possibly due to insufficient iron availability to sustain the enhanced erythropoiesis. Germ line deletion of Tfr2, including haploinsufficiency, had a similar effect in the thalassemic model. Because targeting TFR2 enhances EPO-mediated effects exclusively in cells expressing both receptors, this approach may have advantages over erythropoiesis-stimulating agents in the treatment of other anemias.

Description: Hereditary hemochromatosis (HH) is a genetically heterogeneous disorder characterized by elevated iron absorption from the diet, with consequent iron overload and tissue injury. Adult-onset forms of HH are caused by mutations in the HFE gene and in the gene for transferrin receptor 2 (TFR2). Human patients and mouse models of TFR2 and HFE-related HH show inappropriately low expression of hepcidin, the central regulator of iron metabolism. However, although these genes have been discovered far more than a decade ago, the mechanisms by which HFE and TFR2 influence hepcidin expression remain unclear. The bone morphogenetic protein BMP6 plays a key role in the regulation of hepcidin expression. BMP6 binds to type I (ALK3) and type II serine threonine kinase receptors, and to the coreceptor hemojuvelin (HJV), which phosphorylates intracellular SMAD proteins. Phosphorylated SMADs then bind to SMAD4 and translocate to the nucleus to induce the transcription of hepcidin. Inactivation of Bmp6 or Hjv in mice leads to considerably reduced hepcidin production and severe hepatic iron overload. However, there are major differences in hepcidin expression and extrahepatic tissue iron loading between Bmp6 or Hjv KO males and females, due to the suppressive effect of testosterone on hepcidin in males. In contrast to males, Bmp6-/- and Hjv-/-females still produce some hepcidin and do not massively accumulate iron in the pancreas, heart, or kidneys. The goal of this study was to investigate the role of Hfe and Tfr2 in the residual hepcidin production observed in the absence of Bmp6 in females. We used Bmp6-/-, Tfr2-/-, and B2m-/- mice to generate wild-type, single KO (Bmp6-/-, Tfr2-/-, or B2m-/-) and double KO (Tfr2-/- and Bmp6-/-, or B2m-/- and Bmp6-/-) mice, and we assessed Smad5 phosphorylation, hepcidin expression, and the sites of iron accumulation in the different groups of mice. Notably, B2m-/- mice develop spontaneously hepatic iron overload with a distribution similar to that seen in the liver of Hfe-/-mice and the lack of CD8+ lymphocytes and the absence of classical class I molecules in these mice are not responsible for their iron phenotype. Interestingly, the lack of functional Hfe or the lack of Tfr2 in Bmp6-/- females leads to a very similar phenotype that is much more severe than the single impairment of Bmp6, with massive iron loading in extrahepatic tissues, most notably the exocrine pancreas, the heart, and the kidney. Hepcidin mRNA and pSmad levels in the two categories of double KO females were much more strongly downregulated than in single Bmp6-/- females and, in contrast to Bmp6-/-females, no protein was detectable by ELISA in the double KO mice. Our findings clearly demonstrate that Hfe and Tfr2 regulate hepcidin production independently of Bmp6. The symmetrical phenotype of double Bmp6 and Tfr2, or double Bmp6 and Hfe KO mice suggests that Hfe and Tfr2 could participate in the same signaling complex affecting pSmad levels, even if they do not physically interact. Two complexes, one made of ALK3 and HJV, and the other made of ALK2, ALK3, HFE, and TFR2, very likely affect pSMAD levels independently of each other. Signaling through the second complex occurs in the absence of BMP6 and is most probably initiated by another BMP, for instance BMP2 or BMP4 that are also expressed in the liver and, although not regulated by iron, are capable of stimulating hepcidin expression in hepatocytes. Regulation of hepcidin expression by these two complexes would explain why, whereas Alk3, double Bmp6/Hfe, and double Bmp6/Tfr2 deficient females present with iron overload in extrahepatic tissues as do hepcidin KO mice, Bmp6 and Hjv single KO females present with early-onset iron overload only in the liver, similarly to patients with juvenile HH, and mice KO for Alk2, Hfe, or Tfr2 have the least severe phenotype, comparable with that of patients with adult-onset HH. Notably, TFR2 was also shown to localize in lipid rafts where it promotes MAPK activation. Thus, in addition to its role in the complex affecting pSMAD levels, TFR2 could also regulate hepcidin through a parallel pathway involving ERK1/2 signaling. This would explain the more severe phenotype of mice with combined deletion of Hfe and Tfr2 and the fact that, whereas Tfr2-/- mice do not respond to acute iron loading, Hfe-/-mice still have a significant, although blunted hepcidin response. This work was funded in part by FRM (DEQ2000326528) and ANR (ANR-13-BSV3-0015-01). Disclosures No relevant conflicts of interest to declare.