Congenital dyserythropoietic anemia in children: Case series with review of literature
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Congenital dyserythropoietic anemia (CDA) are a diverse category of heritable anemia. The causative genetic abnormalities interfere with the normal developmental process of erythrocyte maturation inside the bone marrow. As a consequence, red blood cell precursors die prematurely in the marrow (ineffective erythropoiesis) and the altered mature RBCs that come to peripheral blood have reduced survival. Due to relative rarity and resemblance to other common disorders, the diagnosis is often delayed. Apart from having symptoms related to anemia and chronic hemolysis, most of these patients suffer from complications of iron overload even if not transfusion dependent. Classically, 3 major categories of CDAs have been described (I, II, III). Other described CDA variants are rare. With easier accessibility and widespread availability of genetic testing, it is possible to make molecular diagnoses for most cases. The diagnosis can be accelerated by targeted next-generation sequencing. There's no unifying theory explaining the pathogenesis behind the disease causation. In-depth understanding at the cellular level has clarified the multifactorial pathologic process. In this review, we describe the epidemiology, pathophysiology, clinical features, and management options available for CDA. We also summarize a brief report of 17 CDA patients diagnosed and treated at our center in the last 5 years, with their genetic findings, wherever available.Keywords:
Ineffective erythropoiesis
Pathophysiology
Causation
Pathogenesis
Ineffective erythropoiesis
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Growth differentiation factor 15 (GDF15) was identified as a hepcidin-suppression factor that is expressed at high levels in patients with ineffective erythropoiesis. This review addresses the regulation, expression and potential functions of GDF15 in the context of erythroid biology.GDF15 expression during late erythroid differentiation was discovered as part of an erythroblast transcriptome project. As GDF15 expression is associated with cellular stress or apoptosis, further investigation of the cytokine was focused upon its involvement in ineffective erythropoiesis. Remarkably high serum levels were detected in patients with thalassemia syndromes, congenital dyserythropoiesis and some acquired sideroblastic anemias. High-level GDF15 expression is not a feature of normal erythropoiesis, or erythroid recovery after bone-marrow transplantation. As GDF15 is a transforming growth factor-beta superfamily member, it was investigated as an effector of ineffective erythropoiesis that suppresses hepcidin expression despite iron overloading.In contrast to the low levels of GDF15 expressed during normal erythropoiesis, ineffective erythropoiesis causes high-level expression of GDF15. In patients with thalassemia and related anemias, GDF15 expression may contribute to iron overloading or other features of the disease phenotype.
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S ummary . Existing ferrokinetic methods do not provide a direct and quantitative measurement of effective and ineffective red cell production. A new method is described for calculating the daily uptake of iron by maturing red cells and the mean red cell lifespan. Ineffective erythropoiesis and non‐erythroid iron turnover are also measured. The method involves standard laboratory techniques but the analysis requires access to a computer. The preliminary results suggest that it will be a clinically useful tool for the investigation of erythroid disorders.
Ineffective erythropoiesis
Red Cell
Iron Isotopes
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The hematologic disorders myelodysplastic syndromes and beta-thalassemia are characterized by ineffective erythropoiesis and anemia, often managed with regular blood transfusions. Erythropoiesis, the process by which sufficient numbers of functional erythrocytes are produced from hematopoietic stem cells, is highly regulated, and defects can negatively affect the proliferation, differentiation, and survival of erythroid precursors. Treatments that directly target the underlying mechanisms of ineffective erythropoiesis are limited, and management of anemia with regular blood transfusions imposes a significant burden on patients, caregivers, and health care systems. There is therefore a strong unmet need for treatments that can restore effective erythropoiesis. Novel therapies are beginning to address this need by targeting a variety of mechanisms underlying erythropoiesis. Herein, we provide an overview of the role of ineffective erythropoiesis in myelodysplastic syndromes and beta-thalassemia, discuss unmet needs in targeting ineffective erythropoiesis, and describe current management strategies and emerging treatments for these disorders.
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Purpose of review In thalassemia, ineffective erythropoiesis is characterized by apoptosis of the maturing nucleated erythroid cells. New studies also suggest that limited erythroid cell differentiation plays a role in the development of ineffective erythropoiesis. This would further exacerbate anemia and increase iron absorption. Recent findings During erythroid differentiation and maturation, it is critical that the components of hemoglobin are made in stoichiometric amounts. It is, therefore, conceivable that factors that modify this process intrinsically or extrinsically will also affect erythropoiesis. Several proteins have the potential to alter erythroid replication and differentiation in conditions of ineffective erythropoiesis. Elevated erythropoietin levels increase the number of erythroid precursors bearing a phosphorylated form of Jak2. This, in a pathological condition, may contribute to limited erythroid differentiation. Unbalanced synthesis of globins and heme modifies the activity of the heme-regulated inhibitor kinase, affecting proliferation and differentiation of the erythroid precursors. In addition, inefficient elimination of reactive oxygen species, which are increased under conditions of iron overload, may also hamper erythropoiesis. Summary Use of Jak2 inhibitors may limit the overproduction of immature erythroid cells in thalassemia, with the potential of reversing extramedullary hematopoiesis and preventing splenectomy. In addition, preventing iron overload and formation of reactive oxygen species may also be beneficial in limiting tissue damage and ineffective erythropoiesis.
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THE anemia associated with thalassemia provokes a compensatory hyperplasia of the erythroid marrow, which in turn is associated with severe skeletal abnormalities. This study involved two previously splenectomized subjects with anemia and ineffective erythropoiesis. After basal measurements, the two patients were given transfusions to reduce erythropoietin stimulation of the erythroid marrow. This treatment provided an opportunity to evaluate the effect of suppression of erythropoiesis on bone metabolism.Ferrokinetic measurements and studies of erythropoiesis in marrow specimens indicated that rates were more than 10 times normal before transfusion. The bones were osteopenic, with decreased mineralized bone as well as increased osteoid. . . .
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Minihepcidins are hepcidin agonists that have been previously shown to reverse iron overload and improve erythropoiesis in mice affected by non-transfusion-dependent thalassemia. Given the extreme anemia that occurred with the previous model of transfusion-dependent thalassemia, that model was inadequate for investigating whether minihepcidins can improve red blood cell quality, lifespan and ineffective erythropoiesis. To overcome this limitation, we generated a new murine model of transfusion-dependent thalassemia with severe anemia and splenomegaly, but sufficient red cells and hemoglobin production to test the effect of minihepcidins. Furthermore, this new model demonstrates cardiac iron overload for the first time. In the absence of transfusions, minihepcidins improved red blood cell morphology and lifespan as well as ineffective erythropoiesis. Administration of a minihepcidin in combination with chronic red blood cell transfusion further improved the ineffective erythropoiesis and splenomegaly and reversed cardiac iron overload. These studies indicate that drugs such as minihepcidins have therapeutic potential for patients with transfusion-dependent thalassemia.
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In humans, β -thalassemia dyserythropoiesis is characterized by expansion of early erythroid precursors and erythroid progenitors and then ineffective erythropoiesis. This ineffective erythropoiesis is defined as a suboptimal production of mature erythrocytes originating from a proliferating pool of immature erythroblasts. It is characterized by (1) accelerated erythroid differentiation, (2) maturation blockade at the polychromatophilic stage, and (3) death of erythroid precursors. Despite extensive knowledge of molecular defects causing β -thalassemia, less is known about the mechanisms responsible for ineffective erythropoiesis. In this paper, we will focus on the underlying mechanisms leading to premature death of thalassemic erythroid precursors in the bone marrow.
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THE erythropoietic abnormality in patients with homozygous β-thalassemia results from a genetically determined defect in globin (β-chain synthesis. Erythroid activity is vastly increased, and estimates of the degree of hyperplasia vary from five to 30-fold.1 , 2 Much of this activity is known to be ineffective, but quantitative assessment of total, effective and ineffective erythropoiesis has not been possible. We have used a recently developed ferrokinetic technic3 , 4 to measure the amount of erythropoiesis and its effectiveness in patients suffering from homozygous β-thalassemia, and this procedure has allowed a preliminary examination of the effect of blood transfusion on erythroid activity. In patients having . . .
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Abnormality
Beta thalassemia
Transfusion Therapy
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β‐thalassemia is a disease associated with decreased β‐globin production leading to anemia, ineffective erythropoiesis, and iron overload. New mechanisms associated with modulation of erythropoiesis and iron metabolism have recently been discovered in thalassemic mice, improving our understanding of the pathophysiology of this disease. These discoveries have the potential to be translated into clinically‐relevant therapeutic options to reduce ineffective erythropoiesis and iron overload. A new generation of therapies based on limiting ineffective erythropoiesis, iron absorption, and the correction of iron maldistribution could be on the way, possibly complementing and improving the current standard of patient care.
Ineffective erythropoiesis
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