Iron deficiency anemia in pregnancy is a significant health concern. Reticulocyte hemoglobin equivalent (Ret-He) and immature reticulocyte fraction (IRF) are emerging as early markers, yet their response to different iron therapies in pregnancy is underexplored. To determine whether intravenous single-dose iron administration produces a more favorable effect on reticulocyte indices than oral iron therapy in anemic pregnant women. This is a secondary analysis of the RAPIDIRON Trial, a multicenter, three-arm randomized controlled trial comparing ferric carboxymaltose (FCM), ferric derisomaltose (FDM) and standard oral ferrous sulfate. Reticulocyte hemoglobin equivalent (Ret-He), Immature Reticulocyte Fraction (IRF) and other red blood cell indices including Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), Mean Corpuscular Hemoglobin Concentration (MCHC) were measured at baseline (12-16 weeks), mid-gestation (26-30 weeks) and 42 days postpartum. Cord blood indices were assessed at delivery. By 26-30 weeks of gestation, iron deficient anemic women receiving IV iron demonstrated significant improvements in all red cell indices when compared to those receiving oral iron. Specifically, MCV increased by 2.87 fL (95% CI, 2.41-3.33) in the IV FDM group and 3.02 fL (95% CI, 2.54-3.49) in the IV FCM group compared to oral iron. Similarly Ret-He levels were also significantly increased in IV FDM and FCM compared to oral iron (1.32 (1.02, 1.63) and 1.31 (1.01, 1.62) respectively. By 42 days postpartum, intergroup differences in Ret-He, IRF and other parameters were no longer statistically significant, indicating that hematologic parameters had converged across treatment arms, reflecting restoration of iron homeostasis and stabilization of erythropoiesis in all groups. Intravenous iron therapy produces a more rapid and pronounced improvement in maternal red cell and reticulocyte indices than oral iron in moderately anemic pregnant women. Ret-He and IRF are emerging as early and sensitive biomarkers of iron availability and erythropoietic activity, with potential clinical utility for early detection of treatment response and optimization of iron therapy in pregnancy.
Serum ferritin and iron have high inter-individual variability and inflammatory sensitivity, limiting its diagnostic value in several clinical settings. The Reticulocyte Subpopulation Analysis may indicate iron availability during erythropoiesis in real time. This study investigated the associations between reticulocyte parameters and various hematological and iron-related biomarkers in Iron Deficiency Anemia. In this retrospective study, 150 patients with IDA (Iron Deficiency Anemia) were included (146 females, 97.3%; 23 pregnant, 15.8%; 12 on iron treatment, 8.0%), RET-He, LFR/MFR/HFR, and IRF were correlated with iron markers. Associations between anemia severity and treatment status were examined using Spearman correlation, Kruskal-Wallis, and Mann-Whitney U analyses. While other reticulocyte indices exhibited minor connections, RET-He showed strong positive correlations with ferritin (r=0.430, p<0.001), serum iron (r=0.364, p<0.001), and transferrin saturation (r=0.350, p<0.001 A significant decrease in RET-He was seen in mild anemia (24.6 pg) and severe anemia (15.2 pg, p<0.001). RET-He was marginally reduced (p=0.0750) while serum iron and transferrin saturation were considerably lower in iron-treated subjects (p=0.0023). Reticulocyte and iron characteristics did not correlate with age (p>0.05). A sensitive, independent biomarker of iron status, RET-He measures functional iron availability during erythropoiesis. Strong correlation and severity-stratified discrimination support in populations where inflammation confounds ferritin interpretation, RET-He inclusion into iron deficient diagnostic methods. Prospective studies are needed to establish clinical thresholds and validate RET-He in chronic renal disease, inflammatory conditions, and pregnancy-related iron metabolism.
Anemia, inflammation and iron deficiency are linked to Fibroblast growth factor 23 (FGF23). Aim of this study was to explore the dynamics of FGF23 in Hereditary Hemochromatosis type-I (HH1). Twenty-six consecutive patients with genetically confirmed and uncomplicated HH1 and nineteen healthy age-matched voluntary blood donors (CTR) were enrolled for the study. Intact (iFGF23) and C-terminal (cFGF23) FGF23 and iron status markers were evaluated at baseline (T0) and seven days (T7) after phlebotomy/voluntary blood donation (VBD). Bone mineral density (BMD) and vertebral fracture assessment (VFA) were also evaluated at T0. Cross-sectional and longitudinal analyses failed to reveal significant differences in iFGF23 in both HH1 (T0: 54.27 ± 14.42 pg/mL; T7: 54.70 ± 15.48 pg/mL) and CTR (T0: 52.77 ± 17.63 pg/mL; T7: 53.27 ± 15.88 pg/mL) groups. Absence of significant difference was also observed for cFGF23 at baseline between the two groups (HH1, T0: 0.98 ± 0.39 pmol/L; CTR, T0: 1.18 ± 0.91 pmol/L) but not at T7 when the values (HH1, T7: 01.20 ± 0.89; CTR, T7: 1.84 ± 1.11 pmol/L) were significantly increased in CTR compared to T0 (p = 0.0003) and to HH1 (p = 0.0240). After phlebotomy/VBD, in both HH1 and CTR groups, serum levels of phosphate were unchanged from baseline while serum iron, ferritin and transferrin saturation and erythrocyte-related parameters (red blood cells, hemoglobin and hematocrit) were significantly reduced (all p  <  0.0001). Serum iron, ferritin, and transferrin saturation were significantly higher in HH1 than in CTR (p = 0.0002 for serum iron and p  <  0.0001 for both ferritin and transferrin saturation) at T7. In the CTR group, these parameters showed a trend toward iron deficiency whereas in HH1 they remained near the upper limit of the normal range, suggesting a persistent mild iron overload. Correlation and regression analyses did not show significant associations between circulating FGF23 (both iFGF23 and cFGF23) and iron status markers. BMD and VFA were not significantly different between HH1 and CTR. Furthermore, BMD and Trabecular Bone Score values were not associated with circulating FGF23 levels. This pilot study indicates that the serum levels of iFGF23 and cFGF23 and skeletal health evaluated through BMD and VFA do not differ between patients with uncomplicated HH1 and healthy subjects at baseline. The absence of changes in the serum levels of iFGF23 and cFGF23 in HH1 patients with uncomplicated HH1 after phlebotomy may reflect the persistence of iron overload which could counteract the physiological hypoxia-driven stimulation of FGF23 production and cleavage observed in healthy subjects after VBD.
Iron deficiency (ID) can occur before anemia and may impair performance, recovery, and hematological function, particularly in athletes. Female basketball players may be especially vulnerable due to high training demands and sex-specific iron losses. Therefore, this study aimed to compare nutrient intake and hematological and iron status biomarkers between ID and non-ID female basketball players, and to examine diet-biomarker correlations. Twenty-four female basketball players completed the study. Athletes were stratified by ferritin, with ID defined as <30 μg/L, resulting in 12 athletes per group. Dietary intake was assessed using a 48 h food record. Energy, macronutrients, fiber, iron, calcium, folate, vitamin B12, and vitamin C intakes were analyzed. Blood biomarkers included red blood cells (RBCs), hemoglobin (HGB), hematocrit (HTC), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), ferritin, serum iron, transferrin, total iron-binding capacity (TIBC), and unsaturated iron-binding capacity (UIBC). ID athletes had significantly lower fiber, iron, folate, and vitamin C intakes than non-ID. They also showed significantly lower HGB, HTC, MCV, MCH, and ferritin, and higher transferrin, UIBC and TIBC. Iron intake correlated positively with HGB, HTC, MCV, MCH, serum iron, and ferritin, and negatively with UIBC. Iron deficient female basketball players may present less favorable dietary profiles and altered hematological and iron status biomarkers. In this context, quarterly assessment of iron status biomarkers should be supported by nutrition education aimed at improving iron intake, alongside monitoring of energy and macronutrient intake in relation to training load. These approaches may help identify athletes requiring nutrition-focused support, although larger studies with longer-term dietary assessment are warranted.
Iron doping has been reported to significantly modify the properties of metal oxide nanoparticles (NPs), including their interaction with cells and therefore toxicity. The present study explores the ability of Fe³ ⁺-doped CeO2 NPs with the varying content of Fe3+ ions (3, 5, and 10 at%) to stimulate eryptosis, a controllable cell death pathway of mature erythrocytes, as an attempt to shed light on hemocompatibility of iron-doped CeO2 NPs. Overall erythrotoxicity of iron-doped CeO2 NPs was evaluated by investigating their ability to trigger spontaneous hemolysis and affect osmotic fragility of rat erythrocytes. Eryptosis of erythrocytes exposed to iron-doped and non-doped CeO2 NPs for 24 h was evaluated by the state-of-the-art flow cytometry-based annexin V staining. Mechanisms involved in iron-doped CeO2 NP-induced eryptosis were evaluated by 2',7'-dichlorodihydrofluorescein diacetate (H2DCFDA) and caspase-3 assays, as well as the fluorescent O1O (2-(2'-hydroxy-phenyl)-5-phenyl-1,3-oxazole), NR12S, Fluo-3 AM, BODIPY™ 581/591 C11, and BioTracker Far-red Fe2+ Live Cell imaging probes. Dose-dependent effects of iron-doped CeO2 NPs on hemolysis, osmotic fragility, and eryptosis were revealed. Eryptosis triggered by iron-doped CeO2 NPs was found to be oxidative stress-mediated, cation channel-driven, and caspase-dependent. Oxidative stress and alterations of lipid membranes demonstrated by the tested NPs could be attributable to their direct •OH generation and peroxidase-like activity, as well as Fe2+-mediated Fenton reaction at the surface of Fe³⁺-doped CeO₂ NPs (presumably due to Fe³⁺/Fe²⁺ redox cycling). Importantly, non-doped CeO2 NPs did not promote eryptosis. Nor they stimulated generation of ROS and Ca2+ influx. The presence of iron was found to mediate phosphatidylserine externalization, caspase activation, and changes in lipid membranes of erythrocytes. Notably, Fe³⁺-doped CeO2 NP-induced eryptosis was independent of p38 MAPK and CK1α. Iron-doped CeO2 NPs trigger eryptosis, an effect mediated by iron. Iron doping is a promising modification of CeO2 NPs, which can modulate their toxicity and widen their pharmaceutical profile.
The systemic blood milieu profoundly influences the cellular function across tissues, acting as a key driver of age-related cognitive decline. Therapeutic plasma exchange and heterochronic parabiosis have widely explored the role of plasma and blood age on various tissues. However, the role of red blood cells (RBCs) remains largely unexplored. In this study, we investigated the impact of RBCs and their exosomal cargo from young (aged 20-40 years) and old (aged 50-70 years) donors on human brain cells using a human brain microphysiological system (hB-MPS). The RBCs and their exosomes from the donors were circulated in the vascular channel of the hB-MPS device. Compared with that obtained from young donors, RBCs and their exosomes from old donors exhibited elevated levels of the inflammatory marker CD68 and increased the accumulation of heme in the brain cells. Molecular profiling of the RBC-derived exosomes using proteomics and microRNA sequencing analysis revealed age-associated differences in cargo, including downregulation of proteins linked to neuroprotective pathways and upregulation of those involved in inflammation and synaptic dysregulation. Proteomic analysis of the brain cells in response to the RBC-derived exosomes from older donors altered brain cell homeostasis by modulating key signaling pathways directly correlated to neurobiological processes such as cytokine signaling, neurotrophin signaling, metabolic activity, and DNA repair. This highlights a novel role for RBCs in brain aging and neuroinflammation and points toward RBCs and their exosomal profiling as a biomarker for age-associated pathologies.
The importance of iron in hematopoiesis in mammals is studied almost exclusively in relation to the synthesis of red blood cells, erythrocytes, due to the need for hemoglobin. However, other roles of iron during blood cell formation in other animals are less studied. Due to the lack of red blood cells in crustaceans and many other invertebrates, we have a unique opportunity to explore the role of iron in hematopoiesis in a freshwater crayfish, Pacifastacus leniusculus. In a recent scRNAseq analysis, we found that genes involved in iron homeostasis were specifically expressed in a small cell cluster in the hematopoietic tissue (HPT) and in this present study, we show that genes involved in iron metabolism are important for hematopoietic cell differentiation in the crayfish, P. leniusculus. Iron restriction impaired hemocyte migration and altered the expression of key genes involved in iron homeostasis as well as those participating in hemocyte differentiation. These results highlight the importance of IRP-mediated iron regulation for hemocyte differentiation and release of hemocytes from the hematopoietic tissue and demonstrate that iron availability affects mitochondrial and metabolic pathways important for immune cell development in this crustacean and possibly in other invertebrate animals as well.
Hemoglobin (Hgb) lacks sensitivity for early detection of iron deficiency (ID) and associated brain metabolic dysregulation in infancy. The utility of newer erythroid indices for early diagnosis of ID and altered brain metabolome is unknown. This study aimed to compare conventional and newer erythroid indices for predicting ID, anemia, and altered brain metabolome using a nonhuman primate model of infantile ID. Serum iron panel and erythroid indices were determined at 2 wk and 2, 4, and 6 months in male and female infant rhesus monkeys born to mothers consuming a 180 mg Fe/kg diet (n = 51). Cerebrospinal fluid (CSF) metabolomic profiles were obtained at 2 and 4 months in a subset of ID and iron-sufficient infants (n = 10). Accuracy for prediction of ID [transferrin saturation (TSAT) <20%], anemia (Hgb <10 g/dL), and CSF metabolomic changes was evaluated using t tests, regression models, and canonical correlation analysis (CCA). Twenty infants (39.2%) developed ID and 13 (25.5%) progressed to anemia. At 2 wk, newer erythroid indices-immature reticulocyte fraction, reticulocyte hemoglobin equivalent (RET-He), and difference between hemoglobin in reticulocytes and that in mature red blood cells (Delta-He)-were altered in infants who subsequently developed ID, and, along with percentage hypohemoglobinized and hyperhemoglobinized erythrocytes, predicted the future likelihood of ID and anemia (false discovery rate <0.05). Hgb was not predictive of ID or anemia until 2 mo. Among erythroid indices, Delta-He was the best predictor, with an accuracy of 84% for both, and was comparable with TSAT. CCA demonstrated correlations between 4-mo CSF metabolomic profile and 2-wk (r = 0.71), 2-mo (r = 0.82), and 4-mo (r = 0.79) erythroid profiles. Mean corpuscular hemoglobin and RET-He were the largest contributors to the correlations between the 2-wk and 2-mo erythroid profiles and the 4-mo CSF metabolomic profile. Newer erythroid indices detect ID, anemia, and brain metabolomic alterations earlier than conventional indices in infant monkeys.
Alcohol-related liver disease (ALD) and ALD-related mortality are associated with hemolysis, increased erythrophagocytosis, and disturbed iron homeostasis. While macrophage-mediated erythrophagocytosis is well established, we investigated the contribution of liver sinusoidal endothelial cells (LSECs) to handling oxidatively damaged or ethanol-primed red blood cells (RBCs) in ALD. Live-cell imaging demonstrated that damaged RBCs were rapidly taken up by SK-HEP1 cells, an endothelial cell line with LSEC-like characteristics, and RBC uptake was associated with induction of heme oxygenase-1 (HO-1) and activation of its upstream regulator Nrf2. siRNA-mediated knockdown of the scavenger receptor Stabilin-1 attenuated RBC-induced HO-1 expression, supporting a role for Stabilin-1 in efferocytic signaling. Exposure of RBCs to ethanol concentrations as low as 25 mM induced phosphatidylserine externalization and rendered erythrocytes efferocytosis-competent. Lysed RBCs and free hemin elicited comparable oxidative stress responses. In murine models of hemolysis and chronic ethanol feeding, hemoglobin-derived signals were detected within sinusoidal structures showing a diffuse CD206-positive distribution pattern consistent with the sinusoidal scavenger compartment. Similar signals were observed in sinusoidal endothelial regions in human heavy drinkers with clinical signs of hemolysis. Together, these data suggest that LSECs may represent an additional component of RBC clearance in ALD, alongside macrophages and hepatocytes, with implications for hepatic iron handling.
To assess abnormalities in red blood cell parameters, iron metabolism, and vitamin B12 status in children with obesity, and to evaluate the influence of dietary intake and obesity-related complications on these variables. A retrospective analysis was conducted in 152 children with obesity. Anthropometric, biochemical, and hematological parameters were assessed. Dietary intake was evaluated in a subgroup of 33 participants using 3-day food records. No cases of low hemoglobin levels were identified. However, elevated TIBC and occasional low ferritin levels suggested disturbances in iron metabolism. BMI Z-score was positively associated with red blood cell count and selected iron metabolism markers, whereas higher body fat percentage was negatively associated with hemoglobin and hematocrit. Dietary analysis indicated that protein and vitamin B12 intake were associated with erythrocyte parameters, while no associations were found for iron or folate intake. Elevated liver enzymes were associated with higher hemoglobin, hematocrit, and MCV values. Pediatric obesity was not associated with low hemoglobin levels but may be linked to early, subclinical disturbances in iron metabolism. These findings should be confirmed using more comprehensive biomarkers. Dietary factors, particularly vitamin B12 intake, may contribute to variability in erythrocyte parameters; however, these associations should be interpreted with caution. The observed relationship between liver function and erythrocyte indices warrants further investigation.
Sickle cell disease (SCD) causes erythrocyte sickling and downstream sequelae, including hemolysis, iron mishandling, and subclinical renal dysfunction, thereby reducing erythropoietic drive. These effects result in chronic anemia that drives SCD-related complications. Treatment of severe anemia in SCD with frequent subcutaneous injections of erythropoiesis-stimulating agents is often poorly tolerated by patients, underscoring the need for oral treatments. Here, we provide key insights into how daprodustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) that stimulates red cell production, may serve as a targeted treatment for anemia in SCD. In a mouse model of SCD, daprodustat increases red blood cell production, reduces sickling, and improves iron mobilization by suppressing hepatic hepcidin expression, thereby enhancing iron availability for erythropoiesis and ameliorating chronic anemia. In addition to these systemic, non-cell-autonomous effects on iron homeostasis, daprodustat directly induces γ-globin expression and increases the production of fetal hemoglobin-containing erythroid cells (F-cells) derived from CD34+ hematopoietic stem and progenitor cells of patients with SCD, conferring cell-autonomous therapeutic benefits. These findings demonstrate that HIF-PHIs act on multiple therapeutic targets in SCD and represent a promising oral treatment option for chronic anemia in this disease.
Thalassemia is one of the most common and harmful single-gene recessive disorders in the clinic. It is characterized by impaired or absent production of one globin chain of hemoglobin in adults. The most common form is beta-thalassemia, which is associated with defects in the production of beta-globin chain, resulting in an imbalance in the ratio of alpha-globin to beta-globin. As a result, unbound free alpha-globin chains precipitated in red blood cell precursors, resulting in iron overload, ineffective red blood cell production, and changes in mesenchymal stem cells, osteoblasts, osteoclasts, and other associated cells. Among them, iron overload and ineffective red blood cell production will destroy the bone marrow microenvironment, which will cause further damage to the hematopoietic system. Therefore, the correction of the bone marrow microenvironment plays an important role in the treatment of thalassemia. This review summarizes studies on the destruction of the bone marrow microenvironment in beta-thalassemia, treatment options for improving the microenvironment and stem cell transplantation. β-地中海贫血骨髓微环境的研究进展. 地中海贫血是临床最常见且危害严重的单基因隐性遗传病之一，其特征是成人血红蛋白的一条珠蛋白链的产生受损或缺失，最常见的形式是β-地中海贫血，其与β-珠蛋白链的产生缺陷有关，导致α-珠蛋白与β-珠蛋白的比例不平衡，未结合的游离α-珠蛋白链沉淀在红细胞前体中，会导致铁过载、无效红细胞生成、间充质干细胞、成骨破骨细胞及其他相关细胞的改变。其中，铁过载及无效红细胞生成均会破坏骨髓微环境，这将对造血系统造成进一步的损伤。因此，骨髓微环境的纠正对治疗地中海贫血起着重要作用。本文总结了β-地中海贫血的骨髓微环境破坏、针对改善微环境及干细胞移植的治疗方案的相关研究。.
To determine the red blood cell life span (RBCS) in female blood donors using a carbon monoxide (CO) breath test and analyze the influencing factors of RBCS. Female blood donors who donated whole blood at Fujian Blood Center from December 2023 to June 2024 were collected, and RBCS was measured using a CO breath test. The donors were grouped by age and body mass index (BMI), and hematological parameters were analyzed to establish 95% confidence interval. The donors were categorized into ferritin decline group and normal ferritin group based on their iron status, and the RBCS difference between the two groups were compared. The correlation between RBCS and iron metabolism indicators was analyzed and followed by linear regression analysis. The distribution of RBCS in 365 female blood donors was skewed. There were no significant differences in RBCS between different age groups and different BMI groups (P >0.05). The 95% confidence interval for RBCS was 67.7-173.2 days. The RBCS of ferritin decline group was 115.1(96.9,133.5) days, which was significantly longer than 107.1(88.5,127.7) days of normal ferritin group (P < 0.05). RBCS was significantly negatively correlated with serum iron and transferrin saturation (r =-0.412, -0.431), and positively correlated with unsaturated iron binding capacity (r =0.348). The multiple linear regression analysis of RBCS indicated that, in addition to hemoglobin and endtidal carbon monoxide, serum iron was also an important factor affecting RBCS (P < 0.05). As the availability of iron decreases, RBCS is prolonged, which may be an early compensatory response to iron deficiency in the body. 女性献血者红细胞寿命的测定及影响因素分析. 通过一氧化碳呼气试验测定女性献血者红细胞寿命（RBCS），并分析RBCS的相关影响因素。. 选取2023年12月-2024年6月在福建省血液中心捐献全血的女性献血者，采用一氧化碳呼气试验测定RBCS，按年龄、体重指数（BMI）进行分组并对各组血液学指标数据进行分析，建立95%置信区间；根据铁储备状况将女性献血者分为铁蛋白下降组和正常组，对比RBCS在两组间的差异性，分析RBCS与铁代谢指标的相关性，并进行线性回归分析。. 365名女性献血者的RBCS呈偏态分布，不同年龄、不同BMI组别之间的RBCS比较，差异均无统计学意义（P >0.05），其95%置信区间为67.7-173.2 d。铁蛋白下降组RBCS为115.1(96.9,133.5)d，明显长于正常组107.1(88.5,127.7)d（P < 0.05）。RBCS与血清铁、转铁蛋白饱和度呈显著负相关（r =-0.412、-0.431），与不饱和铁结合力呈显著正相关（r =0.348）。RBCS的多重线性回归分析显示，除了血红蛋白和呼气末一氧化碳浓度外，血清铁也是影响RBCS的重要因素（P < 0.05）。. 随着铁的可利用性下降，RBCS延长，RBCS延长可能是对机体缺铁的早期代偿性反应。.
Thalassemia major is a severe hemoglobinopathy that requires blood transfusion; however, long term blood transfusion might increase morbidity and mortality. Hemoglobin (Hb) after transfusion determines the need for next transfusion. There is controversy regarding the effect of fresh packed RBC compared to old packed RBC transfusion on Hb. This study compared hemoglobin changes following transfusion between fresh and old packed RBC in transfusion-related thalassemia (TRT) patients. In this cohort study, 140 TRT patients (age > 5years) referred to Bahrami Children's Hospital in mid-2013 were included. Equal number (n = 70) of age and gender matched TRT patients with exposure to fresh (stored for less than 7 days) and old (stored for more than 7 days) packed RBC transfusion were followed for 14 days. In both groups, demographic information (age, sex) were recorded at enrolment. Physical examination data and blood parameters, including red blood cells (RBC), white blood cells (WBC), platelets (PLT), Hb, ferritin, transferrin, total iron binding capacity and bilirubin at baseline and follow up. Time-group interaction was significant only for WBC (p < 0.001) and Hb (p = 0.029) indicating that fresh packed RBC transfusion resulted in higher Hb and lower WBC at follow up compared to baseline levels. Among the baseline variables only fresh packed RBC transfusion was found to increase the odds of having Hb of at least 1 mg/dL higher than baseline (OR = 15.465, p < 0.001). Fresh packed RBC transfusion might increase the interval between transfusions due to more Hb elevation rate after transfusion in thalassemia major.
Although anticancer agents are designed to selectively target malignant cells, they often also exhibit considerable nonspecific toxicity toward normal tissues, leading to adverse side effects in patients. In this context, the present study aimed to evaluate the toxic effects of a novel unsymmetrical bisacridine anticancer agent (UA) on normal, noncancerous cells and to compare its activity with that of three established acridine monomers (AMs). To assess the potential side effects of UA in different regions of the human body, four non-tumor cell models were selected: (i) erythrocytes, representing the circulatory system; (ii) MRC-5 cells, derived from normal lung tissue; (iii) CCD 841 CoN cells, originating from normal colon epithelium; and (iv) hTERT-HPNE cells, representing immortalized normal pancreatic epithelial cells. The results demonstrated that, apart from the dimer C-2042, which caused a slight increase in erythrocyte hemolysis and potassium leakage, neither UA nor the acridine monomers induced significant erythrocyte damage, promoted heme iron oxidation, or caused structural alterations in hemoglobin. In the remaining non-tumor cell models, UA and the three acridine monomers exhibited measurable cytotoxicity, with the cytotoxicity of UA falling between the levels observed for the monomers. Importantly, the cytotoxicity of all tested compounds toward non-tumor cells was several times lower than that previously observed in cancer cells derived from the corresponding tissues. Taken together, these findings indicate that UA exhibits limited toxicity toward normal, noncancerous cells, supporting its potential as an effective and safer anticancer agent.
Red blood cell (RBC) membrane lipid peroxidation during blood bank storage profoundly impacts transfusion efficacy; however, the genetic determinants underlying RBC resilience remain incompletely defined. Here, we identify a critical role for glutathione peroxidase 4 (GPX4) - a pivotal enzyme protecting against iron-dependent lipid peroxidation (ferroptosis) - in regulating RBC storage quality and post-transfusion survival. Conditional erythroid-specific deletion of Gpx4 in mice exacerbated lipid hydroperoxide accumulation, oxidation and ubiquitination of membrane proteins, and reduced RBC recovery after transfusion. Multi-omics analyses in 13,091 human blood donors from the REDS RBC Omics cohort identified regulatory intergenic (rs8178962), intronic and missense genetic variants in GPX4 (rs73507255, rs8178967), particularly prevalent among donors of African descent, that were linked to increased lipid peroxidation and compromised post-transfusion hemoglobin increments. Single protein- and metabolome-wide association studies (pQTL/mQTL) highlighted genetic variants associated with enhanced (rs8178962) or impaired GPX4 expression, disrupted glutathione homeostasis, lipid hydroperoxide accumulation, accelerated membrane damage, and activation of ferroptotic signatures during RBC storage. These effects were exacerbated by genetic traits impairing redox homeostasis, including glucose 6-phosphate dehydrogenase (G6PD) deficiency (African variant rs1050828 V68M/N126D). Storage of murine RBCs in presence of the ferroptosis inhibitor ferrostatin-1 prevented storage-induced lipid peroxidation and boosted post-transfusion recovery, a beneficial effect in part phenocopied by supplementation of lipophilic antioxidants vitamin E and Lands cycle fueling via L-carnitine, and in part ablated by GPX4 inhibition via the covalent inhibitor ML210. This study offers mechanistic insights into RBC ferroptosis and positions GPX4 genetic status as a promising biomarker for precision transfusion medicine.
Ultra-endurance running imposes extreme demands on oxygen transport, yet how red blood cells (RBCs) respond at the molecular level remains poorly defined. We integrated plasma and RBC multi-omics with hematology and hemorheology in athletes sampled before and after two trail races of distinct duration: a 40-km marathon (MCC) and a 171-km ultramarathon (UTMB). Both races elicited systemic inflammation, but UTMB was distinguished by marked IL-6 and kynurenine increases, acute-phase protein induction, and profound lipid remodeling. In RBCs, acylcarnitine accumulation, pantothenate depletion, and oxidized lipid species indicated Lands cycle activation, while purine salvage and carboxylate metabolism reflected redox-sensitive rerouting of energy pathways. Proteomics revealed non-random oxidation, particularly methionine oxidation of antioxidant enzymes, metabolic proteins, and proteasome components, correlating with impaired deformability as gleaned by testing of rheological properties. Elevated copper provided an additional correlate of reduced RBC mechanics. Despite minimal signatures of intravascular hemolysis, plasma bilirubin and hypoxanthine rose, consistent with extravascular clearance of damaged RBCs. Collectively, these results demonstrate that ultra-running accelerates RBC aging through inflammatory and oxidative pathways beyond mechanical trauma, linking systemic cytokine responses to molecular lesions, biomechanical dysfunction, and splenic sequestration. These findings not only identify actionable biomarkers of exercise-induced hemolysis but also provide translational insight into oxidative lesions that similarly limit RBC survival in transfusion and inflammatory disease settings.
Severe microcytic anemia may serve as a potentially reversible precipitating factor in heart failure with reduced ejection fraction (HFrEF). This case highlights the diagnostic complexity and hemodynamic consequences of severe, microcytic anemia with undetermined etiology in a patient presenting with newly diagnosed heart failure. A 60-year-old Hispanic woman presented with new-onset acute dyspnea, chest pain, and bilateral edema. Investigations revealed severe microcytic anemia (hemoglobin 4.5 g/dL, MCV 60.8 fL) and an ejection fraction of 33%. Iron studies (iron 40 μg/dL, ferritin 14 ng/mL, total iron binding capacity 541 μg/dL, transferrin saturation 7%) were consistent with presumed iron deficiency anemia. Imaging and fecal occult blood testing did not identify a source of bleeding or malignancy, and endoscopic imaging was not completed due to financial constraints. The patient received packed red blood cells and intravenous iron to stabilize the acute condition. This case highlights the importance of considering severe anemia as a possible precipitating factor in new-onset heart failure, as well as the need for comprehensive evaluation to identify potentially reversible triggers.
Exagamglogene autotemcel (exa-cel) is a one-time nonviral gene-edited therapy approved in the United States (US) for treatment of patients aged ≥12 with transfusion-dependent β-thalassemia (TDT). Standard of care (SOC) for TDT includes regular red blood cell transfusions (RBCTs) and iron chelation therapy. This study estimated long-term clinical outcomes and cost-effectiveness of exa-cel vs. SOC among patients with TDT in the US. A Markov model was developed to compare the expected lifetime costs and clinical outcomes of patients with TDT treated with exa-cel compared to SOC from the US payer and societal perspectives. The model structure is based on transfusion status, which impacts iron levels and risk of developing TDT-related complications. The model incorporated data from the phase 3 pivotal CLIMB THAL-111 trial and other inputs from literature. Model outcomes included life years (LYs) and quality-adjusted LYs (QALYs) as well as number of RBCTs and proportion of patients developing complications over a lifetime; costs and incremental cost-effectiveness ratios (ICERs) were also estimated. Costs and outcomes were discounted at 3% annually. In the eligible patient population (average age at baseline: 21 years), exa-cel was projected to improve survival by 17.6 years (mean age of death, exa-cel: 64.9 years vs. SOC: 47.3 years), reduce the number of RBCTs received by 425 (exa-cel: 26 vs. SOC: 451), and lower the proportion of patients developing TDT-related complications. Exa-cel was associated with increased discounted costs compared to SOC (exa-cel: $2.9 M vs. SOC: $1.8 M). The ICER per discounted QALY for exa-cel versus SOC was $114,100 from the payer perspective and $55,400 from the societal perspective. Compared to SOC, exa-cel was projected to considerably reduce the number of RBCTs and TDT-related complications, improve survival, and reduce disease-related costs. Exa-cel is projected to be a cost-effective treatment option for patients with TDT in the US. Transfusion-dependent beta-thalassemia (TDT) is an inherited blood disorder which requires frequent red blood cell transfusions and medicines to remove extra iron in the body. These treatments help patients live longer but come with serious side effects and high costs over time.Exagamglogene autotemcel (exa-cel) is a one-time gene-editing therapy approved in the United States (US) for patients aged 12 years and older with TDT. Patients treated with exa-cel can become transfusion independent and live without the need for transfusions.This study used an economic model to compare exa-cel with standard treatment (frequent transfusions and iron removal therapy) in the US. The model estimated survival, occurrence of complications, quality of life, and costs from the time of exa-cel treatment (average age: 21 years) until death.The model predicted that patients treated with exa-cel would live about 18 years longer than those receiving standard treatment (average life expectancy 65 vs. 47 years) and also have better quality of life. Patients treated with exa-cel were also expected to need far fewer transfusions (26 vs. 451), experience fewer disease-related complications, and cost $2.2 million less in disease-related costs over a lifetime.In summary, exa-cel has the potential to greatly improve survival and quality of life for people with TDT, while reducing long-term health care costs, making it a valuable new treatment option.
Some routine red blood cell (RBC) measurements and indexes (count, mean volume, volume dispersion, and mean hemoglobin [HGB] concentration) can be used to differentiate iron deficiency from heterozygous beta-thalassemia. A number of formulas that incorporate two or more of these measurements have been described to amplify such differences. The H*1 hematology analyzer directly measures volume and HGB concentration of individual RBCs. We have assessed the diagnostic usefulness of conventional and new RBC measurements provided by the H*1 on a learning data set that comprised 119 patients with iron deficiency and 172 patients with beta-thalassemia trait, both untreated and uncomplicated. The most striking finding was the inverse behavior of percentages of microcytes (volume, less than 60 fL) and hypochromic RBCs (HGB concentration, less than 280 g/L) in the two conditions. In 162 of 172 patients with beta-thalassemia trait, the percentage of microcytes (mean, 33.1%; central 95th percentile range, 9.2% to 54.5%) was higher than the percentage of hypochromic RBCs (mean, 13.9%; central 95th percentile range, 1.7% to 24.7%). In 105 of 119 patients with iron deficiency, on the contrary, the percentage of hypochromic cells (mean, 34.6%; central 95th percentile range, 9.7% to 73.1%) was higher than the percentage of microcytes (mean, 12.8%; central 95th percentile range, 1.7% to 29.6%). The ratio between the percentage of microcytes and the percentage of hypochromic cells provided by the H*1 (microcytic-hypochromic ratio) was useful in differentiating the two types of microcytic anemia: with the use of a discriminant value of 0.9, the discriminant efficiency of the microcytic-hypochromic ratio was 92.4% (95% confidence interval, 88.8% to 95.2%), higher than that of the five previously described discriminant formulas and simple RBC measurements. When assessed on a test data set that comprised 149 unselected cases of microcytic anemia, a microcytic-hypochromic ratio lower than 0.9 demonstrated high sensitivity (94.0%), specificity (92.3%), and predictive value (94.0%) for the presence of iron-deficient erythropoiesis in patients with isolated iron deficiency, polycythemia vera treated by phlebotomy, and iron deficiency complicating heterozygous thalassemia. In conclusion, our results showed that iron-deficient erythropoiesis is characterized by the production of RBCs with a severely decreased HGB concentration, while microcytes of beta-thalassemia trait are generally smaller, with a more preserved HGB concentration. Such properties, as assessed by the H*1 hematology analyzer, are very useful in distinguishing these two common types of microcytic anemia.