-thalassemia is a disease characterized by anemia and is associated with ineffective erythropoiesis and iron dysregulation resulting in iron overload. The peptide hormone hepcidin regulates iron metabolism, and insufficient hepcidin synthesis is responsible for iron overload in minimally transfused patients with this disease. Understanding the crosstalk between erythropoiesis and iron metabolism is an area of active investigation in which patients with and models of -thalassemia have provided significant insight. The dependence of erythropoiesis on iron presupposes that iron demand for hemoglobin synthesis is involved in the regulation of iron metabolism. Major advances have been made in understanding iron availability for erythropoiesis and its dysregulation in -thalassemia. In this review, we describe the clinical characteristics and current therapeutic standard in -thalassemia, explore the definition of ineffective erythropoiesis, and discuss its role in hepcidin regulation. In preclinical experiments using interventions such as transferrin, hepcidin agonists, and JAK2 inhibitors, we provide evidence of potential new treatment alternatives that elucidate mechanisms by which expanded or ineffective erythropoiesis may regulate iron supply, distribution, and utilization in diseases such as -thalassemia.
IntroductionErythroid cells are highly dependent on iron for survival. In light of this dependence, mutual regulation of erythropoiesis and iron metabolism has been proposed. However, how iron demand for erythropoiesis is communicated to the iron regulatory machinery is incompletely understood. In the past few decades, significant progress has been made to advance our understanding of iron metabolism and its regulation. Furthermore, several diseases, -thalassemia in particular, have provided glimpses of the crosstalk between iron regulation and erythropoiesis. By exploring ineffective erythropoiesis (IE) and its associated dysfunctional iron regulation, this disease may lay the foundation for more completely understanding, diagnosing, and treating patients with different forms of -thalassemia as well as other anemias or iron overloadrelated disorders. In this review, we focus on the current state of knowledge on the regulation of iron metabolism and attempt to elucidate the interface between iron regulation and erythropoiesis with the use of evidence in part derived from animal models of -thalassemia; despite being all nonhuman models of disease, their utility as in vivo tools for experimentation is worthy of note. We discuss potential ways in which this new knowledge can be translated into clinical application for patients with -thalassemia.
-thalassemia
Clinical characteristics-thalassemias are caused by mutations in the -globin gene or its promoter, resulting in reduced or absent -globin synthesis. 1 Patients either homozygous or compound heterozygous for mutation in the -globin gene present with a broad range of clinical severity; the disease course can be associated with severe transfusion dep...