Iron toxicity - Its effect on the bone marrow.

Excess iron can be extremely toxic for the body and may cause organ damage in the absence of iron chelation therapy. Preclinical studies on the role of free iron on bone marrow function have shown that iron toxicity leads to the accumulation of reactive oxygen species, affects the expression of genes coding for proteins that regulate hematopoiesis, and disrupts hematopoiesis. These effects could be partially attenuated by iron-chelation treatment with deferasirox, suggesting iron toxicity may have a negative impact on the hematopoietic microenvironment. Iron toxicity is of concern in transfusion-dependent patients. Importantly, iron chelation with deferasirox can cause the loss of transfusion dependency and may induce hematological responses, although the mechanisms through which deferasirox exerts this action are currently unknown. This review will focus on the possible mechanisms of toxicity of free iron at the bone marrow level and in the bone marrow microenvironment.

Effect of nutritional supplement on bone marrow-derived mesenchymal stem cells from aplastic anaemia.

Aplastic anaemia (AA) is characterised by pancytopenia resulting from a marked reduction in haemopoietic stem cells (HSC). The regulation of haemopoiesis depends on the interaction between HSC and various cells of the bone marrow (BM) microenvironment, including BM-derived mesenchymal stromal cells (BMSC). The purpose of this study was to analyse the biological effect of nutritional supplement (NS), a dietary supplement consisting of thirty-six compounds: amino acids, nucleotides, vitamins and micronutrients on the BMSC of AA rats. The AA rat model was established by irradiating X-ray (2·5 Gy) and intraperitoneal injections of cyclophosphamide (35 mg/kg; Sigma) and chloramphenicol (35 mg/kg; Sigma). Then AA rats were fed with NS in a dose-dependent manner (2266·95, 1511·3, 1057·91 mg/kg d) by intragastric administration. The effect of NS on the BMSC of AA rats was analysed. As compared with AA rats, NS treatment significantly improved these peripheral blood parameters and stimulated the proliferation of total femoral nucleated cells. NS treatment affected proliferative behaviour of BMSC and suppressed BMSC differentiation to adipocytes. Furthermore, NS treatment of AA rats accelerated osteogenic differentiation of BMSC and enhanced bone mineral density. Co-incubation of HSC with mesenchymal stromal cells and serum from AA rats subjected to high-dose NS markedly improved the yield of CD34+cells. Protein microarray analysis revealed that there were eleven differentially expressed proteins in the NS group compared with the AA rat group. The identified specific NS might be implicated in rehabilitation of BMSC in AA rats, suggesting their potential of nutritional support in AA treatment.

Decreased expression of vitamin D receptor may contribute to the hyperimmune status of patients with acquired aplastic anemia.

Acquired aplastic anemia (AA) is an immune-mediated bone marrow failure syndrome. 1α,25-Dihydroxyvitamin D3 [1,25(OH)2 D3 ], the biologically active metabolite of vitamin D, is a critical modulator of immune response via binding with vitamin D receptor (VDR). Previous studies have established that 1,25(OH)2 D3 and VDR were involved in the pathogenesis of some autoimmune diseases. In this study, we evaluated the involvement of 1,25(OH)2 D3 and VDR on T-cell responses in AA. Plasma 25(OH)D3 levels were comparable between patients with AA and healthy controls. Surprisingly, VDR mRNA was significantly lower in untreated patients with AA than in healthy controls. Subsequent in vitro experiments revealed that 1,25(OH)2 D3 treatment suppressed the proliferation of lymphocytes and inhibited the secretion of interferon-γ, tumor necrosis factor-α, and interleukin-17A, meanwhile promoting the production of transforming growth factor-ß1 in patients with AA. Moreover, 1,25(OH)2 D3 inhibited the differentiation of type 1 and Th17 cells but induced the differentiation of type 2 and regulatory T cells. Interestingly, VDR mRNA was elevated in healthy controls after 1,25(OH)2 D3 treatment, but not in patients with AA. In conclusion, decreased expression of VDR might contribute to the hyperimmune status of AA and appropriate vitamin D supplementation could partly correct the immune dysfunction by strengthening signal transduction through VDR in patients with AA.

Deferasirox Decreases Liver Iron Concentration in Iron-Overloaded Patients with Myelodysplastic Syndromes, Aplastic Anemia and Other Rare Anemias.

Iron overload in transfusion-dependent patients with rare anemias can be managed with chelation therapy. This study evaluated deferasirox efficacy and safety in patients with myelodysplastic syndromes (MDS), aplastic anemia (AA) or other rare anemias. A 1-year, open-label, multicenter, single-arm, phase II trial was performed with deferasirox (10­40 mg/kg/day, based on transfusion frequency and therapeutic goals), including an optional 1-year extension. The primary end point was a change in liver iron concentration (LIC) after 1 year. Secondary end points included changes in efficacy and safety parameters (including ophthalmologic assessments) overall as well as in a Japanese subpopulation. Overall, 102 patients (42 with MDS, 29 with AA and 31 with other rare anemias) were enrolled; 57 continued into the extension. Mean absolute change in LIC was ­10.9 mg Fe/g dry weight (d.w.) after 1 year (baseline: 24.5 mg Fe/g d.w.) and ­13.5 mg Fe/g d.w. after 2 years. The most common drug-related adverse event was increased serum creatinine (23.5%), predominantly in MDS patients. Four patients had suspected drug-related ophthalmologic abnormalities. Outcomes in Japanese patients were generally consistent with the overall population. Results confirm deferasirox efficacy in patients with rare anemias, including a Japanese subpopulation. The safety profile was consistent with previous studies and ophthalmologic parameters generally agreed with baseline values (EUDRACT 2006-003337-32).

Busuishengxue ranules mediate their effects upon non-severe aplastic anemia via mitogen-activated protein kinase/extracellular signal-regulated kinase pathway.

OBJECTIVE: To observe the clinical efficacy of Busuishengxue granules on non-severe aplastic anemia (NSAA) and investigate its effect on the mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK) pathway. METHODS: Sixty NSAA patients were divided equally into two groups. Subjects in the experimental group were treated with Busuishengxue granules, and the control group with Zaizaoshengxue tablets. The treatment course was 6 months and curative efficacy was compared between the two groups as well as with 10 healthy individuals. Flow cytometry (FCM) was used to detect the intracellular concentration of Ca2+ ([Ca2+]i). Western blotting was employed to detect the expression of enzymes in the MAPK/ERK pathway. RESULTS: The efficacy of Busuishengxue granules was significantly better than that of Zaizaoshengxue tablets (P < 0.05). Before treatment, expression of JNK, phospho-ERK 1/2 and p-JNK was higher, and [Ca2+]i higher, than that of the control group (P < 0.05). After treatment with Busuishengxue granules, expression of all enzymes related to signal transduction pathways in the blood cells of NSSA patients were altered to different degrees. CONCLUSION: Busuishengxue granules had a better effect with regard to improving symptom scores, increasing the number of blood leukocytes, and increasing hemoglobin levels than Zaizaosh-engxue tablets, and they differed slightly in terms of increasing the number of platelets.

Comparative metabolomics analysis on hematopoietic functions of herb pair Gui-Xiong by ultra-high-performance liquid chromatography coupled to quadrupole time-of-flight mass spectrometry and pattern recognition approach.

The compatibility of Angelicae Sinensis Radix (Danggui, DG) and Chuanxiong Rhizoma (Chuanxiong, CX), a famous herb pair Gui-Xiong (GX), can produce synergistic and complementary hematopoiesis. In present study, global metabolic profiling with ultra-high-performance liquid chromatography coupled to quadrupole time-of-flight mass spectrometry (UHPLC-QTOF/MS) combined with pattern recognition method was performed to discover the underlying hematopoietic regulation mechanisms of DG, CX and GX on hemolytic and aplastic anemia rats (HAA) induced by acetyl phenylhydrazine (APH) and cyclophosphamide (CP). Thirteen endogenous metabolites contributing to the separation of model group and control group were tentatively identified. The levels of LPCs including lysoPC (18:0), lysoPC (20:4), lysoPC (16:0) and lysoPC (18:2), sphinganine, nicotinic acid, thiamine pyrophosphate, phytosphingosine, and glycerophosphocholine increased significantly (p<0.05) in HAA, while the levels of oleic acid, 8,11,14-eicosatrienoic acid, ceramides (d18:1/14:0), and 17a-hydroxypregnenolone decreased significantly (p<0.05) in comparison with control rats. Those endogenous metabolites were chiefly involved in thiamine metabolism and sphingolipid metabolism. The metabolic deviations could be regulated closer to normal level after DG, CX and GX intervention. In term of hematopoietic function, GX was the most effective as shown by the relative distance in PLS-DA score plots and relative intensity of metabolomic strategy, reflecting the synergic action between DG and CX. The relative distance calculation was firstly used in metabolomics for semi-quantization.

[Effects of Busui Shengxue Granule on bFGF and bFGFR in bone marrow derived stroma cells of chronic aplastic anemia patients].

OBJECTIVE: To observe the therapeutic effects of Busui Shengxue Granule (BSSXG) on chronic aplastic anemia (CAA) patients and its effects on bone marrow derived stroma cells (BMDSCs) correlated cytokines. METHODS: One hundred and twenty-four patients with CAA were randomly assigned to two groups according to the random digit table. Patients in the test group (61 cases) were treated with BSSXG, while those in the control group (63 cases) were treated with Zaizao Shengxue Tablet (ZST). The therapeutic course was 6 months for all. Besides, 10 healthy subjects were recruited as the normal control group. Changes of the symptom integral, therapeutic efficacy judgment, and changes of peripheral hemogram of patients were observed. The mRNA expression of b-fibroblast growth factors (bFGF) and b-fibroblast growth factors receptor (bFGFR) were detected by reverse transcription PCR. RESULTS: The total effective rate of the test group was 75.0% (45/61), higher than that of the control group (58.7%, 37/63). Its symptom integral and peripheral hemogram were obviously improved, better than those of the control group (P < 0.05, P < 0.01). The mRNA expressions of bFGF and bFGFR of the test group were obviously lower than those of the normal control group (P < 0.05, P < 0.01). They were somewhat improved after treatment in the two groups, with better results obtained in the test group. CONCLUSIONS: BSSXG showed better clinical effects. It could improve the symptom integral and peripheral hemogram of CAA patients, improve the clinical efficacy, and regulate the expression levels of bFGF and bFGFR. It improved the hematopoietic microenvironment and promoted the hematopoiesis of the bone marrow through regulating the proliferation and oriental differentiation of stroma cells, and promoting the bone marrow angiogenesis.

Effect of kidney-reinforcing, blood-activating and stasis-removing recipes on adhesion molecule expression of bone marrow mesenchymal stem cells from chronic aplastic anemia patients.

OBJECTIVE: To explore the effect of kidney-reinforcing, blood-activating and stasis-removing recipes on adhesion molecule expression of bone marrow mesenchymal stem cells (MSCs) from patients with chronic aplastic anemia (CAA). METHODS: We used three Traditional Chinese Medicine recipes, namely a kidney-reinforcing recipe (KRR), blood-activating and stasis-removing recipe (BASRR), and kidney-reinforcing, blood-activating and stasis-removing recipe (KRBASRR), and a normal saline control to prepare herbal medicine serum in Sprague Dawley rats. Thirty CAA patients were enrolled in the experimental group, including 17 kidney-Yang deficient patients and 13 kidney-Yin deficient patients. Ten healthy individuals were included in the control group. MSCs were isolated from bone marrow samples, and the cell density was observed to measure their proliferation ability by microscopy on days 2, 7, and 14 after isolation. In addition, the expression of adhesion molecules of bone marrow MSCs (CD106, CD49d, CD31 and CD44) were detected by flow cytometry after 48 h of treatment with the four different herbal medicine serums. RESULTS: The proliferation of MSCs from kidney-Yang deficient and kidney-Yin deficient patients was weaker than that of MSCs from the control group. The expression of all adhesion molecules of bone marrow MSCs from CAA patients was obviously lower than that in the control group (P < 0.01). The expression of CD49d and CD31 in MSCs from patients with a kidney-Yin deficiency was lower than in those with a kidney-yang deficiency (P < 0.05 and P < 0.01, respectively). For kidney-Yang deficient patients, CD31 expression in the KRBASRR group was significantly higher than that in the BASRR group (P < 0.01), while CD44 in the KRBASRR group was significantly higher than that in both KRR and BASRR groups (P < 0.01). For kidney-Yin deficient patients, CD106 and CD49d expression in the KRBASRR group was obviously higher than that in the KRR group (P < 0.05), while CD31 and CD44 expression in the KRBASRR group was significantly higher than that in both KRR and BASRR groups (P < 0.05 and P < 0.01, respectively). CONCLUSION: The bone marrow microenvironment in CAA patients is abnormal. The effect of KRBASRR may be better than that of KRR and BASRR for kidney-Yang deficient and kidney-Yin deficient patients by improving the expression levels of MSC adhesion molecules.

Effect of busui shengxue granule (see text) on chronic aplastic anemia patients' hematopoietic adhesion molecule VLA-6/CD49f and its ligand laminin.

OBJECTIVE: To observe the effect of Busui Shengxue Granule ((see text) Herbal granule for replenishing marrow to produce blood) on chronic aplastic anemia (CAA) patients' integrin alpha 6 (VLA-6/CD49f) and laminin (Ln). METHODS: Sixty-five patients were divided into experimental group and control group through random number table. There were 34 patients, 17 were male and 17 female, aged 2-67, with a medianage of 30.2 +/- 8.6, in the experimental group, including 17 patients of kidney-yin deficiency and 17 of kidney-yang deficiency, treated by Busui Shengxue Granule. There were 31 patients in the control group, 16 were male and 15 female, aged 4-65, with a medianage of 31.2 +/- 8.0; administered Zaizhang Shengxue Tablet (see text) Herbal tablet for chronic aplastic anemia). Both groups were treated for six months and compared with 10 normal persons after the treatment. Flow cytometry was adopted to detect the change in the expression of VLA-6/CD49f, receptor in mononuclear cells of CAA patients and normal persons. Enzyme-linked immunosorbent assay was applied to detect the expression of peripheral serum Ln. RESULTS: CAA patients' VLA-6/CD49f was in the state of low expression and Ln in the state of high expression. After the treatment, both VLA-6/CD49f and Ln were regulated to some extent and the change in the experimental group was better than that of the control group. Compared with the kidney-yin deficiency patients, those indices of kidney-yang deficiency patients were easier to correct. CONCLUSION: The VLA-6/CD49f and Ln expressions of CAA patients are abnormal. The treatment with Busui Shengxue Granule makes both of them improved.

[Influence of Shengxue mixture on the expression of T-bet/GATA-3, their relevant signal transduction molecules, cytokines, and Th1/Th2 balance in patients with chronic aplastic anemia].

OBJECTIVE: To study the actions of transcription factors, T-bet and GATA-3, and their relevant signal transduction pathways on the immune-related pathogenesis with chronic aplastic anemia (CAA), and to investigate the immunological regulation mechanism of Shengxue Mixture (SXM) in regulating levels of Th cell imbalance, transcriptional factor and relevant signal pathways. METHODS: All CAA patients selected from Yueyang Hospital of Shanghai University of traditional Chinese medicine were equally randomized into the treated group and the control group, 20 patients in each group, and 20 healthy persons were selected as normal group, the former was treated with SXM according to patients' syndrome patterns, namely, SXM-1 was given to patients of Pi-Shen yang-deficiency pattern, and SXM-2 to those of Pi-Shen yin-deficiency pattern. Patients in the control group were treated with cyclosporin A (CsA). The mRNA expressions of T-bet, GATA-3, signal transducers and activators of transcription 4 (STAT4) and 6 (STAT6) in peripheral blood mononuclear cell (PBMNC) of patients were determined using real-time fluorescent quantitation polymerase chain reaction before and after treatment, meantime, the Th1/Th2 proportion in peripheral blood, and levels of IFN-gamma, IL-12 and IL-4 in PBMNC-cultured supernatant were detected by flow cytometry and enzyme linked immunosorbent assay. RESULTS: The mRNA expressions of PBMNC T-bet and STAT4, ratios of T-bet/GATA-3, Th1 proportion and Th1/Th2 ratio, levels of IFN-gamma and IL-12 in PBMNC-cultured supernatant were all significantly higher in CAA patients than in healthy controls (P < 0.01), which were lowered after treatment but didn't reach the normal range (all P < 0.01), excepting for IL-12 level. Comparisons of the changes between the two treated groups showed insignificant difference (P > 0.05). While the difference between patients and healthy persons in terms of GATA-3, STAT6, Th2 proportion, and IL-4 were insignificant (P > 0.05), either before or after treatment. CONCLUSIONS: Abnormal activation of IFN-gamma/T-bet and IL-12/ STAT4 pathways, as well as Th1/Th2 balance deviating to Th1 excursion play vital roles in the immunological pathogenesis of CAA. SXM and CsA could lower the aforesaid abnormal activation and correct Th1 hyper-polarization, so as to alleviate the over-activated cell-mediated immunity to eliminate hematopoietic depression in CAA patients.

Iron chelation therapy in the myelodysplastic syndromes and aplastic anemia: a review of experience in South Korea.

Emerging clinical data indicate that transfusion-dependent patients with bone marrow-failure syndromes (BMFS) are at risk of the consequences of iron overload, including progressive damage to hepatic, endocrine, and cardiac organs. Despite the availability of deferoxamine (DFO) in Korea since 1998, data from patients with myelodysplastic syndromes, aplastic anemia, and other BMFS show significant iron overload and damage to the heart and liver. The recent introduction of deferasirox, a once-daily, oral iron chelator, may improve the availability of iron chelation therapy to iron-overloaded patients, and improve compliance in patients who may otherwise find adherence to the DFO regimen difficult.

Retrospective nationwide survey of Japanese patients with transfusion-dependent MDS and aplastic anemia highlights the negative impact of iron overload on morbidity/mortality.

OBJECTIVE: Myelodysplastic syndromes (MDS) and aplastic anemia (AA) are the most common anemias that require transfusion therapy in Japan. This retrospective survey investigated relationships between iron overload, chelation practices, and morbidity/mortality in patients with these diseases. METHOD: Medical histories of transfusion-dependent patients were assessed at transfusion onset, chelation onset, and study end. RESULTS: Data were collected from 292 patients with MDS, AA, pure red cell aplasia, myelofibrosis, and other conditions. Patients received a mean of 61.5 red blood cell units during the previous year. Fewer than half (43%) of patients had previously received deferoxamine (DFO) therapy. Only 8.6% received daily/continuous DFO. In all, 75 deaths were reported, with cardiac and liver failure noted in 24.0 and 6.7% of cases. Of these, 97% had ferritin levels >1000 ng/mL. Abnormal cardiac and liver function was observed in 21.9% (14/64) and 84.6% (11/13) of all patients assessed. Effective chelation with DFO resulted in improved serum ferritin, liver enzymes, and fasting blood sugar. CONCLUSIONS: Mortality is higher in heavily iron-overloaded patients, with liver and cardiac dysfunction being the primary cause. Daily/continuous chelation therapy was effective at reducing iron burden and improving organ function. Chelation therapy should be initiated once serum ferritin levels exceed 1000 ng/mL.

[Influence of Shenmai injection on blood serum tumor necrosis factor and bone marrow CD34+ cell's apoptosis of chronic aplastic anemia patient].

OBJECTIVE: To investigate the effect of Shenmai injection on chronic aplastic anemia patients and its mechanism. METHOD: Sixty-five chronic aplastic anemia patients were randomized into treatment group and control group. The patients of the treatment group were treated by injecting Shenmai injection and taking western medicine orally, those of the control group taking western medicine orally only, then the effect was evaluated. The concentration of tumor necrosis factor-alpha (TNF-alpha) in blood serum was detected and the apoptosis of bone marrow CD34+ cell was analysed by DNA ISEL technic before and after treatment. RESULT: The effective rate of the treatment group and the control group was 63.6 % and 40.6 % respectively, the effect of the Shenmai injection on the treatment group was obviously better than that of the control group (P < 0.01). Before treatment, the concentration of TNF-alpha in blood serum and the apoptosis rate of bone marrow CD34+ cell of the chronic aplastic anemia patient were higher than normal (P < 0.01). After treatment, the concentration of TNF-alpha in blood serum of the treatment group decreased obviously (P < 0.01), and the apoptosis rate of bone marrow CD34+ cell of the treatment group also decreased (P < 0.05), which had significant difference compared with those of the control group (P < 0.05). CONCLUSION: Shenmai injection is efficient to chronic aplastic anemia. The mechanism is decreasing the concentration of TNF-alpha in blood serum and the apoptosis rate of bone marrow CD34+ cell.

[Effect of composite blood-activating decoction on expression of adherent molecule and cyclin in bone marrow hematopoietic cells in mice of immune-induced aplastic anemia].

OBJECTIVE: To study the effect of composite blood-activating decoction (CBAD) on expression of adherent molecule CD49 d and cyclin D2 in bone marrow hematopoietic cells in experimental immune-mediated aplastic anemia (AA) mice. METHODS: After the model of AA was established, the animals were fed with 0.2 ml of 100% CBAD, twice a day for 12 days. Te CD49 d and cyclin D2 expression level of bone marrow hematopoietic cells in model mice were measured by flow cytometor analysis system at the 13th day of experiment. RESULTS: CD49 d expression level in CBAD group was significantly higher than that in the AA group (P < 0.05), and was similar to that in the normal group (P > 0.05). The expression of cyclin D2 in CBAD group was significantly higher than that in the AA group (P < 0.01), but the cell count of G0 + G1 phase was significantly lower in the CBAD group, as compared with the AA group, P < 0.01. CONCLUSION: CBAD can increase the expression of adherent molecule CD49 d and cyclin D2 in bone marrow hematopoietic cells, and promote the growth of hematopoietic cells.

Contents of trace elements in the hair of aplastic anemia patients and their treatment based on an overall analysis of symptoms and signs.

The content of 12 trace elements in the hair of 20 aplastic anemia patients was determined and compared with that of normal subjects as control. The results showed that patients with deficiency of yin had a significant decrease in lithium, calcium, strontium, and chromium, those with deficiency of yang had a distinct decrease in zinc magnesium barium, strontium, calcium, and lithium, and those with deficiency of both yin and yang had a general decrease in all the 12 trace elements. Changes in trace element content in hair may serve as a guide to opening up new vistas in the treatment of aplastic anemia on the basis of an overall analysis of symptoms and signs.

[Changes in bone mineral content in kidney deficiency].

UNLABELLED: Bone mineral determination (BMD) of ulna and radius in 184 patients with and without Kidney Deficiency (KD) were assayed. RESULT: (BMD) in KD patients was apparently lower than that without KD as well as normal group, no difference between the patients without KD and the normal group, but there was a significant difference between the patients who had same disease with and without KD. The study indicated that BMD in patients with KD had characteristic change. It revealed also the objectivity of Syndrome in TCM.