Serum iron metabolism and erythropoiesis in patients with myelodysplastic syndrome not receiving RBC transfusions

Dysregulation of hepcidin, a key iron regulating hormone, is important in the pathogenesis of iron overload in patients with myelodysplatic syndrome (MDS). However, most studies of hepcidin levels are complicated by concomitant RBC transfusions. To evaluate the relationship between iron metabolism and erythropoiesis, we measured serum levels of hepcidin, growth-differentiation factor-15 (GDF15) and other markers of erythropoiesis in 107 subjects with MDS not receiving RBC transfusions. Patients with MDS had significantly higher levels of hepcidin than normals. However, their hepcidin-ferritin ratio was markedly decreased compared to normals (P< 0.001) and varied substantially between MDS subtypes (P= 0.011). GDF15 levels positively correlated with percent of bone marrow erythroblasts (P< 0.001), soluble transferrin receptor (sTfR) (P= 0.018), and also with transferrin saturation (ISAT) (P= 0.038). The hepcidin-ferritin ratio negatively correlated with serum erythropoietin (EPO) levels (P< 0.001), and also with GDF15 levels (P= 0.014). Colony forming cells (CFC) were evaluated in 70 subjects. Those with serum ferritin (SF) levels <500. ng/ml had significantly more BFU-E than subjects with SF. ≥. 500. ng/L (P= 0.007), but numbers of granulocyte/macrophage-colony-forming cells (CFU-GM) were similar (P= 0.190). Our data indicate serum hepcidin levels are inappropriately low in patients MDS not receiving RBC transfusions. GDF15 levels correlated with low hepcidin levels and may contribute to iron overload in this setting. Iron overload may in turn suppress erythropoiesis by imparing the proliferative capacity of the erythroid progenitor cells.