title: Protease inhibitors-based therapy induces acquired spherocytic-like anaemia and ineffective erythropoiesis in chronic hepatitis C virus patients.
abstract: OBJECTIVE
  The addition of protease inhibitors, boceprevir (BOC) or telaprevir (TRV), to peg-interferon and ribavirin (PR) increases the incidence of anaemia in patients with chronic hepatitis C virus (HCV) infection. Although genetic variants in inosine triphosphatase (ITPA) gene have been linked to the haemolytic anaemia induced by PR, the mechanism sustaining severe anaemia during triple therapy is still unknown. This study aims to elucidate the molecular mechanisms underlying anaemia in chronic HCV patients with combined therapy.
  
  
  METHODS
  We studied 59 patients with chronic HCV genotype-1: 29 treated with TRV/PR and 30 with BOC/PR. We evaluated biochemical and haematological parameters, red cell index at baseline, 4, 12, 16 and 24 weeks of treatment; in a subgroup, we performed functional studies: osmotic fragility, red cell membrane protein separation, mass spectrometry analysis, quantification of erythroid microparticles release. IL28B and ITPA polymorphisms were also evaluated.
  
  
  RESULTS
  We found early acute normochromic normocytic haemolytic anaemia (4-8 weeks) followed by a late macrocytic hypo-regenerative anaemia with inappropriate low reticulocyte count (12-24 weeks). Studies on red cells revealed: (i) presence of spherocytes; (ii) increased osmotic fragility; (iii) abnormalities in red cell membrane protein composition; (iv) reduced membrane-cytoskeleton stability; (v) increased release of erythroid microparticles. ITPA polymorphisms impacted only the early phase of anaemia.
  
  
  CONCLUSIONS
  The bimodal pattern of anaemia in chronic HCV patients on triple therapy might be because of acquired spherocytic-like anaemia in the early phase, followed by hyporegenerative anaemia, most likely related to the combined effects of PR and TRV or BOC on erythropoiesis.
authors.affiliation: Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Lupo
authors.affiliation: Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Napoli, Italy.|CEINGE Biotecnologie Avanzate, Napoli, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Russo
authors.affiliation: Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Napoli, Italy.|CEINGE Biotecnologie Avanzate, Napoli, Italy.
authors.forename: Achille
authors.initials: A
authors.lastname: Iolascon
authors.affiliation: Clinical Unit of Gastroenterology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
authors.forename: Donatella
authors.initials: D
authors.lastname: Ieluzzi
authors.affiliation: Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy.
authors.forename: Angela
authors.initials: A
authors.lastname: Siciliano
authors.affiliation: Department of Medicine and Pathology Clinical and Experimental, Medical Liver Transplantation Unit, Internal Medicine, University of Udine, Udine, Italy.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Toniutto
authors.affiliation: Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Matté
authors.affiliation: Department of Molecular Medicine, University of Padova, Padova, Italy.|Clinical Unit of General Medicine, Azienda Ospedaliera Universitaria Integrata Padova, Padova, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Piovesan
authors.affiliation: Unit of Hygiene, Epidemiology and Public Health, University of Brescia, Brescia, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Raffetti
authors.affiliation: Department of Oncology, University of Torino, Torino, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Turrini
authors.affiliation: Department of Medicine and Pathology Clinical and Experimental, Medical Liver Transplantation Unit, Internal Medicine, University of Udine, Udine, Italy.
authors.forename: Denis
authors.initials: D
authors.lastname: Dissegna
authors.affiliation: Unit of Hygiene, Epidemiology and Public Health, University of Brescia, Brescia, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Donato
authors.affiliation: Department of Molecular Medicine, University of Padova, Padova, Italy.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Alberti
authors.affiliation: Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Zuliani
authors.affiliation: Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy.|Clinical Unit of Gastroenterology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
authors.forename: Giovanna
authors.initials: G
authors.lastname: Fattovich
authors.affiliation: Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy.
authors.forename: Lucia
authors.initials: L
authors.lastname: De Franceschi
mesh_terms: D000328:Adult; D000368:Aged; D000740:Anemia / Q000097:blood / Q000139:chemically induced / Q000175:diagnosis / Q000235:genetics / Q000503:physiopathology; D000998:Antiviral Agents / Q000008:administration & dosage / Q000009:adverse effects; D016903:Drug Monitoring / Q000379:methods; D004359:Drug Therapy, Combination; D004909:Erythrocyte Indices; D004910:Erythrocyte Membrane; D004920:Erythropoiesis / Q000187:drug effects*; D005260:Female; D019698:Hepatitis C, Chronic / Q000097:blood / Q000188:drug therapy; D006801:Humans; D016898:Interferon-alpha / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009842:Oligopeptides / Q000008:administration & dosage / Q000009:adverse effects; D020641:Polymorphism, Single Nucleotide; D011392:Proline / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D011480:Protease Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D011755:Pyrophosphatases / Q000235:genetics; D012254:Ribavirin / Q000008:administration & dosage / Q000009:adverse effects; D016896:Treatment Outcome; D000097630:Inosine Triphosphatase
chemical_list: D000998:Antiviral Agents; D016898:Interferon-alpha; D009842:Oligopeptides; D011392:Proline; D011480:Protease Inhibitors; D011755:Pyrophosphatases; D012254:Ribavirin; C486464:telaprevir; C512204:N-(3-amino-1-(cyclobutylmethyl)-2,3-dioxopropyl)-3-(2-((((1,1-dimethylethyl)amino)carbonyl)amino)-3,3-dimethyl-1-oxobutyl)-6,6-dimethyl-3-azabicyclo(3.1.0)hexan-2-carboxamide; C511829:ITPA protein, human; D000097630:Inosine Triphosphatase
keywords: chronic hepatitis C; first-generation protease inhibitors; microparticles; spherocytic-like anaemia