Dyserythropoiesis evaluated by the RED score and hepcidin: ferritin ratio predicts response to erythropoietin in lower-risk myelodysplastic syndromes

There were 22 patients with refractory cytopenia with multilineage dysplasia, 19 with refractory cytopenia with unilineage dysplasia, 14 with refractory anemia with ring sideroblasts, four with refractory anemia with excess blasts-1, six with chronic myelomonocytic leukemia, two with del5qand three with unclassifiable myelodysplastic syndrome. According to the revised International Prognostic Scoring System, 13 had very low risk, 47 had low risk, nine intermediate risk and one had high-risk disease. Twenty patients were transfusion dependent. Forty-eight percent had an erythroid response and the median duration of the response was 26 months. At baseline, non-responders had significantly higher RED scores and lower hepcidin: ferritin ratios. In multivariate analysis, only a RED score > 4 (P=0.05) and a hepcidin: ferritin ratio < 9 (P=0.02) were statistically significantly associated with worse erythroid response. The median response duration was shorter in patients with growth-differentiation factor-15 > 2000 pg/mL and a hepcidin: ferritin ratio < 9 (P=0.0008 and P=0.01, respectively). In multivariate analysis, both variables were associated with shorter response duration. Erythroid response to epoetin zeta was similar to that obtained with other erythropoiesis-stimulating agents and was correlated with higher baseline hepcidin: ferritin ratio and lower RED score. ClinicalTrials. gov registration: NCT 03598582.