Involvement of oxygen-sensing pathways in physiologic and pathologic erythropoiesis

Red blood cells deliver O-2 from the lungs to every cell in the human body. Reduced tissue oxygenation triggers increased production of erythropoietin by hypoxiainducible factor 1 (HIF-1), which is a transcriptional activator composed of an O-2-regulated alpha subunit and a constitutively expressed beta subunit. Hydroxylation of HIF-1 alpha or HIF-2 alpha by the asparaginyl hydroxylase FIH-1 blocks coactivator binding and transactivation. Hydroxylation of HIF-1 alpha or HIF-2 alpha by the prolyl hydroxylase PHD2 is required for binding of the von Hippel-Lindau protein (VHL), leading to ubiquitination and proteasomal degradation. Mutations in the genes encoding VHL, PHD2, and HIF-2 alpha have been identified in patients with familial erythrocytosis. Patients with Chuvash polycythemia, who are homozygous for a missense mutation in the VHL gene, have multisystem pathology attributable to dysregulated oxygen homeostasis. Intense efforts are under way to identify small molecule hydroxylase inhibitors that can be administered chronically to selectively induce erythropoiesis without undesirable side effects. (Blood. 2009; 114: 2015-2019)