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Pyruvate Kinase Deficiency (PKLR) — QSP Model References

267 references, every PMID retrieved by direct query against the NCBI PubMed E-utilities API while this model was being built. Nothing here is recalled from memory. Sections follow the structure of the mechanistic map (pkd_qsp_model.dot) and the mrgsolve model (pkd_mrgsolve_model.R).

§0 — The load-bearing references, and exactly what each one carries

The model has four fitted parameters and roughly two hundred that are either taken from literature or back-calculated from the normal erythrocyte operating point. The list below is not "key papers"; it is the set of papers a specific number in the model came from, with the number named. If one of these is wrong, a stated result moves.

Quantity in the model Value used Source
Reduced glycolysis / 2,3-BPG kinetic structure and reference metabolite set ATP 1.70, ADP 0.22, 2,3-BPG 4.80, 3-PG 0.060, PEP 0.017, FBP 0.012 mM; flux 1.60 mmol/L RBC/h Mulquiney & Kuchel 1999, PMID 10477269 and PMID 10477270
Mitapivat haemoglobin response rate and endpoint definition 16/40 (40%) vs 0/40 placebo, ≥1.5 g/dL sustained at ≥2 of weeks 16/20/24 ACTIVATE, Al-Samkari 2022, PMID 35417638
Time-to-response, and the genotype restriction on response median 10 d to first >1.0 g/dL (range 7–187); responses only with ≥1 missense variant, correlated with baseline PK-R protein DRIVE-PK, Grace 2019, PMID 31483964
Transfusion-burden endpoint ≥33% reduction in 10/27 (37%) ACTIVATE-T, Glenthøj 2022, PMID 35988546
Splenectomy effect; complication frequencies median Hb +1.6 g/dL; iron overload 48%, gallstones 45%, post-splenectomy thrombosis 11%, neonatal phototherapy 93%, exchange transfusion 46%; 48% of splenectomies without simultaneous cholecystectomy later need one PK Deficiency Natural History Study, Grace 2018, PMID 29549173
Iron axis response to mitapivat (direction and magnitude of every analyte) hepcidin +4770 ng/L, erythroferrone −9835 ng/L, sTfR −56.0 nmol/L, EPO −32.9 IU/L at wk 24; liver iron −2.0 mg Fe/g dw at wk 96 van Beers 2024, PMID 38330179
Splenic sequestration as distinct from destruction organ sequestration measured alongside red cell life-span Nathan 1968, PMID 5634483
Dose-dependent ↑ATP and ↓2,3-BPG in healthy volunteers — the observation the whole "two opposing trunks" structure rests on glycolytic intermediates shifted consistently with pathway activation at all multiple-dose levels Yang 2019, PMID 30091852
Genotype–phenotype relation and molecular heterogeneity missense vs non-missense classification driving the "activatable protein" parameter Zanella 2007 PMID 17360088; Bianchi 2020 PMID 32043619, PMID 33054047
UGT1A1 co-inheritance multiplying gallstone risk in chronic haemolysis used to set the UGT activity multiplier (1.0 / 0.7 / 0.3) del Giudice 1999, PMID 10498597
Statistical structure of red cell survival (age-dependent vs random hazard) motivates the 14-cohort age axis rather than a single pool Korell 2011, PMID 20950630
Gene-therapy correction thresholds (fraction of corrected output needed) sets the GTFRAC values simulated Garcia-Gomez 2016 PMID 27138040; Navarro 2021 PMID 34514027

The single most load-bearing parameter is NOT in this table, and that is worth saying plainly: the 3-PG inhibition constant of the 2,3-BPG phosphatase (KIPG3 = 30 µM). It is what makes 2,3-BPG rise 2-fold rather than 9% when pyruvate kinase activity falls, and the entire oxygen-transport argument scales with the size of that excursion. It is the least well pinned number in the model. The break-even table in §3.2 of pkd_reference_output.txt exists so the conclusion can be re-scored against a different 2,3-BPG estimate without rebuilding anything.


1. Pyruvate kinase deficiency: disease, genetics, natural history

31 references

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  • Grace RF. How we manage patients with pyruvate kinase deficiency. Br J Haematol 2019. PMID 30681718
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  • VanDemark AP. Itavastatin and resveratrol increase triosephosphate isomerase protein in a newly identified variant of TPI deficiency. Dis Model Mech 2022. PMID 35315486
  • Grace RF. The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry: rationale and study design. BMJ Open 2023. PMID 36958777
  • Al-Samkari H. Diagnosis and management of pyruvate kinase deficiency: international expert guidelines. Lancet Haematol 2024. PMID 38330977
  • Holme S. Glucose phosphate isomerase deficiency demasked by whole-genome sequencing: a case report. J Med Case Rep 2024. PMID 38539245
  • Ahmed SH. Efficacy and safety of pyruvate kinase activator in treating hemolytic anemias: a systematic review. Expert Rev Hematol 2025. PMID 40526104
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2. Erythrocyte glycolysis, the Rapoport-Luebering shunt and kinetic modelling

8 references

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3. 2,3-BPG, haemoglobin oxygen affinity and oxygen delivery

22 references

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4. Red cell ATP, cation homeostasis, deformability and lifespan

2 references

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5. The spleen: filtration, sequestration and splenectomy

25 references

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  • Guizzetti L. Total versus partial splenectomy in pediatric hereditary spherocytosis: A systematic review and meta-analysis. Pediatr Blood Cancer 2016. PMID 27300151
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  • Horvat M. Audit of Post-Splenectomy Prophylaxis in a Single Tertiary Center in Slovenia: Where Are We and What Should Be Done?. Surg Infect (Larchmt) 2021. PMID 32639189
  • Celik SS. Clinical Characteristics and Treatment Outcome of Hereditary Spherocytosis: A Single Center's Experience. Sisli Etfal Hastan Tip Bul 2023. PMID 38268662
  • Saldanha A. The immune thrombocytopenia paradox: Should we be concerned about thrombosis in ITP?. Thromb Res 2024. PMID 39137700
  • Tang X. The efficacy of partial versus total splenectomy in the treatment of hereditary spherocytosis in children: a systematic review and meta-analysis. Pediatr Surg Int 2024. PMID 39470805
  • Cappellini MD. Thalassemia and hypercoagulability. Hematology Am Soc Hematol Educ Program 2025. PMID 41348010
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6. Erythropoiesis, erythropoietin and reticulocyte kinetics

37 references

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7. Iron: erythroferrone, hepcidin, overload and chelation

32 references

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8. Bilirubin, UGT1A1, gallstones and the neonatal presentation

31 references

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9. Mitapivat and other PK-R activators: trials and pharmacology

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10. Curative approaches: gene therapy, editing, transplantation

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11. Systemic complications and patient-reported outcomes

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12. Related red cell disorders, transfusion biology and redox

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13. QSP and pharmacometric methodology

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