Single-cell profiling of human bone marrow progenitors reveals mechanisms of failing erythropoiesis in Diamond-Blackfan anemia

Ribosome dysfunction underlies the pathogenesis of many cancers and heritable ribosomopathies. Here we investigate how mutations in either ribosomal protein large (RPL) or ribosomal protein small (RPS) subunit genes selectively affect erythroid progenitor development and clinical phenotypes in Diamond-Blackfan anemia (DBA), a rare ribosomopathy with limited therapeutic options. Using single-cell assays of patient-derived bone marrow, we delineated two distinct cellular trajectories segregating with ribosomal protein genotypes: almost complete loss of erythroid specification were observed in <em>RPS</em>-DBA. In contrast, we observed relative preservation of qualitatively abnormal erythroid progenitors and precursors in <em>RPL</em>-DBA. Although both DBA genotypes exhibited a pro-inflammatory bone marrow milieu, <em>RPS</em>-DBA was characterized by erythroid differentiation arrest, whereas <em>RPL</em>-DBA was characterized by preserved GATA1 expression and activity. Compensatory stress erythropoiesis in <em>RPL</em>-DBA exhibited disordered differentiation underpinned by an altered glucocorticoid molecular signature, including reduced <em>ZFP36L2</em> expression<em>,</em> leading to milder anemia and improved corticosteroid response. This integrative analysis approach identified distinct pathways of erythroid failure and defined genotype-phenotype correlations in DBA. These findings may help facilitate therapeutic target discovery.