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Sanges S, Tian W, Dubucquoi S, Chang JL, Collet A, Launay D, Nicolls MR. B-cells in pulmonary arterial hypertension: friend, foe or bystander? Eur Respir J 2024; 63:2301949. [PMID: 38485150 PMCID: PMC11043614 DOI: 10.1183/13993003.01949-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/01/2024] [Indexed: 04/22/2024]
Abstract
There is an unmet need for new therapeutic strategies that target alternative pathways to improve the prognosis of patients with pulmonary arterial hypertension (PAH). As immunity has been involved in the development and progression of vascular lesions in PAH, we review the potential contribution of B-cells in its pathogenesis and evaluate the relevance of B-cell-targeted therapies. Circulating B-cell homeostasis is altered in PAH patients, with total B-cell lymphopenia, abnormal subset distribution (expansion of naïve and antibody-secreting cells, reduction of memory B-cells) and chronic activation. B-cells are recruited to the lungs through local chemokine secretion, and activated by several mechanisms: 1) interaction with lung vascular autoantigens through cognate B-cell receptors; 2) costimulatory signals provided by T follicular helper cells (interleukin (IL)-21), type 2 T helper cells and mast cells (IL-4, IL-6 and IL-13); and 3) increased survival signals provided by B-cell activating factor pathways. This activity results in the formation of germinal centres within perivascular tertiary lymphoid organs and in the local production of pathogenic autoantibodies that target the pulmonary vasculature and vascular stabilisation factors (including angiotensin-II/endothelin-1 receptors and bone morphogenetic protein receptors). B-cells also mediate their effects through enhanced production of pro-inflammatory cytokines, reduced anti-inflammatory properties by regulatory B-cells, immunoglobulin (Ig)G-induced complement activation, and IgE-induced mast cell activation. Precision-medicine approaches targeting B-cell immunity are a promising direction for select PAH conditions, as suggested by the efficacy of anti-CD20 therapy in experimental models and a trial of rituximab in systemic sclerosis-associated PAH.
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Affiliation(s)
- Sébastien Sanges
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
- Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord, Nord-Ouest, Méditerranée et Guadeloupe (CeRAINOM), F-59000 Lille, France
- Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), F-59000 Lille, France
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-first authorship
| | - Wen Tian
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-first authorship
| | - Sylvain Dubucquoi
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Institut d'Immunologie, Pôle de Biologie Pathologie Génétique, F-59000 Lille, France
| | - Jason L Chang
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | - Aurore Collet
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Institut d'Immunologie, Pôle de Biologie Pathologie Génétique, F-59000 Lille, France
| | - David Launay
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
- Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord, Nord-Ouest, Méditerranée et Guadeloupe (CeRAINOM), F-59000 Lille, France
- Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), F-59000 Lille, France
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-last authorship
| | - Mark R Nicolls
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-last authorship
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Medrek S, Melendres-Groves L. Evolving nonvasodilator treatment options for pulmonary arterial hypertension. Curr Opin Pulm Med 2022; 28:361-368. [PMID: 35838352 DOI: 10.1097/mcp.0000000000000887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW With the establishment of vasodilator therapy as a mainstay of treatment for pulmonary arterial hypertension (PAH), new therapeutic approaches are needed to prevent the development of the vasculopathy associated with this disease. Many studies are currently underway to investigate nonvasodilator treatment options. RECENT FINDINGS Modulation of bone morphogenic protein receptor type 2 (BMPR2) signaling with sotatercept showed promising results in phase 2 studies. Rituximab, an anti-CD20 monoclonal antibody, showed some signal for beneficial effect in patients with scleroderma-associated PAH. Studies evaluating agents including tocilizumab, selonsertib, bardoxolone, 10-nitro-9(E)-enoic acid (CXA-10) and intravenous iron have not shown acceptable efficacy in treating PAH. SUMMARY Pharmacologic approaches for the treatment of PAH include altering of transforming growth factor β/BMPR2 signaling, proliferation via growth factors, immune response, oxidative stress, estrogen signaling, metabolism, and neurohormonal modulation. Other treatment modalities including pulmonary artery nerve denervation, stem cell therapy, and inter-atrial shunt formation are also being explored.
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Affiliation(s)
- Sarah Medrek
- Division of Pulmonary Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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Kreidy M, Al-Hilli A, Yachoui R, Resnick J. Severe but reversible pulmonary hypertension in scleromyxedema and multiple myeloma: a case report. BMC Pulm Med 2020; 20:8. [PMID: 31918690 PMCID: PMC6953266 DOI: 10.1186/s12890-019-1020-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 12/06/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Scleromyxedema is a progressive, systemic connective tissue disorder characterized by fibro-mucous skin lesions and increased serum monoclonal immunoglobulin levels. Pulmonary involvement occurs in a subset of patients, though the overall prevalence of pulmonary lesions in scleromyxedema is unknown. Since pulmonary hypertension presumably occurs in these patients due to disease progression and development of additional conditions, treatment of the underlying plasma cell dyscrasia and connective tissue disorder may improve pulmonary hypertension symptoms. CASE PRESENTATION An elderly patient with scleromyxedema developed pulmonary hypertension refractory to vasodilator and diuretic therapy and subsequently multiple myeloma that responded to a combination therapy of bortezomib, cyclophosphamide, and dexamethasone treatment. CONCLUSIONS Treatment of the underlying disease(s) that contributed to pulmonary hypertension development with anti-neoplastic agents like bortezomib may improve cardiopulmonary symptoms secondary to reducing abnormal blood cell counts and paraprotein levels.
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Affiliation(s)
- Mazen Kreidy
- Department of Pulmonary and Critical Care Medicine, Marshfield Clinic, Marshfield, WI USA
- Present affiliation: Christiana Care Health System, PO Box 1668, Wilmington, DE 19899 USA
| | - Ali Al-Hilli
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI USA
| | - Ralph Yachoui
- Department of Rheumatology, Ronald Reagan UCLA Medical Center, Santa Monica, California, USA
| | - Jeffrey Resnick
- Department of Pathology, Marshfield Clinic, Marshfield, WI USA
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