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Sun F, Peers de Nieuwburgh M, Hubinont C, Debiève F, Colson A. Gene therapy in preeclampsia: the dawn of a new era. Hypertens Pregnancy 2024; 43:2358761. [PMID: 38817101 DOI: 10.1080/10641955.2024.2358761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/16/2024] [Indexed: 06/01/2024]
Abstract
Preeclampsia is a severe complication of pregnancy, affecting an estimated 4 million women annually. It is one of the leading causes of maternal and fetal mortality worldwide, and it has life-long consequences. The maternal multisystemic symptoms are driven by poor placentation, which causes syncytiotrophoblastic stress and the release of factors into the maternal bloodstream. Amongst them, the soluble fms-like tyrosine kinase-1 (sFLT-1) triggers extensive endothelial dysfunction by acting as a decoy receptor for the vascular endothelial growth factor (VEGF) and the placental growth factor (PGF). Current interventions aim to mitigate hypertension and seizures, but the only definite treatment remains induced delivery. Thus, there is a pressing need for novel therapies to remedy this situation. Notably, CBP-4888, a siRNA drug delivered subcutaneously to knock down sFLT1 expression in the placenta, has recently obtained Fast Track approval from the Food and Drug Administration (FDA) and is undergoing a phase 1 clinical trial. Such advance highlights a growing interest and significant potential in gene therapy to manage preeclampsia. This review summarizes the advances and prospects of gene therapy in treating placental dysfunction and illustrates crucial challenges and considerations for these emerging treatments.
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Affiliation(s)
- Fengxuan Sun
- Department of Reproduction Physiopathology, Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
| | - Maureen Peers de Nieuwburgh
- Department of Reproduction Physiopathology, Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
- Department of Neonatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Corinne Hubinont
- Department of Obstetrics, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Frédéric Debiève
- Department of Reproduction Physiopathology, Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
- Department of Obstetrics, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Arthur Colson
- Department of Reproduction Physiopathology, Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
- Department of Obstetrics, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Department of Pharmacotherapy and Therapeutics, Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium
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Karumanchi SA. Two decades of advances in preeclampsia research: molecular mechanisms and translational studies. J Clin Invest 2024; 134:e184052. [PMID: 39087479 PMCID: PMC11291264 DOI: 10.1172/jci184052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
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3
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Jenner B. "Deeds not words": the forgotten class. J Hum Hypertens 2024:10.1038/s41371-024-00935-0. [PMID: 39033217 DOI: 10.1038/s41371-024-00935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/23/2024]
Abstract
The Sir Stanley Peart Essay Competition is an annual event run by the British and Irish Hypertension Society to encourage Early Career Researchers to continue the ethos of Sir Stanley Peart. Sir Stanley Peart was a clinician and clinical researcher who made a major contribution to our understanding of blood pressure regulation. He was the first to demonstrate the release of noradrenaline in response to sympathetic nerve stimulation. He was also the first to purify, and determine the structure of, angiotensin and he later isolated the enzyme, renin, and carried out many important investigations of the factors controlling its release in the body. This year, the essay topic was "Do we need new classes of antihypertensive drugs?". In her prize-winning essay, "Deeds not words": the forgotten class, Dr Jenner proposes that there is a need to address the unmet needs of hypertensive women, to increase their involvement in clinical trials and develop antihypertensives that are fit for purpose. Dr Jenner proposes that women are therefore the perfect class for new antihypertensives.
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Affiliation(s)
- Bernadette Jenner
- Division of Experimental Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB20QQ, UK.
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4
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van Kammen CM, Taal SEL, Wever KE, Granger JP, Lely AT, Terstappen F. Reduced uterine perfusion pressure as a model for preeclampsia and fetal growth restriction in murine: a systematic review and meta-analysis. Am J Physiol Heart Circ Physiol 2024; 327:H89-H107. [PMID: 38758122 PMCID: PMC11380978 DOI: 10.1152/ajpheart.00056.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
The reduced uterine perfusion pressure (RUPP) model is frequently used to study preeclampsia and fetal growth restriction. An improved understanding of influential factors might improve reproducibility and reduce animal use considering the variability in RUPP phenotype. We performed a systematic review and meta-analysis by searching Medline and Embase (until 28 March, 2023) for RUPP studies in murine. Primary outcomes included maternal blood pressure (BP) or proteinuria, fetal weight or crown-rump length, fetal reabsorptions, or antiangiogenic factors. We aimed to identify influential factors by meta-regression analysis. We included 155 studies. Our meta-analysis showed that the RUPP procedure results in significantly higher BP (MD = 24.1 mmHg; [22.6; 25.7]; n = 148), proteinuria (SMD = 2.3; [0.9; 3.8]; n = 28), fetal reabsorptions (MD = 50.4%; [45.5; 55.2]; n = 42), circulating soluble FMS-like tyrosine kinase-1 (sFlt-1) (SMD = 2.6; [1.7; 3.4]; n = 34), and lower fetal weight (MD = -0.4 g; [-0.47; -0.34]; n = 113. The heterogeneity (variability between studies) in primary outcomes appeared ≥90%. Our meta-regression identified influential factors in the method and time point of BP measurement, randomization in fetal weight, and type of control group in sFlt-1. The RUPP is a robust model considering the evident differences in maternal and fetal outcomes. The high heterogeneity reflects the observed variability in phenotype. Because of underreporting, we observed reporting bias and a high risk of bias. We recommend standardizing study design by optimal time point and method chosen for readout measures to limit the variability. This contributes to improved reproducibility and thereby eventually improves the translational value of the RUPP model.
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Affiliation(s)
- Caren M van Kammen
- Division of Nanomedicine, Department CDL Research, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Seija E L Taal
- Department of Woman and Baby, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Kimberley E Wever
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joey P Granger
- Department of Physiology and Biophysics, Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, United States
| | - A Titia Lely
- Department of Woman and Baby, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Fieke Terstappen
- Department of Woman and Baby, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Murugesan S, Addis DR, Hussey H, Powell MF, Saravanakumar L, Sturdivant AB, Sinkey RG, Tubinis MD, Massey ZR, Mobley JA, Tita AN, Jilling T, Berkowitz DE. Decreased Extracellular Vesicle Vasorin in Severe Preeclampsia Plasma Mediates Endothelial Dysfunction. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.24.600441. [PMID: 38979275 PMCID: PMC11230191 DOI: 10.1101/2024.06.24.600441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Background Preeclampsia (PE) is a serious pregnancy complication affecting 5-8% of pregnancies globally. It is a leading cause of maternal and neonatal morbidity and mortality. Despite its prevalence, the underlying mechanisms of PE remain unclear. This study aimed to determine the potential role of vasorin (VASN) in PE pathogenesis by investigating its levels in extracellular vesicles (EV) and its effects on vascular function. Methods & Results We conducted unbiased proteomics on urine-derived EV from severe PE (sPE) and normotensive pregnant women (NTP), identifying differential protein abundances. Out of one hundred and twenty proteins with ≥ ±1.5-fold regulation at P<0.05 between sPE and NTP, we focused on Vasorin (VASN), which is downregulated in sPE in urinary EV, in plasma EV and in the placenta and is a known regulator of vascular function. We generated EV with high VASN content from both human and murine placenta explants (Plex EV), which recapitulated disease-state-dependent effects on vascular function observed when treating murine aorta rings (MAR) or human aortic endothelial cells (HAEC) with murine or human plasma-derived EV. In normal murine pregnancy, VASN increases with gestational age (GA), and VASN is decreased in plasma EV, in placenta tissue and in Plex EV after intravenous administration of adenovirus encoding short FMS-like tyrosine kinase 1 (sFLT-1), a murine model of PE (murine-PE). VASN is decreased in plasma EV, in placenta tissue and in EV isolated from conditioned media collected from placenta explants (Plex EV) in patients with sPE as compared to NTP. Human sPE and murine-PE plasma EV and Plex EV impair migration, tube formation, and induces apoptosis in human aortic endothelial cells (HAEC) and inhibit acetylcholine-induced vasorelaxation in murine vascular rings (MAR). VASN over-expression counteracts the effects of sPE EV treatment in HAEC and MAR. RNA sequencing revealed that over-expression or knock down of VASN in HAEC results in contrasting effects on transcript levels of hundreds of genes associated with vasculogenesis, endothelial cell proliferation, migration and apoptosis. Conclusions The data suggest that VASN, delivered to the endothelium via EV, regulates vascular function and that the loss of EV VASN may be one of the mechanistic drivers of PE. CLINICAL PERSPECTIVE What is NewVASN in circulating plasma EV in sPE is reduced compared with VASN content in plasma EV of gestational age-matched pregnant women.VASN is encapsulated and transported in EV and plays a pro-angiogenic role during pregnancy.VASN should be explored both for its pro-angiogenic mechanistic role and as a novel biomarker and potential predictive diagnostic marker for the onset and severity of PE.What Are the Clinical Implications?VASN plays a role in maintaining vascular health and the normal adaptive cardiovascular response in pregnancy. A decrease of VASN is observed in sPE patients contributing to cardiovascular maladaptation.Strategies to boost diminished VASN levels and/or to pharmacologically manipulate mechanisms downstream of VASN may be explored for potential therapeutic benefit in PE.The decrease in EV-associated VASN could potentially be used as a (predictive) biomarker for PE.
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Gong X, He W, Jin W, Ma H, Wang G, Li J, Xiao Y, Zhao Y, Chen Q, Guo H, Yang J, Qi Y, Dong W, Fu M, Li X, Liu J, Liu X, Yin A, Zhang Y, Wei Y. Disruption of maternal vascular remodeling by a fetal endoretrovirus-derived gene in preeclampsia. Genome Biol 2024; 25:117. [PMID: 38715110 PMCID: PMC11075363 DOI: 10.1186/s13059-024-03265-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Preeclampsia, one of the most lethal pregnancy-related diseases, is associated with the disruption of uterine spiral artery remodeling during placentation. However, the early molecular events leading to preeclampsia remain unknown. RESULTS By analyzing placentas from preeclampsia, non-preeclampsia, and twin pregnancies with selective intrauterine growth restriction, we show that the pathogenesis of preeclampsia is attributed to immature trophoblast and maldeveloped endothelial cells. Delayed epigenetic reprogramming during early extraembryonic tissue development leads to generation of excessive immature trophoblast cells. We find reduction of de novo DNA methylation in these trophoblast cells results in selective overexpression of maternally imprinted genes, including the endoretrovirus-derived gene PEG10 (paternally expressed gene 10). PEG10 forms virus-like particles, which are transferred from the trophoblast to the closely proximate endothelial cells. In normal pregnancy, only a low amount of PEG10 is transferred to maternal cells; however, in preeclampsia, excessive PEG10 disrupts maternal vascular development by inhibiting TGF-beta signaling. CONCLUSIONS Our study reveals the intricate epigenetic mechanisms that regulate trans-generational genetic conflict and ultimately ensure proper maternal-fetal interface formation.
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Affiliation(s)
- Xiaoli Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Wei He
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wan Jin
- Euler Technology, Beijing, China
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hongwei Ma
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, China
- Department Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Gang Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
- Human Genetic Resources Preservation Center of Hubei Province, Wuhan, China
- Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jiaxin Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yu Xiao
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, China
- Human Genetic Resources Preservation Center of Hubei Province, Wuhan, China
- Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | | | | | - Jiexia Yang
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Yiming Qi
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wei Dong
- Maternity Ward, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Meng Fu
- Department of Obstetrics and Gynecology, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Xiaojuan Li
- Euler Technology, Beijing, China
- Present Address: International Max Planck Research School for Genome Science, and University of Göttingen, Göttingen Center for Molecular Biosciences, Göttingen, Germany
| | | | - Xinghui Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, China.
- Department Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
| | - Aihua Yin
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China.
| | - Yi Zhang
- Euler Technology, Beijing, China.
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
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Shi M, Zhang S, Rong J, Heng Z, Xu Y, Wang Y, Zhang Z. Identification of 18β-glycyrrhetinic acid as an AGT inhibitor against LPS-induced myocardial dysfunction via high throughput screening. Biochem Pharmacol 2024; 223:116127. [PMID: 38490519 DOI: 10.1016/j.bcp.2024.116127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/21/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Abstract
Sepsis induced myocardial dysfunction (SIMD) is a serious complication of sepsis. There is increasing evidence that the renin-angiotensin system (RAS) is activated in SIMD. Angiotensinogen (AGT) is a precursor of the RAS, and the inhibition of AGT may have significant cardiovascular benefits. But until now, there have been no reports of small molecule drugs targeting AGT. In this study, we designed a promoter-luciferase based system to screen for novel AGT inhibitors to alleviate SIMD. As a result of high-throughput screening, a total of 5 compounds from 351 medicinal herb-derived natural compounds were found inhibiting AGT. 18β-glycyrrhetinic acid (18βGA) was further identified as a potent suppressor of AGT. In vitro experiments, 18βGA could inhibit the secretion of AGT by HepG2 cells and alleviate the elevated level of mitochondrial oxidative stress in cardiomyocytes co-cultured with HepG2 supernatants. In vivo, 18βGA prolonged the survival rate of SIMD mice, enhanced cardiac function, and inhibited the damage of mitochondrial function and inflammation. In addition, the results showed that 18βGA may reduce AGT transcription by downregulating hepatocyte nuclear factor 4 (HNF4) and that further alleviated SIMD. In conclusion, we provided a more efficient screening strategy for AGT inhibitors and expanded the novel role of 18βGA as a promising lead compound in rescuing cardiovascular disease associated with RAS overactivation.
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Affiliation(s)
- Mengying Shi
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou 310058, China
| | - Shujing Zhang
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou 310058, China
| | - Jiabing Rong
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zetao Heng
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yinchuan Xu
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
| | - Yi Wang
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou 310058, China.
| | - Zhaocai Zhang
- Department of Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
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Chaudhary N, Newby AN, Whitehead KA. Non-Viral RNA Delivery During Pregnancy: Opportunities and Challenges. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2023:e2306134. [PMID: 38145340 PMCID: PMC11196389 DOI: 10.1002/smll.202306134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/25/2023] [Indexed: 12/26/2023]
Abstract
During pregnancy, the risk of maternal and fetal adversities increases due to physiological changes, genetic predispositions, environmental factors, and infections. Unfortunately, treatment options are severely limited because many essential interventions are unsafe, inaccessible, or lacking in sufficient scientific data to support their use. One potential solution to this challenge may lie in emerging RNA therapeutics for gene therapy, protein replacement, maternal vaccination, fetal gene editing, and other prenatal treatment applications. In this review, the current landscape of RNA platforms and non-viral RNA delivery technologies that are under active development for administration during pregnancy is explored. Advancements of pregnancy-specific RNA drugs against SARS-CoV-2, Zika, influenza, preeclampsia, and for in-utero gene editing are discussed. Finally, this study highlights bottlenecks that are impeding translation efforts of RNA therapies, including the lack of accurate cell-based and animal models of human pregnancy and concerns related to toxicity and immunogenicity during pregnancy. Overcoming these challenges will facilitate the rapid development of this new class of pregnancy-safe drugs.
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Affiliation(s)
- Namit Chaudhary
- Department of Chemical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213
| | - Alexandra N. Newby
- Department of Chemical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213
| | - Kathryn A. Whitehead
- Department of Chemical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213
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Ye D, Cruz-López EO, Tu HC, Zlatev I, Danser AJ. Targeting Angiotensinogen With N-Acetylgalactosamine-Conjugated Small Interfering RNA to Reduce Blood Pressure. Arterioscler Thromb Vasc Biol 2023; 43:2256-2264. [PMID: 37855126 PMCID: PMC10659251 DOI: 10.1161/atvbaha.123.319897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
Blood pressure management involves antihypertensive therapies blocking the renin-angiotensin system (RAS). Yet, it might be inadequate due to poor patient adherence or the so-called RAS escape phenomenon, elicited by the compensatory renin elevation upon RAS blockade. Recently, evidence points toward targeting hepatic AGT (angiotensinogen) as a novel approach to block the RAS pathway that could circumvent the RAS escape phenomenon. Removing AGT, from which all angiotensins originate, should prevent further angiotensin generation, even when renin rises. Furthermore, by making use of a trivalent N-acetylgalactosamine ligand-conjugated small interfering RNA that specifically targets the degradation of hepatocyte-produced mRNAs in a highly potent and specific manner, it may be possible in the future to manage hypertension with therapy that is administered 1 to 2× per year, thereby supporting medication adherence. This review summarizes all current findings on AGT small interfering RNA in preclinical models, making a comparison versus classical RAS blockade with either ACE (angiotensin-converting enzyme) inhibitors or AT1 (angiotensin II type 1) receptor antagonists and AGT suppression with antisense oligonucleotides. It ends with discussing the first-in-human study with AGT small interfering RNA.
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Affiliation(s)
- Dien Ye
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.Y., E.O.C.-L., A.H.J.D.)
| | - Edwyn O. Cruz-López
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.Y., E.O.C.-L., A.H.J.D.)
| | - Ho-Chou Tu
- Alnylam Pharmaceuticals, Cambridge, MA (H.-C.T., I.Z.)
| | - Ivan Zlatev
- Alnylam Pharmaceuticals, Cambridge, MA (H.-C.T., I.Z.)
| | - A.H. Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.Y., E.O.C.-L., A.H.J.D.)
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Desai AS, Webb DJ, Taubel J, Casey S, Cheng Y, Robbie GJ, Foster D, Huang SA, Rhyee S, Sweetser MT, Bakris GL. Zilebesiran, an RNA Interference Therapeutic Agent for Hypertension. N Engl J Med 2023; 389:228-238. [PMID: 37467498 DOI: 10.1056/nejmoa2208391] [Citation(s) in RCA: 77] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Angiotensinogen is the sole precursor of angiotensin peptides and has a key role in the pathogenesis of hypertension. Zilebesiran, an investigational RNA interference therapeutic agent with a prolonged duration of action, inhibits hepatic angiotensinogen synthesis. METHODS In this phase 1 study, patients with hypertension were randomly assigned in a 2:1 ratio to receive either a single ascending subcutaneous dose of zilebesiran (10, 25, 50, 100, 200, 400, or 800 mg) or placebo and were followed for 24 weeks (Part A). Part B assessed the effect of the 800-mg dose of zilebesiran on blood pressure under low- or high-salt diet conditions, and Part E the effect of that dose when coadministered with irbesartan. End points included safety, pharmacokinetic and pharmacodynamic characteristics, and the change from baseline in systolic and diastolic blood pressure, as measured by 24-hour ambulatory blood-pressure monitoring. RESULTS Of 107 patients enrolled, 5 had mild, transient injection-site reactions. There were no reports of hypotension, hyperkalemia, or worsening of renal function resulting in medical intervention. In Part A, patients receiving zilebesiran had decreases in serum angiotensinogen levels that were correlated with the administered dose (r = -0.56 at week 8; 95% confidence interval, -0.69 to -0.39). Single doses of zilebesiran (≥200 mg) were associated with decreases in systolic blood pressure (>10 mm Hg) and diastolic blood pressure (>5 mm Hg) by week 8; these changes were consistent throughout the diurnal cycle and were sustained at 24 weeks. Results from Parts B and E were consistent with attenuation of the effect on blood pressure by a high-salt diet and with an augmented effect through coadministration with irbesartan, respectively. CONCLUSIONS Dose-dependent decreases in serum angiotensinogen levels and 24-hour ambulatory blood pressure were sustained for up to 24 weeks after a single subcutaneous dose of zilebesiran of 200 mg or more; mild injection-site reactions were observed. (Funded by Alnylam Pharmaceuticals; ClinicalTrials.gov number, NCT03934307; EudraCT number, 2019-000129-39.).
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Affiliation(s)
- Akshay S Desai
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - David J Webb
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Jorg Taubel
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Sarah Casey
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Yansong Cheng
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Gabriel J Robbie
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Don Foster
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Stephen A Huang
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Sean Rhyee
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - Marianne T Sweetser
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
| | - George L Bakris
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston (A.S.D.), and Alnylam Pharmaceuticals, Cambridge (Y.C., G.J.R., D.F., S.A.H., S.R., M.T.S.) - both in Massachusetts; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (D.J.W.), Richmond Pharmacology and St. George's University of London, London (J.T.), and the Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester (S.C.) - all in the United Kingdom; and University Chicago Medicine, Chicago (G.L.B.)
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11
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Wu P, Green M, Myers JE. Hypertensive disorders of pregnancy. BMJ 2023; 381:e071653. [PMID: 37391211 DOI: 10.1136/bmj-2022-071653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.
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Affiliation(s)
- Pensée Wu
- School of Medicine, Keele University, Newcastle-under-Lyme, UK
- Academic Department of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, UK
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Jenny E Myers
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK
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12
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Vatish M, Powys VR, Cerdeira AS. Novel therapeutic and diagnostic approaches for preeclampsia. Curr Opin Nephrol Hypertens 2023; 32:124-133. [PMID: 36683536 DOI: 10.1097/mnh.0000000000000870] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW This review will summarize recent findings relating to the diagnostic approach to preeclampsia and current avenues of research aimed at modifying the underlying disease process. RECENT FINDINGS Growing international consensus supports a broad preeclampsia definition that incorporates maternal end-organ and uteroplacental dysfunction. Recent evidence demonstrates that this definition better identifies women and babies at risk of adverse outcomes compared to the traditional definition of hypertension and proteinuria. Multiple studies have demonstrated the usefulness and cost-effectiveness of angiogenic biomarkers such as soluble fms-like tyrosine kinase-1 and placental growth factor as a clinical adjunct to diagnose and predict severity of preeclampsia associated outcomes. Current novel therapeutic approaches to preeclampsia target pathogenic pathways (e.g. antiangiogenesis) or downstream effects such as oxidative stress and nitric oxide. Recent findings relating to these promising candidates are discussed. Multicenter clinical trials are needed to evaluate their effectiveness and ability to improve fetal and maternal outcomes. SUMMARY We provide an updated framework of the current approaches to define and diagnose preeclampsia. Disease modifying therapies (in particular, targeting the angiogenic pathway) are being developed for the first time and promise to revolutionize the way we manage preeclampsia.
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Affiliation(s)
- Manu Vatish
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
| | | | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
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13
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Issotina Zibrila A, Wang Z, Sangaré-Oumar MM, Zeng M, Liu X, Wang X, Zeng Z, Kang YM, Liu J. Role of blood-borne factors in sympathoexcitation-mediated hypertension: Potential neurally mediated hypertension in preeclampsia. Life Sci 2022; 320:121351. [PMID: 36592790 DOI: 10.1016/j.lfs.2022.121351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/19/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023]
Abstract
Hypertension remains a threat for society due to its unknown causes, preventing proper management, for the growing number of patients, for its state as a high-risk factor for stroke, cardiac and renal complication and as cause of disability. Data from clinical and animal researches have suggested the important role of many soluble factors in the pathophysiology of hypertension through their neuro-stimulating effects. Central targets of these factors are of molecular, cellular and structural nature. Preeclampsia (PE) is characterized by high level of soluble factors with strong pro-hypertensive activity and includes immune factors such as proinflammatory cytokines (PICs). The potential neural effect of those factors in PE is still poorly understood. Shedding light into the potential central effect of the soluble factors in PE may advance our current comprehension of the pathophysiology of hypertension in PE, which will contribute to better management of the disease. In this paper, we summarized existing data in respect of hypothesis of this review, that is, the existence of the neural component in the pathophysiology of the hypertension in PE. Future studies would address this hypothesis to broaden our understanding of the pathophysiology of hypertension in PE.
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Affiliation(s)
- Abdoulaye Issotina Zibrila
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China; Department of Animal Physiology, Faculty of science and Technology, University of Abomey-Calavi, 06 BP 2584 Cotonou, Benin
| | - Zheng Wang
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, PR China
| | - Machioud Maxime Sangaré-Oumar
- Department of Animal Physiology, Faculty of science and Technology, University of Abomey-Calavi, 06 BP 2584 Cotonou, Benin
| | - Ming Zeng
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China
| | - Xiaoxu Liu
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China
| | - Xiaomin Wang
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China
| | - Zhaoshu Zeng
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China
| | - Yu-Ming Kang
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China.
| | - Jinjun Liu
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University School of Basic Medical Sciences, Key Laboratory of Environment and Genes Related to Diseases, Xi'an 710061, Shaanxi, PR China.
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14
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Ferrario CM, Saha A, VonCannon JL, Meredith WJ, Ahmad S. Does the Naked Emperor Parable Apply to Current Perceptions of the Contribution of Renin Angiotensin System Inhibition in Hypertension? Curr Hypertens Rep 2022; 24:709-721. [PMID: 36272015 DOI: 10.1007/s11906-022-01229-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To address contemporary hypertension challenges, a critical reexamination of therapeutic accomplishments using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, and a greater appreciation of evidence-based shortcomings from randomized clinical trials are fundamental in accelerating future progress. RECENT FINDINGS Medications targeting angiotensin II mechanism of action are essential for managing primary hypertension, type 2 diabetes, heart failure, and chronic kidney disease. While the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to control blood pressure is undisputed, practitioners, hypertension specialists, and researchers hold low awareness of these drugs' limitations in preventing or reducing the risk of cardiovascular events. Biases in interpreting gained knowledge from data obtained in randomized clinical trials include a pervasive emphasis on using relative risk reduction over absolute risk reduction. Furthermore, recommendations for clinical practice in international hypertension guidelines fail to address the significance of a residual risk several orders of magnitude greater than the benefits. We analyze the limitations of the clinical trials that have led to current recommended treatment guidelines. We define and quantify the magnitude of the residual risk in published hypertension trials and explore how activation of alternate compensatory bioprocessing components within the renin angiotensin system bypass the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to achieve a significant reduction in total and cardiovascular deaths. We complete this presentation by outlining the current incipient but promising potential of immunotherapy to block angiotensin II pathology alone or possibly in combination with other antihypertensive drugs. A full appreciation of the magnitude of the residual risk associated with current renin angiotensin system-based therapies constitutes a vital underpinning for seeking new molecular approaches to halt or even reverse the cardiovascular complications of primary hypertension and encourage investigating a new generation of ACE inhibitors and ARBs with increased capacity to reach the intracellular compartments at which Ang II can be generated.
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Affiliation(s)
- Carlos M Ferrario
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA.
| | - Amit Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Jessica L VonCannon
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Wayne J Meredith
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Sarfaraz Ahmad
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
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15
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Kahlon T, Carlisle S, Otero Mostacero D, Williams N, Trainor P, DeFilippis AP. Angiotensinogen: More Than its Downstream Products: Evidence From Population Studies and Novel Therapeutics. JACC. HEART FAILURE 2022; 10:699-713. [PMID: 35963818 DOI: 10.1016/j.jchf.2022.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
The renin-angiotensin-aldosterone system (RAAS) is a well-defined pathway playing a key role in maintaining circulatory homeostasis. Abnormal activation of RAAS contributes to development of cardiovascular disease, including heart failure, cardiac hypertrophy, hypertension, and atherosclerosis. Although several key RAAS enzymes and peptide hormones have been thoroughly investigated, the role of angiotensinogen-the precursor substrate of the RAAS pathway-remains less understood. The study of angiotensinogen single-nucleotide polymorphisms (SNPs) has provided insight into associations between angiotensinogen and hypertension, congestive heart failure, and atherosclerotic cardiovascular disease. Targeted drug therapy of RAAS has dramatically improved clinical outcomes for patients with heart failure, myocardial infarction, and hypertension. However, all such therapeutics block RAAS components downstream of angiotensinogen and elicit compensatory pathways that limit their therapeutic efficacy as monotherapy. Upstream RAAS targeting by an angiotensinogen inhibitor has the potential to be more efficacious in patients with suboptimal RAAS inhibition and has a better safety profile than multiagent RAAS blockade. Newly developed therapeutics that target angiotensinogen through antisense oligonucleotides or silencer RNA technologies are providing a novel perspective into the pathobiology of angiotensinogen and show promise as the next frontier in the treatment of cardiovascular disease.
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Affiliation(s)
- Tanvir Kahlon
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Samantha Carlisle
- Department of Chemistry and Biochemistry, New Mexico State University, Las Cruces, New Mexico, USA
| | - Diana Otero Mostacero
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Nina Williams
- Warren Clinic Cardiology of Tulsa, St Francis Hospital, Tulsa, Oklahoma, USA
| | - Patrick Trainor
- Department of Chemistry and Biochemistry, New Mexico State University, Las Cruces, New Mexico, USA
| | - Andrew P DeFilippis
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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16
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Abstract
Cardiovascular complications of pregnancy have risen substantially over the past decades, and now account for the majority of pregnancy-induced maternal deaths, as well as having substantial long-term consequences on maternal cardiovascular health. The causes and pathophysiology of these complications remain poorly understood, and therapeutic options are limited. Preclinical models represent a crucial tool for understanding human disease. We review here advances made in preclinical models of cardiovascular complications of pregnancy, including preeclampsia and peripartum cardiomyopathy, with a focus on pathological mechanisms elicited by the models and on relevance to human disease.
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Affiliation(s)
- Zolt Arany
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Denise Hilfiker-Kleiner
- Institute of Cardiovascular Complications in Pregnancy and in Oncologic Therapies, Philipps University Marburg, Germany (D.H.-K.)
| | - S Ananth Karumanchi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (S.A.K.)
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17
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Tong S, Kaitu’u-Lino TJ, Hastie R, Brownfoot F, Cluver C, Hannan N. Pravastatin, proton-pump inhibitors, metformin, micronutrients, and biologics: new horizons for the prevention or treatment of preeclampsia. Am J Obstet Gynecol 2022; 226:S1157-S1170. [PMID: 32946849 DOI: 10.1016/j.ajog.2020.09.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/25/2020] [Accepted: 09/10/2020] [Indexed: 12/14/2022]
Abstract
There has been increasing research momentum to identify new therapeutic agents for the prevention or treatment of preeclampsia, drugs that can affect the underlying disease pathophysiology. Molecular targets of candidate treatments include oxidative stress, antiangiogenic factors, and the angiotensin, nitric oxide, and proinflammatory pathways. The proposed treatments undergoing preclinical and clinical trial evaluation are thought to act on placental or endothelial disease or both. Most have adopted the pragmatic strategy of repurposing drugs. Of all the therapeutic agents proposed, pravastatin has received the most interest. There are preclinical studies showing that it has pleiotropic actions that favorably impact on multiple molecular targets and can resolve a preeclampsia phenotype in many animal models. An early phase clinical trial suggests that it may have therapeutic activity. Several large prevention trials are planned or ongoing and, when completed, could definitively address whether pravastatin can prevent preeclampsia. Proton-pump inhibitors, metformin, and sulfasalazine are other drugs with preclinical evidence of multiple molecular actions that could resolve the pathophysiology of preeclampsia. These agents are also currently being evaluated in clinical trials. There have been many recent preclinical studies identifying the potential of numerous natural compounds to treat preeclampsia, such as plant extracts and micronutrients that have potent anti-inflammatory or antioxidant activity. Recent preclinical studies have also proposed novel molecular-targeted strategies, such as monoclonal antibodies targeting tumor necrosis factor alpha, placental growth factor, and short interfering RNA technology, to silence the gene expression of soluble fms-like tyrosine kinase-1 or angiotensinogen. Other treatment approaches that have transitioned to human trials (ranging from single-arm to phase III trials that have been completed or are ongoing) include folic acid, nitric oxide donors (such as L-arginine), recombinant antithrombin III, digoxin immune antigen-binding fragment, and melatonin. There have been case series showing the removal of circulating soluble fms-like tyrosine kinase-1 may help stabilize the disease and prolong pregnancy. Interestingly, there are case reports suggesting that monoclonal antibody eculizumab (complement inhibitor) may have therapeutic potential. If new agents are discovered that are proven to be effective in preventing or treating preeclampsia, the potential to improve global maternal and perinatal health will be significant.
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18
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Wiegel RE, Fares DA, Willemsen SP, Steegers EA, Danser AJ, Steegers-Theunissen RP. First-trimester maternal renin-angiotensin-aldosterone system activation and fetal growth and birth weight: The Rotterdam Periconceptional Cohort. Reprod Biomed Online 2022; 44:1110-1122. [DOI: 10.1016/j.rbmo.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
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19
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Chappell LC, Cluver CA, Kingdom J, Tong S. Pre-eclampsia. Lancet 2021; 398:341-354. [PMID: 34051884 DOI: 10.1016/s0140-6736(20)32335-7] [Citation(s) in RCA: 400] [Impact Index Per Article: 133.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Abstract
Pre-eclampsia is a multisystem pregnancy disorder characterised by variable degrees of placental malperfusion, with release of soluble factors into the circulation. These factors cause maternal vascular endothelial injury, which leads to hypertension and multi-organ injury. The placental disease can cause fetal growth restriction and stillbirth. Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity, especially in low-income and middle-income countries. Prophylactic low-dose aspirin can reduce the risk of preterm pre-eclampsia, but once pre-eclampsia has been diagnosed there are no curative treatments except for delivery, and no drugs have been shown to influence disease progression. Timing of delivery is planned to optimise fetal and maternal outcomes. Clinical trials have reported diagnostic and prognostic strategies that could improve fetal and maternal outcomes and have evaluated the optimal timing of birth in women with late preterm pre-eclampsia. Ongoing studies are evaluating the efficacy, dose, and timing of aspirin and calcium to prevent pre-eclampsia and are evaluating other drugs to control hypertension or ameliorate disease progression.
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Affiliation(s)
- Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Kings' College London, London, UK.
| | - Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa; Tygerberg Hospital, Cape Town, South Africa
| | - John Kingdom
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Mercy Hospital for Women, Heidelberg, VIC, Australia
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20
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Sun Y, Tan L, Neuman RI, Broekhuizen M, Schoenmakers S, Lu X, Danser AHJ. Megalin, Proton Pump Inhibitors and the Renin-Angiotensin System in Healthy and Pre-Eclamptic Placentas. Int J Mol Sci 2021; 22:ijms22147407. [PMID: 34299027 PMCID: PMC8306182 DOI: 10.3390/ijms22147407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/22/2022] Open
Abstract
Soluble Fms-like tyrosine kinase-1 (sFlt-1) is increased in pre-eclampsia. The proton pump inhibitor (PPI) lowers sFlt-1, while angiotensin increases it. To investigate whether PPIs lower sFlt-1 by suppressing placental renin–angiotensin system (RAS) activity, we studied gene expression and protein abundance of RAS components, including megalin, a novel endocytic receptor for prorenin and renin, in placental tissue obtained from healthy pregnant women and women with early-onset pre-eclampsia. Renin, ACE, ACE2, and the angiotensin receptors were expressed at identical levels in healthy and pre-eclamptic placentas, while both the (pro)renin receptor and megalin were increased in the latter. Placental prorenin levels were upregulated in pre-eclamptic pregnancies. Angiotensinogen protein, but not mRNA, was detectable in placental tissue, implying that it originates from maternal blood. Ex vivo placental perfusion revealed a complete washout of angiotensinogen, while prorenin release remained constant. The PPI esomeprazole dose-dependently reduced megalin/(pro)renin receptor-mediated renin uptake in Brown Norway yolk sac epithelial cells and decreased sFlt-1 secretion from placental villous explants. Megalin inhibition blocked angiotensinogen uptake in epithelial cells. In conclusion, our data suggest that placental RAS activity depends on angiotensinogen taken up from the maternal systemic circulation. PPIs might interfere with placental (pro)renin-AGT uptake/transport, thereby reducing angiotensin formation as well as angiotensin-induced sFlt-1 synthesis.
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Affiliation(s)
- Yuan Sun
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, 3015 CN Rotterdam, The Netherlands; (Y.S.); (L.T.); (R.I.N.); (M.B.)
- Department of Pharmacology, College of Pharmacy, Shenzhen Technology University, Shenzhen 518118, China
- Health Science Center, Department of Physiology, Shenzhen University, Shenzhen 518061, China;
| | - Lunbo Tan
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, 3015 CN Rotterdam, The Netherlands; (Y.S.); (L.T.); (R.I.N.); (M.B.)
- Health Science Center, Department of Physiology, Shenzhen University, Shenzhen 518061, China;
| | - Rugina I. Neuman
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, 3015 CN Rotterdam, The Netherlands; (Y.S.); (L.T.); (R.I.N.); (M.B.)
| | - Michelle Broekhuizen
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, 3015 CN Rotterdam, The Netherlands; (Y.S.); (L.T.); (R.I.N.); (M.B.)
- Division of Neonatology, Department of Pediatrics, Erasmus MC, 3015 CN Rotterdam, The Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus MC, 3015 CN Rotterdam, The Netherlands;
| | - Xifeng Lu
- Health Science Center, Department of Physiology, Shenzhen University, Shenzhen 518061, China;
| | - A. H. Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, 3015 CN Rotterdam, The Netherlands; (Y.S.); (L.T.); (R.I.N.); (M.B.)
- Correspondence: ; Tel.: +31-10-7043540
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21
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Sun H, Hodgkinson CP, Pratt RE, Dzau VJ. CRISPR/Cas9 Mediated Deletion of the Angiotensinogen Gene Reduces Hypertension: A Potential for Cure? Hypertension 2021; 77:1990-2000. [PMID: 33813849 PMCID: PMC9896968 DOI: 10.1161/hypertensionaha.120.16870] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/17/2021] [Indexed: 02/06/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Hualing Sun
- Mandel Center and the Duke Cardiovascular Research Center, Duke University Medical Center, Durham, NC 27710
| | - Conrad P. Hodgkinson
- Mandel Center and the Duke Cardiovascular Research Center, Duke University Medical Center, Durham, NC 27710
| | - Richard E. Pratt
- Mandel Center and the Duke Cardiovascular Research Center, Duke University Medical Center, Durham, NC 27710
| | - Victor J. Dzau
- Mandel Center and the Duke Cardiovascular Research Center, Duke University Medical Center, Durham, NC 27710
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22
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Wiegel RE, von Versen-Höynck F, Steegers-Theunissen RPM, Steegers EAP, Danser AHJ. Prorenin periconceptionally and in pregnancy: Does it have a physiological role? Mol Cell Endocrinol 2021; 529:111281. [PMID: 33878417 DOI: 10.1016/j.mce.2021.111281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/24/2020] [Accepted: 12/06/2020] [Indexed: 12/30/2022]
Abstract
Pregnancy demands major cardiovascular, renal and endocrine changes to provide an adequate blood supply for the growing fetus. The renin-angiotensin-aldosterone system plays a key role in this adaptation process. One of its components, prorenin, is released in significant amounts from the ovary and uteroplacental unit. This review describes the sources of prorenin in the periconception period and in pregnancy, including its modulation by in-vitro fertilization protocols, and discusses its potential effects, among others focusing on preeclampsia. It ends with discussing the long-term consequences, even in later life, of inappropriate renin-angiotensin-aldosterone system activity in pregnancy and offers directions for future research. Ultimately, a full understanding of the role of prorenin periconceptionally and during pregnancy will help to develop tools to diagnose and/or prevent reproductive complications.
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Affiliation(s)
- Rosalieke E Wiegel
- Departments of Obstetrics and Gynecology, Erasmus MC, Rotterdam, the Netherlands
| | | | | | - Eric A P Steegers
- Departments of Obstetrics and Gynecology, Erasmus MC, Rotterdam, the Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
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Wiegel RE, von Versen-Höynck F, Steegers-Theunissen RPM, Steegers EAP, Danser AHJ. Prorenin periconceptionally and in pregnancy: Does it have a physiological role? Mol Cell Endocrinol 2021; 522:111118. [PMID: 33340569 DOI: 10.1016/j.mce.2020.111118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/24/2020] [Accepted: 12/06/2020] [Indexed: 01/19/2023]
Abstract
Pregnancy demands major cardiovascular, renal and endocrine changes to provide an adequate blood supply for the growing fetus. The renin-angiotensin-aldosterone system plays a key role in this adaptation process. One of its components, prorenin, is released in significant amounts from the ovary and uteroplacental unit. This review describes the sources of prorenin in the periconception period and in pregnancy, including its modulation by in-vitro fertilization protocols, and discusses its potential effects, among others focusing on preeclampsia. It ends with discussing the long-term consequences, even in later life, of inappropriate renin-angiotensin-aldosterone system activity in pregnancy and offers directions for future research. Ultimately, a full understanding of the role of prorenin periconceptionally and during pregnancy will help to develop tools to diagnose and/or prevent reproductive complications.
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Affiliation(s)
- Rosalieke E Wiegel
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, the Netherlands
| | | | | | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, the Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
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Xu Y, Rong J, Zhang Z. The emerging role of angiotensinogen in cardiovascular diseases. J Cell Physiol 2020; 236:68-78. [PMID: 32572956 DOI: 10.1002/jcp.29889] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022]
Abstract
Angiotensinogen (AGT) is the unique precursor of all angiotensin peptides. Many of the basic understandings of AGT in cardiovascular diseases have come from research efforts to define its effects on blood pressure regulation. The development of novel techniques targeting AGT manipulation such as genetic animal models, adeno-associated viral approaches, and antisense oligonucleotides made it possible to deeply investigate the relationship between AGT and cardiovascular diseases. In this brief review, we provide contemporary insights into the emerging role of AGT in cardiovascular diseases. In light of the recent progress, we emphasize some newly recognized features and mechanisms of AGT in heart failure, hypertension, atherosclerosis, and cardiovascular risk factors.
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Affiliation(s)
- Yinchuan Xu
- Department of Cardiology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiabing Rong
- Department of Cardiology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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