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Smits AJ, Botros L, Mol MA, Ziesemer KA, Wilkins MR, Vonk Noordegraaf A, Bogaard HJ, Aman J. A Systematic Review with Meta-analysis of Biomarkers for detection of Pulmonary Arterial Hypertension. ERJ Open Res 2022; 8:00009-2022. [PMID: 35651362 PMCID: PMC9149393 DOI: 10.1183/23120541.00009-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/04/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale The blood is a rich source of potential biomarkers for the diagnosis of idiopathic and hereditary pulmonary arterial hypertension (iPAH and hPAH, referred to as “PAH”). While a lot of biomarkers have been identified for PAH, the clinical utility of these biomarkers often remains unclear. Here, we performed an unbiased meta-analysis of published biomarkers to identify biomarkers with the highest performance for detection of PAH. Methods A literature search (in PubMed, Embase.com, Clarivate Analytics/Web of Science Core Collection and Wiley/Cochrane Library) was performed up to 28 January 2021. Primary end points were blood biomarker levels in PAH versus asymptomatic controls or patients suspected of pulmonary hypertension (PH) with proven normal haemodynamic profiles. Results 149 articles were identified by the literature search. Meta-analysis of 26 biomarkers yielded 17 biomarkers that were differentially expressed in PAH and non-PH control subjects. Red cell distribution width, low density lipid-cholesterol, d-dimer, N-terminal prohormone of brain natriuretic protein (NT-proBNP), interleukin-6 (IL-6) and uric acid were biomarkers with the largest observed differences, largest sample sizes and a low risk of publication bias. Receiver operating characteristic curves and sensitivity/specificity analyses demonstrated that NT-proBNP had a high sensitivity, but low specificity for PAH. For the other biomarkers, insufficient data on diagnostic accuracy with receiver operating characteristic curves were available for meta-analysis. Conclusion This meta-analysis validates NT-proBNP as a biomarker with high sensitivity for PAH, albeit with low specificity. The majority of biomarkers evaluated in this meta-analysis lacked either external validation or data on diagnostic accuracy. Further validation studies are required as well as studies that test combinations of biomarkers to improve specificity. Meta-analysis of 26 biomarkers yielded 17 differentially expressed biomarkers in PAH. NT-proBNP had the highest diagnostic accuracy but had a low specificity for PAH. Other markers, including IL-6, RDW, LDL-c, D-dimer and UA, lacked clinical validation.https://bit.ly/3J4YAyC
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He W, Su X, Chen L, Liu C, Lu W, Wang T, Wang J. Potential biomarkers and therapeutic targets of idiopathic pulmonary arterial hypertension. Physiol Rep 2022; 10:e15101. [PMID: 34981661 PMCID: PMC8724678 DOI: 10.14814/phy2.15101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/22/2021] [Accepted: 10/16/2021] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Peripheral blood mononuclear cells (PBMCs) play an important role in the pathogenesis of pulmonary arterial hypertension (PAH). However, the specific roles of PBMCs in the development and progression of idiopathic PAH (IPAH) have not been fully understood. METHODS Here, differentially expressed genes (DEGs) of PBMCs or lung tissues between IPAH patients and healthy controls were identified via bioinformatics analysis of Gene Expression Omnibus (GEO) datasets GSE33463 and GSE48149, respectively. Subsequently, extensive target prediction and network analysis were performed to assess protein-protein interaction (PPI) networks, Gene Ontology (GO) terms, and pathway enrichment for DEGs. Co-expressed DEGs between PBMCs and lung tissues coupled with corresponding predicted miRNAs involved in PAH were also assessed. We identified 251 DEGs in PBMCs and 151 DEGs in lung tissue samples from IPAH. PDK4, RBPMS2, and PDE5A expression were altered in both PBMCs and lung tissues from IPAH patients compared to healthy control. RESULTS CXCL8, JUN, TLR8, IL1B, and TLR7 could be implicated as the hub genes in PBMCs, whereas ENO1, STAT1, CXCL10, GPI, and IRF1 in lung tissues. Finally, co-expressed DEGs of PDK4, RBPMS2, and PDE5A coupled with corresponding predicted miRNAs, especially miR-103a-3p, miR-185-5p, and miR-515-5p, are significantly associated with IPAH. CONCLUSION Our findings collectively suggest that the expression levels of PDK4, RBPMS2, and PDE5A in PBMCs are associated with the expression of these genes in lung tissues. Thus, these molecules may serve as potential circulating biomarkers and/or possible therapeutic targets for IPAH.
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Affiliation(s)
- Wenjun He
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
- Department of Pulmonary MedicineAmsterdam University Medical CenterLocation VU University Medical CenterAmsterdamThe Netherlands
| | - Xi Su
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
- Shanghai Chest Hospital, Shanghai Jiao Tong UniversityShanghaiChina
| | - Lingdan Chen
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Chunli Liu
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Wenju Lu
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Tao Wang
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Jian Wang
- State Key Laboratory of Respiratory DiseasesGuangdong Key Laboratory of Vascular DiseasesNational Clinical Research Center for Respiratory DiseasesGuangzhou Institute of Respiratory HealthThe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
- Division of CardiologyDepartment of MedicineUniversity of CaliforniaSan DiegoCaliforniaUSA
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Qin K, Lei J, Yang J. The Differentiation of Pluripotent Stem Cells towards Endothelial Progenitor Cells - Potential Application in Pulmonary Arterial Hypertension. Int J Stem Cells 2021; 15:122-135. [PMID: 34711697 PMCID: PMC9148829 DOI: 10.15283/ijsc21044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives Endothelial progenitor cells (EPCs) and endothelial cells (ECs) have been applied in the clinic to treat pulmonary arterial hypertension (PAH), a disease characterized by disordered pulmonary vasculature. However, the lack of sufficient transplantable cells before the deterioration of disease condition is a current limitation to apply cell therapy in patients. It is necessary to differentiate pluripotent stem cells (PSCs) into EPCs and identify their characteristics. Methods and Results Comparing previously reported methods of human PSCs-derived ECs, we optimized a highly efficient differentiation protocol to obtain cells that match the phenotype of isolated EPCs from healthy donors. The protocol is compatible with chemically defined medium (CDM), it could produce a large number of clinically applicable cells with low cost. Moreover, we also found PSCs-derived EPCs express CD133, have some characteristics of mesenchymal stem cells and are capable of homing to repair blood vessels in zebrafish xenograft assays. In addition, we further revealed that IPAH PSCs-derived EPCs have higher expression of proliferation-related genes and lower expression of immune-related genes than normal EPCs and PSCs-derived EPCs through microarray analysis. Conclusions In conclusion, we optimized a highly efficient differentiation protocol to obtain PSCs-derived EPCs with the phenotypic and molecular characteristics of EPCs from healthy donors which distinguished them from EPCs from PAH.
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Affiliation(s)
- Kezhou Qin
- Department of Cell Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jia Lei
- Department of Physiology, and Department of Cardiology of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Yang
- Department of Cell Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Department of Physiology, and Department of Cardiology of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Circulating Cell Biomarkers in Pulmonary Arterial Hypertension: Relationship with Clinical Heterogeneity and Therapeutic Response. Cells 2021; 10:cells10071688. [PMID: 34359858 PMCID: PMC8304946 DOI: 10.3390/cells10071688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Endothelial dysfunction is central to PAH. In this study, we simultaneously analysed circulating levels of endothelial microvesicles (EMVs) and progenitor cells (PCs) in PAH and in controls, as biomarkers of pulmonary endothelial integrity and evaluated differences among PAH subtypes and as a response to treatment. METHODS Forty-seven controls and 144 patients with PAH (52 idiopathic, 9 heritable, 31 associated with systemic sclerosis, 15 associated with other connective tissue diseases, 20 associated with HIV and 17 associated with portal hypertension) were evaluated. Forty-four patients with scleroderma and 22 with HIV infection, but without PAH, were also studied. Circulating levels of EMVs, total (CD31+CD42b-) and activated (CD31+CD42b-CD62E+), as well as circulating PCs (CD34+CD133+CD45low) were measured by flow cytometry and the EMVs/PCs ratio was computed. In treatment-naïve patients, measurements were repeated after 3 months of PAH therapy. RESULTS Patients with PAH showed higher numbers of EMVs and a lower percentage of PCs, compared with healthy controls. The EMV/PC ratio was increased in PAH patients, and in patients with SSc or HIV without PAH. After starting PAH therapy, individual changes in EMVs and PCs were variable, without significant differences being observed as a group. Conclusion: PAH patients present disturbed vascular homeostasis, reflected in changes in circulating EMV and PC levels, which are not restored with PAH targeted therapy. Combined measurement of circulating EMVs and PCs could be foreseen as a potential biomarker of endothelial dysfunction in PAH.
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Sweatt AJ, Reddy R, Rahaghi FN, Al-Naamani N. What's new in pulmonary hypertension clinical research: lessons from the best abstracts at the 2020 American Thoracic Society International Conference. Pulm Circ 2021; 11:20458940211040713. [PMID: 34471517 PMCID: PMC8404658 DOI: 10.1177/20458940211040713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
In this conference paper, we review the 2020 American Thoracic Society International Conference session titled, "What's New in Pulmonary Hypertension Clinical Research: Lessons from the Best Abstracts". This virtual mini-symposium took place on 21 October 2020, in lieu of the annual in-person ATS International Conference which was cancelled due to the COVID-19 pandemic. Seven clinical research abstracts were selected for presentation in the session, which encompassed five major themes: (1) standardizing diagnosis and management of pulmonary hypertension, (2) improving risk assessment in pulmonary arterial hypertension, (3) evaluating biomarkers of disease activity, (4) understanding metabolic dysregulation across the spectrum of pulmonary hypertension, and (5) advancing knowledge in chronic thromboembolic pulmonary hypertension. Focusing on these five thematic contexts, we review the current state of knowledge, summarize presented research abstracts, appraise their significance and limitations, and then discuss relevant future directions in pulmonary hypertension clinical research.
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Affiliation(s)
- Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Raju Reddy
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Farbod N. Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - on behalf of the American Thoracic Society Pulmonary Circulation Assembly Early Career Working Group
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Dierick F, Solinc J, Bignard J, Soubrier F, Nadaud S. Progenitor/Stem Cells in Vascular Remodeling during Pulmonary Arterial Hypertension. Cells 2021; 10:cells10061338. [PMID: 34071347 PMCID: PMC8226806 DOI: 10.3390/cells10061338] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/12/2021] [Accepted: 05/21/2021] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by an important occlusive vascular remodeling with the production of new endothelial cells, smooth muscle cells, myofibroblasts, and fibroblasts. Identifying the cellular processes leading to vascular proliferation and dysfunction is a major goal in order to decipher the mechanisms leading to PAH development. In addition to in situ proliferation of vascular cells, studies from the past 20 years have unveiled the role of circulating and resident vascular in pulmonary vascular remodeling. This review aims at summarizing the current knowledge on the different progenitor and stem cells that have been shown to participate in pulmonary vascular lesions and on the pathways regulating their recruitment during PAH. Finally, this review also addresses the therapeutic potential of circulating endothelial progenitor cells and mesenchymal stem cells.
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Affiliation(s)
- France Dierick
- Lady Davis Institute for Medical Research, McGill University, Montréal, QC H3T 1E2, Canada;
| | - Julien Solinc
- UMR_S 1166, Faculté de Médecine Pitié-Salpêtrière, INSERM, Sorbonne Université, 75013 Paris, France; (J.S.); (J.B.); (F.S.)
| | - Juliette Bignard
- UMR_S 1166, Faculté de Médecine Pitié-Salpêtrière, INSERM, Sorbonne Université, 75013 Paris, France; (J.S.); (J.B.); (F.S.)
| | - Florent Soubrier
- UMR_S 1166, Faculté de Médecine Pitié-Salpêtrière, INSERM, Sorbonne Université, 75013 Paris, France; (J.S.); (J.B.); (F.S.)
| | - Sophie Nadaud
- UMR_S 1166, Faculté de Médecine Pitié-Salpêtrière, INSERM, Sorbonne Université, 75013 Paris, France; (J.S.); (J.B.); (F.S.)
- Correspondence:
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Zhang T, Huang C, Luo H, Li J, Huang H, Liu X, Zhan S. Identification of key genes and immune profile in limited cutaneous systemic sclerosis-associated pulmonary arterial hypertension by bioinformatics analysis. Life Sci 2021; 271:119151. [PMID: 33539912 DOI: 10.1016/j.lfs.2021.119151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
AIMS Limited cutaneous systemic sclerosis-associated pulmonary arterial hypertension (lcSSc-PAH) is a complex multi-system disease with high morbidity and mortality. The purpose of this study is to identify the hub genes and immune characteristics of limited cutaneous systemic sclerosis (lcSSc) and lcSSc-PAH through bioinformatics. MAIN METHODS LcSSc-PAH raw data were obtained from the GEO database (GSE19617). Weighted gene Co-expression Network analysis (WGCNA) was used to evaluate key modules. Then, we performed Gene Ontology (GO) terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis with R software and verified the diagnostic value of the hub genes. Finally, Immune Cell Abundance Identifier (ImmuCellAI) was used to analyze the immune characteristics of the normal subjects, lcSSc and lcSSc-PAH patients, the results were displayed graphically. KEY FINDINGS Enrichment of two important modules by GO and KEGG identified key biological processes and pathways related to pathogen infection and immune function. Three hub genes (BID, IFNGR1, ZAP70) related to immune function were identified. The analysis of immune characteristics showed that the correlation and abundance of immune cells such as inducible regulatory T (iTreg) cells, B cells, macrophages, natural killer (NK) cells, CD8T cells, mucosal-associated invariant T(MAIT) cells and dendritic cells(DCs) were significantly different in the normal subjects, lcSSc and lcSSc-PAH patients. SIGNIFICANCE Pathogen infection, changes in the number and function of immune cells, and interactions among immune cells may preliminarily reveal the pathological mechanism of lcSSc-PAH. The hub genes, pathways and immune characteristics identified in this research remains to be further studied.
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Affiliation(s)
- Tiange Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chaoyuan Huang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hu Luo
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun Li
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Huiting Huang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaohong Liu
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Shaofeng Zhan
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
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Hemnes A, Rothman AMK, Swift AJ, Zisman LS. Role of biomarkers in evaluation, treatment and clinical studies of pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020957234. [PMID: 33282185 PMCID: PMC7682212 DOI: 10.1177/2045894020957234] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary arterial hypertension is a complex disease resulting from the interplay of myriad biological and environmental processes that lead to remodeling of the pulmonary vasculature with consequent pulmonary hypertension. Despite currently available therapies, there remains significant morbidity and mortality in this disease. There is great interest in identifying and applying biomarkers to help diagnose patients with pulmonary arterial hypertension, inform prognosis, guide therapy, and serve as surrogate endpoints. An extensive literature on potential biomarker candidates is available, but barriers to the implementation of biomarkers for clinical use in pulmonary arterial hypertension are substantial. Various omic strategies have been undertaken to identify key pathways regulated in pulmonary arterial hypertension that could serve as biomarkers including genomic, transcriptomic, proteomic, and metabolomic approaches. Other biologically relevant components such as circulating cells, microRNAs, exosomes, and cell-free DNA have recently been gaining attention. Because of the size of the datasets generated by these omic approaches and their complexity, artificial intelligence methods are being increasingly applied to decipher their meaning. There is growing interest in imaging the lung with various modalities to understand and visualize processes in the lung that lead to pulmonary vascular remodeling including high resolution computed tomography, Xenon magnetic resonance imaging, and positron emission tomography. Such imaging modalities have the potential to demonstrate disease modification resulting from therapeutic interventions. Because right ventricular function is a major determinant of prognosis, imaging of the right ventricle with echocardiography or cardiac magnetic resonance imaging plays an important role in the evaluation of patients and may also be useful in clinical studies of pulmonary arterial hypertension.
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Affiliation(s)
- Anna Hemnes
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrew J Swift
- University of Sheffield and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
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Hashimoto R, Lanier GM, Dhagia V, Joshi SR, Jordan A, Waddell I, Tuder R, Stenmark KR, Wolin MS, McMurtry IF, Gupte SA. Pluripotent hematopoietic stem cells augment α-adrenergic receptor-mediated contraction of pulmonary artery and contribute to the pathogenesis of pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2020; 318:L386-L401. [PMID: 31913656 PMCID: PMC7052680 DOI: 10.1152/ajplung.00327.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) is a multicellular and progressive disease with a high mortality rate. Among many cell types, hematopoietic stem cells (HSCs) are incriminated in the pathogenesis of PH. However, our understanding of the mechanisms that increase HSCs in blood and lungs of hypertensive animals or patients and the role played by HSCs in the pathogenesis of PH remains elusive. Studies suggest that glycolysis is critical for the survival and growth of HSCs. In various cell types from hypertensive lungs of animals and patients, glycolysis and the glucose-6-phosphate dehydrogenase (G6PD) activity are increased. Herein, we demonstrated in mice that chronic hypoxia increased HSCs (CD34+, CD117+, CD133+, CD34+/CD117+, and CD34+/CD133+) in bone marrow and blood and around hypertensive pulmonary arteries in a time-dependent manner. Intriguingly, we found fewer CD133+ cells in the bone marrow of C57BL/6 mice compared with Sv129J mice, and C57BL mice developed less severe chronic hypoxia-elicited PH and heart failure than Sv129J mice. Similarly, the numbers of CD34+ and CD117+ cells in blood of patients with pulmonary arterial hypertension (PAH) were higher (>3-fold) compared with healthy individuals. By allogeneic bone marrow transplantation, we found that GFP+ bone marrow cells infiltrated the lungs and accumulated around the pulmonary arteries in lungs of hypoxic mice, and these cells contributed to increased α-adrenergic receptor-mediated contraction of the pulmonary artery cultured in hypoxia. Inhibition of G6PD activity with (3β,5α)-3,21-dihydroxypregnan-20-one, a novel and potent G6PD inhibitor, decreased HSCs in bone marrow, blood, and lungs of hypoxic mice and reduced α-agonist-induced contraction of the pulmonary artery and established hypoxia-induced PH. We did not observe CD133+ cells around the pulmonary arteries in the lungs of chronically hypoxic G6PD-deficient mice. Furthermore, knockdown of G6PD and inhibition of G6PD activity: 1) downregulated canonical and noncanonical Wnt and Fzd receptors genes; 2) upregulated Bmpr1a; 3) decreased Cxcl12, and 4) reduced HSC (CD117+ and CD133+) numbers. In all, our findings demonstrate unexpected function for bone marrow-derived HSCs in augmenting α-adrenergic receptor-mediated contraction of pulmonary arteries and remodeling of pulmonary arteries that contribute to increase pulmonary vascular resistance in PAH patients and hypoxic mice and suggest that G6PD, by regulating expression of genes in the WNT and BMPR signaling, contributed to increase and release of HSCs from the bone marrow in response to hypoxic stimuli.
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Affiliation(s)
- Ryota Hashimoto
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Gregg M Lanier
- Department of Cardiology, and Heart and Vascular Institute, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Vidhi Dhagia
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Sachindra R Joshi
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Allan Jordan
- Drug Discovery Unit, Cancer Research, UK Manchester Institute, University of Manchester, Manchester, United Kingdom
| | - Ian Waddell
- Drug Discovery Unit, Cancer Research, UK Manchester Institute, University of Manchester, Manchester, United Kingdom
| | - Rubin Tuder
- Department of Pathology, University of Colorado Health Center, Denver, Colorado
| | - Kurt R Stenmark
- Department of Pediatrics, University of Colorado Health Center, Denver, Colorado
| | - Michael S Wolin
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Ivan F McMurtry
- Department of Pharmacology and Medicine, University of South Alabama, Mobile, Alabama
| | - Sachin A Gupte
- Department of Pharmacology, New York Medical College, Valhalla, New York
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Bloodworth NC, Clark CR, West JD, Snider JC, Gaskill C, Shay S, Scott C, Bastarache J, Gladson S, Moore C, D'Amico R, Brittain EL, Tanjore H, Blackwell TS, Majka SM, Merryman WD. Bone Marrow-Derived Proangiogenic Cells Mediate Pulmonary Arteriole Stiffening via Serotonin 2B Receptor Dependent Mechanism. Circ Res 2019; 123:e51-e64. [PMID: 30566041 DOI: 10.1161/circresaha.118.313397] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
RATIONALE Pulmonary arterial hypertension is a deadly disease of the pulmonary vasculature for which no disease-modifying therapies exist. Small-vessel stiffening and remodeling are fundamental pathological features of pulmonary arterial hypertension that occur early and drive further endovascular cell dysfunction. Bone marrow (BM)-derived proangiogenic cells (PACs), a specialized heterogeneous subpopulation of myeloid lineage cells, are thought to play an important role in pathogenesis. OBJECTIVE To determine whether BM-derived PACs directly contributed to experimental pulmonary hypertension (PH) by promoting small-vessel stiffening through 5-HT2B (serotonin 2B receptor)-mediated signaling. METHODS AND RESULTS We performed BM transplants using transgenic donor animals expressing diphtheria toxin secondary to activation of an endothelial-specific tamoxifen-inducible Cre and induced experimental PH using hypoxia with SU5416 to enhance endovascular injury and ablated BM-derived PACs, after which we measured right ventricular systolic pressures in a closed-chest procedure. BM-derived PAC lineage tracing was accomplished by transplanting BM from transgenic donor animals with fluorescently labeled hematopoietic cells and treating mice with a 5-HT2B antagonist. BM-derived PAC ablation both prevented and reversed experimental PH with SU5416-enhanced endovascular injury, reducing the number of muscularized pulmonary arterioles and normalizing arteriole stiffness as measured by atomic force microscopy. Similarly, treatment with a pharmacological antagonist of 5-HT2B also prevented experimental PH, reducing the number and stiffness of muscularized pulmonary arterioles. PACs accelerated pulmonary microvascular endothelial cell injury response in vitro, and the presence of BM-derived PACs significantly correlated with stiffer pulmonary arterioles in pulmonary arterial hypertension patients and mice with experimental PH. RNA sequencing of BM-derived PACs showed that 5-HT2B antagonism significantly altered biologic pathways regulating cell proliferation, locomotion and migration, and cytokine production and response to cytokine stimulus. CONCLUSIONS Together, our findings illustrate that BM-derived PACs directly contribute to experimental PH with SU5416-enhanced endovascular injury by mediating small-vessel stiffening and remodeling in a 5-HT2B signaling-dependent manner.
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Affiliation(s)
- Nathaniel C Bloodworth
- From the Department of Biomedical Engineering (N.C.B., C.R.C., J.C.S., C.S., R.D., W.D.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Cynthia R Clark
- From the Department of Biomedical Engineering (N.C.B., C.R.C., J.C.S., C.S., R.D., W.D.M.), Vanderbilt University Medical Center, Nashville, TN
| | - James D West
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - J Caleb Snider
- From the Department of Biomedical Engineering (N.C.B., C.R.C., J.C.S., C.S., R.D., W.D.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Christa Gaskill
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Sheila Shay
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Christine Scott
- From the Department of Biomedical Engineering (N.C.B., C.R.C., J.C.S., C.S., R.D., W.D.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Julie Bastarache
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Santhi Gladson
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Christy Moore
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Reid D'Amico
- From the Department of Biomedical Engineering (N.C.B., C.R.C., J.C.S., C.S., R.D., W.D.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine (E.L.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Harikrishna Tanjore
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - Timothy S Blackwell
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN.,Department of Veterans Affairs Medical Center, Nashville, TN (T.S.B.)
| | - Susan M Majka
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine (J.D.W., C.G., S.S., J.B., S.G., C.M., H.T., T.S.B., S.M.M.), Vanderbilt University Medical Center, Nashville, TN
| | - W David Merryman
- From the Department of Biomedical Engineering (N.C.B., C.R.C., J.C.S., C.S., R.D., W.D.M.), Vanderbilt University Medical Center, Nashville, TN
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11
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Stenmark KR, Frid MG, Graham BB, Tuder RM. Dynamic and diverse changes in the functional properties of vascular smooth muscle cells in pulmonary hypertension. Cardiovasc Res 2019; 114:551-564. [PMID: 29385432 DOI: 10.1093/cvr/cvy004] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/26/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension (PH) is the end result of interaction between pulmonary vascular tone and a complex series of cellular and molecular events termed 'vascular remodelling'. The remodelling process, which can involve the entirety of pulmonary arterial vasculature, almost universally involves medial thickening, driven by increased numbers and hypertrophy of its principal cellular constituent, smooth muscle cells (SMCs). It is noted, however that SMCs comprise heterogeneous populations of cells, which can exhibit markedly different proliferative, inflammatory, and extracellular matrix production changes during remodelling. We further consider that these functional changes in SMCs of different phenotype and their role in PH are dynamic and may undergo significant changes over time (which we will refer to as cellular plasticity); no single property can account for the complexity of the contribution of SMC to pulmonary vascular remodelling. Thus, the approaches used to pharmacologically manipulate PH by targeting the SMC phenotype(s) must take into account processes that underlie dominant phenotypes that drive the disease. We present evidence for time- and location-specific changes in SMC proliferation in various animal models of PH; we highlight the transient nature (rather than continuous) of SMC proliferation, emphasizing that the heterogenic SMC populations that reside in different locations along the pulmonary vascular tree exhibit distinct responses to the stresses associated with the development of PH. We also consider that cells that have often been termed 'SMCs' may arise from many origins, including endothelial cells, fibroblasts and resident or circulating progenitors, and thus may contribute via distinct signalling pathways to the remodelling process. Ultimately, PH is characterized by long-lived, apoptosis-resistant SMC. In line with this key pathogenic characteristic, we address the acquisition of a pro-inflammatory phenotype by SMC that is essential to the development of PH. We present evidence that metabolic alterations akin to those observed in cancer cells (cytoplasmic and mitochondrial) directly contribute to the phenotype of the SM and SM-like cells involved in PH. Finally, we raise the possibility that SMCs transition from a proliferative to a senescent, pro-inflammatory and metabolically active phenotype over time.
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Affiliation(s)
- Kurt R Stenmark
- Cardiovascular Pulmonary Research Laboratories, Departments of Pediatrics and Medicine, University of Colorado Anschutz Medical Campus, 12700 E. 19th Avenue, RC2, B131, Aurora, CO 80045, USA
| | - Maria G Frid
- Cardiovascular Pulmonary Research Laboratories, Departments of Pediatrics and Medicine, University of Colorado Anschutz Medical Campus, 12700 E. 19th Avenue, RC2, B131, Aurora, CO 80045, USA
| | - Brian B Graham
- Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12700 E. 19th Avenue, RC2, B131, Aurora, CO 80045, USA
| | - Rubin M Tuder
- Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12700 E. 19th Avenue, RC2, B131, Aurora, CO 80045, USA
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12
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Odler B, Foris V, Gungl A, Müller V, Hassoun PM, Kwapiszewska G, Olschewski H, Kovacs G. Biomarkers for Pulmonary Vascular Remodeling in Systemic Sclerosis: A Pathophysiological Approach. Front Physiol 2018; 9:587. [PMID: 29971007 PMCID: PMC6018494 DOI: 10.3389/fphys.2018.00587] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/02/2018] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe complication of systemic sclerosis (SSc) associated with high morbidity and mortality. There are several biomarkers of SSc-PAH, reflecting endothelial physiology, inflammation, immune activation, extracellular matrix, metabolic changes, or cardiac involvement. Biomarkers associated with diagnosis, disease severity and progression have been identified, however, very few have been tested in a prospective setting. Some antinuclear antibodies such as nucleosome antibodies (NUC), anti-centromere antibodies (CENP-A/B) and anti-U3-ribonucleoprotein (anti-U3-RNP) are associated with PAH while anti-U1-ribonucleoprotein (anti-U1-RNP) is associated with a reduced PAH risk. Anti-endothelin receptor and angiotensin-1 receptor antibodies might be good markers of SSc-PAH and progression of pulmonary vasculopathy. Regarding the markers reflecting immune activation and inflammation, there are many inconsistent results. CXCL-4 was associated with SSc progression including PAH and lung fibrosis. Growth differentiation factor (GDF)-15 was associated with PAH and mortality but is not specific for SSc. Among the metabolites, kynurenine was identified as diagnostic marker for PAH, however, its pathologic role in the disease is unclear. Endostatin, an angiostatic factor, was associated with heart failure and poor prognosis. Established heart related markers, such as N-terminal fragment of A-type natriuretic peptide/brain natriuretic peptide (NT-proANP, NT-proBNP) or troponin I/T are elevated in SSc-PAH but are not specific for the right ventricle and may be increased to the same extent in left heart disease. Taken together, there is no universal specific biomarker for SSc-PAH, however, there is a pattern of markers that is strongly associated with a risk of vascular complications in SSc patients. Further comprehensive, multicenter and prospective studies are warranted to develop reliable algorithms for detection and prognosis of SSc-PAH.
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Affiliation(s)
- Balazs Odler
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Anna Gungl
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Paul M Hassoun
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Grazyna Kwapiszewska
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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13
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Hashimoto R, Gupte S. Pentose Shunt, Glucose-6-Phosphate Dehydrogenase, NADPH Redox, and Stem Cells in Pulmonary Hypertension. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 967:47-55. [PMID: 29047080 DOI: 10.1007/978-3-319-63245-2_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Redox signaling plays a critical role in the pathophysiology of cardiovascular diseases. The pentose phosphate pathway is a major source of NADPH redox in the cell. The activities of glucose-6-phosphate dehydrogenase (the rate-limiting enzyme in the pentose shunt) and glucose flux through the shunt pathway is increased in various lung cells including, the stem cells, in pulmonary hypertension. This chapter discusses the importance of the shunt pathway and glucose-6-phosphate dehydrogenase in the pathogenesis of pulmonary artery remodeling and occlusive lesion formation within the hypertensive lungs.
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Affiliation(s)
- Ryota Hashimoto
- Department of Pharmacology, New York Medical College, School of Medicine, Basic Science Building, Rm. 546, 15 Dana Road, Valhalla, NY, 10595, USA
| | - Sachin Gupte
- Department of Pharmacology, New York Medical College, School of Medicine, Basic Science Building, Rm. 546, 15 Dana Road, Valhalla, NY, 10595, USA.
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14
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Marsh LM, Jandl K, Grünig G, Foris V, Bashir M, Ghanim B, Klepetko W, Olschewski H, Olschewski A, Kwapiszewska G. The inflammatory cell landscape in the lungs of patients with idiopathic pulmonary arterial hypertension. Eur Respir J 2018; 51:51/1/1701214. [PMID: 29371380 PMCID: PMC6383570 DOI: 10.1183/13993003.01214-2017] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/15/2017] [Indexed: 12/20/2022]
Abstract
Increasing evidence points towards an inflammatory component underlying pulmonary hypertension. However, the conclusive characterisation of multiple inflammatory cell populations in the lung is challenging due to the complexity of marker specificity and tissue inaccessibility. We used an unbiased computational flow cytometry approach to delineate the inflammatory landscape of idiopathic pulmonary arterial hypertension (IPAH) and healthy donor lungs. Donor and IPAH samples were discriminated clearly using principal component analysis to reduce the multidimensional data obtained from single-cell flow cytometry analysis. In IPAH lungs, the predominant CD45+ cell type switched from neutrophils to CD3+ T-cells, with increases in CD4+, CD8+ and γδT-cell subsets. Additionally, diversely activated classical myeloid-derived dendritic cells (CD14−HLA-DR+CD11c+CD1a+/−) and nonclassical plasmacytoid dendritic cells (pDCs; CD14−CD11c−CD123+HLA-DR+), together with mast cells and basophils, were more abundant in IPAH samples. We describe, for the first time, the presence and regulation of two cell types in IPAH, γδT-cells and pDCs, which link innate and adaptive immunity. With our high-throughput flow cytometry with multidimensional dataset analysis, we have revealed the interactive interplay between multiple inflammatory cells is a crucial part of their integrative network. The identification of γδT-cells and pDCs in this disease potentially provides a missing link between IPAH, autoimmunity and inflammation. Computational flow cytometry details the complex inflammatory cell landscape in patients with pulmonary hypertensionhttp://ow.ly/rjFZ30g1tew
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Affiliation(s)
- Leigh M Marsh
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Katharina Jandl
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabriele Grünig
- Dept of Environmental Medicine and Medicine, NYU School of Medicine, New York, NY, USA
| | - Vasile Foris
- Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Mina Bashir
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Bahil Ghanim
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Thoracic Surgery, Dept of Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Division of Thoracic Surgery, Dept of Surgery, Medical University of Vienna, Vienna, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Dept of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Institute of Physiology, Medical University of Graz, Graz, Austria
| | - Grazyna Kwapiszewska
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Institute of Physiology, Medical University of Graz, Graz, Austria
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15
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García-Lucio J, Tura-Ceide O, Del Pozo R, Blanco I, Pizarro S, Ferrer E, Díez M, Coll-Bonfill N, Piccari L, Peinado VI, Barberà JA. Effect of targeted therapy on circulating progenitor cells in precapillary pulmonary hypertension. Int J Cardiol 2016; 228:238-243. [PMID: 27865192 DOI: 10.1016/j.ijcard.2016.11.175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/06/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endothelial dysfunction is key in the development of pulmonary hypertension (PH) and is associated with reduced number of circulating progenitor cells. Studies to date evaluating levels of circulating progenitor cells in PH have provided conflicting results. Current treatment of pulmonary arterial hypertension (PAH) and medical treatment of chronic thromboembolic pulmonary hypertension (CTEPH) targets endothelium dependent signalling pathways. The effect of PAH-targeted therapy on circulating progenitor cells has not been clearly established. OBJECTIVES To investigate whether levels of circulating progenitor cells in treatment-naïve patients with PAH or CTEPH differ from healthy subjects and to assess the effect of PAH-targeted therapy on the circulating levels of these progenitors. METHODS Thirty controls, 33 PAH and 11 CTEPH treatment-naïve patients were studied. Eighteen patients with PAH and 9 with CTEPH were re-evaluated 6-12months after starting PAH-targeted therapy. Levels of progenitors were measured by flow cytometry as CD45+CD34+ and CD45+CD34+CD133+ cells. RESULTS Compared with controls, the number of circulating progenitor cells was reduced in PAH but not in CTEPH. After 6-12months of treatment, levels of circulating progenitors increased in PAH and remained unchanged in CTEPH. Patients with lower exercise tolerance presented lower levels of circulating progenitors. No other relation was found between levels of progenitors and clinical or hemodynamic parameters. CONCLUSIONS Patients with PAH, but not those with CTEPH, present reduced levels of circulating progenitor cells. PAH-targeted therapy increases levels of progenitors in PAH but not in CTEPH, suggesting different involvement of progenitor cells in the pathobiology of these pulmonary hypertensive disorders.
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Affiliation(s)
- Jéssica García-Lucio
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Olga Tura-Ceide
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain.
| | - Roberto Del Pozo
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Isabel Blanco
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Sandra Pizarro
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Elisabet Ferrer
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Marta Díez
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Núria Coll-Bonfill
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Lucilla Piccari
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Víctor I Peinado
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Joan Albert Barberà
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
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