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Egom EEA, Moyou-Somo R, Essame Oyono JL, Kamgang R. Identifying Potential Mutations Responsible for Cases of Pulmonary Arterial Hypertension. APPLICATION OF CLINICAL GENETICS 2021; 14:113-124. [PMID: 33732008 PMCID: PMC7958998 DOI: 10.2147/tacg.s260755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/18/2021] [Indexed: 01/09/2023]
Abstract
Pulmonary Arterial Hypertension (PAH) is a progressive and devastating disease for which there is an escalating body of genetic and related pathophysiological information on disease pathobiology. Nevertheless, the success to date in identifying susceptibility genes, genetic variants and epigenetic processes has been limited due to PAH clinical multi-faceted variations. A number of germline gene candidates have been proposed but demonstrating consistently the association with PAH has been problematic, at least partly due to the reduced penetrance and variable expressivity. Although the data for bone morphogenetic protein receptor type 2 (BMPR2) and related genes remains undoubtedly the most extensive, recent advanced gene sequencing technologies have facilitated the discovery of further gene candidates with mutations among those with and without familial forms of PAH. An in depth understanding of the multitude of biologic variations associated with PAH may provide novel opportunities for therapeutic intervention in the coming years. This knowledge will irrevocably provide the opportunity for improved patient and family counseling as well as improved PAH diagnosis, risk assessment, and personalized treatment.
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Affiliation(s)
- Emmanuel Eroume-A Egom
- Institut du Savoir Montfort (ISM), Hôpital Montfort, Ottawa, ON, Canada.,Laboratory of Endocrinology and Radioisotopes, Institute of Medical Research and Medicinal Plants Studies (IMPM), Yaoundé, Cameroon.,Reflex Medical Centre Cardiac Diagnostics, Reflex Medical Centre, Mississauga, ON, Canada
| | - Roger Moyou-Somo
- Laboratory of Endocrinology and Radioisotopes, Institute of Medical Research and Medicinal Plants Studies (IMPM), Yaoundé, Cameroon
| | - Jean Louis Essame Oyono
- Laboratory of Endocrinology and Radioisotopes, Institute of Medical Research and Medicinal Plants Studies (IMPM), Yaoundé, Cameroon
| | - Rene Kamgang
- Laboratory of Endocrinology and Radioisotopes, Institute of Medical Research and Medicinal Plants Studies (IMPM), Yaoundé, Cameroon
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2
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Yuan SM. Pulmonary artery hypertension in childhood: The transforming growth factor-β superfamily-related genes. Pediatr Neonatol 2018; 59:112-119. [PMID: 28967497 DOI: 10.1016/j.pedneo.2016.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 10/20/2016] [Accepted: 12/05/2016] [Indexed: 01/08/2023] Open
Abstract
Pulmonary artery hypertension (PAH) is very rare in childhood, and it can be divided into heritable, idiopathic drug- and toxin-induced and other disease (connective tissue disease, human immunodeficiency virus infection, portal hypertension, congenital heart disease, or schistosomiasis)-associated types. PAH could not be interpreted solely by pathophysiological theories. The impact of the transforming growth factor-β superfamily-related genes on the development of PAH in children remains to be clarified. Pertinent literature on the transforming growth factor-β superfamily-related genes in relation to PAH in children published after the year 2000 was reviewed and analyzed. Bone morphogenetic protein receptor type II gene mutation promotes cell division or prevents cell death, resulting in an overgrowth of cells in small arteries throughout the lungs. About 20% of individuals with a bone morphogenetic protein receptor type II gene mutation develop symptomatic PAH. In heritable PAH, bone morphogenetic protein receptor type II mutations may be absent; while mutations of other genes, such as type I receptor activin receptor-like kinase 1 and the type III receptor endoglin (both associated with hereditary hemorrhagic telangiectasia), caveolin-1 and KCNK3, the gene encoding potassium channel subfamily K, member 3, can be detected, instead. Gene mutations, environmental changes and acquired adjustment, etc. may explain the development of PAH. The researches on PAH rat model and familial PAH members may facilitate the elucidations of the mechanisms and further provide theories for prophylaxis and treatment of PAH.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China.
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3
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Zhu N, Gonzaga-Jauregui C, Welch C, Ma L, Qi H, King AK, Krishnan U, Rosenzweig EB, Ivy DD, Austin ED, Hamid R, Nichols WC, Pauciulo MW, Lutz KA, Sawle A, Reid JG, Overton JD, Baras A, Dewey F, Shen Y, Chung WK. Exome Sequencing in Children With Pulmonary Arterial Hypertension Demonstrates Differences Compared With Adults. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2018; 11:e001887. [PMID: 29631995 PMCID: PMC5896781 DOI: 10.1161/circgen.117.001887] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 01/31/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a rare disease characterized by pulmonary arteriole remodeling, elevated arterial pressure and resistance, and subsequent heart failure. Compared with adult-onset disease, pediatric-onset PAH is more heterogeneous and often associated with worse prognosis. Although BMPR2 mutations underlie ≈70% of adult familial PAH (FPAH) cases, the genetic basis of PAH in children is less understood. METHODS We performed genetic analysis of 155 pediatric- and 257 adult-onset PAH patients, including both FPAH and sporadic, idiopathic PAH (IPAH). After screening for 2 common PAH risk genes, mutation-negative FPAH and all IPAH cases were evaluated by exome sequencing. RESULTS We observed similar frequencies of rare, deleterious BMPR2 mutations in pediatric- and adult-onset patients: ≈55% in FPAH and 10% in IPAH patients in both age groups. However, there was significant enrichment of TBX4 mutations in pediatric- compared with adult-onset patients (IPAH: 10/130 pediatric versus 0/178 adult-onset), and TBX4 carriers had younger mean age-of-onset compared with BMPR2 carriers. Mutations in other known PAH risk genes were infrequent in both age groups. Notably, among pediatric IPAH patients without mutations in known risk genes, exome sequencing revealed a 2-fold enrichment of de novo likely gene-damaging and predicted deleterious missense variants. CONCLUSIONS Mutations in known PAH risk genes accounted for ≈70% to 80% of FPAH in both age groups, 21% of pediatric-onset IPAH, and 11% of adult-onset IPAH. Rare, predicted deleterious variants in TBX4 are enriched in pediatric patients and de novo variants in novel genes may explain ≈19% of pediatric-onset IPAH cases.
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Affiliation(s)
- Na Zhu
- Department of Pediatrics, Columbia University Medical Center, New York
- Department of Systems Biology, Columbia University, New York, NY
| | | | - Carrie Welch
- Department of Pediatrics, Columbia University Medical Center, New York
| | - Lijiang Ma
- Department of Pediatrics, Columbia University Medical Center, New York
| | - Hongjian Qi
- Department of Applied Physics and Applied Mathematics, Columbia University, New York, NY
- Department of Systems Biology, Columbia University, New York, NY
| | | | - Usha Krishnan
- Department of Pediatrics, Columbia University Medical Center, New York
| | - Erika B. Rosenzweig
- Department of Pediatrics, Columbia University Medical Center, New York
- Department of Medicine, Columbia University Medical Center, New York
| | - D. Dunbar Ivy
- Children’s Hospital Colorado, Department of Pediatric Cardiology, Denver, CO
| | - Eric D. Austin
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Rizwan Hamid
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - William C. Nichols
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center & Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael W. Pauciulo
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center & Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Katie A. Lutz
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center & Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashley Sawle
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York
| | - Jeffrey G. Reid
- Regeneron Genetics Center, Regeneron Pharmaceuticals, Tarrytown
| | - John D. Overton
- Regeneron Genetics Center, Regeneron Pharmaceuticals, Tarrytown
| | - Aris Baras
- Regeneron Genetics Center, Regeneron Pharmaceuticals, Tarrytown
| | - Frederick Dewey
- Regeneron Genetics Center, Regeneron Pharmaceuticals, Tarrytown
| | - Yufeng Shen
- Department of Systems Biology, Columbia University, New York, NY
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Wendy K. Chung
- Department of Pediatrics, Columbia University Medical Center, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York
- Department of Medicine, Columbia University Medical Center, New York
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4
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Frank BS, Ivy DD. Diagnosis, Evaluation and Treatment of Pulmonary Arterial Hypertension in Children. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E44. [PMID: 29570688 PMCID: PMC5920390 DOI: 10.3390/children5040044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/28/2018] [Accepted: 03/16/2018] [Indexed: 12/23/2022]
Abstract
Pulmonary Hypertension (PH), the syndrome of elevated pressure in the pulmonary arteries, is associated with significant morbidity and mortality for affected children. PH is associated with a wide variety of potential underlying causes, including cardiac, pulmonary, hematologic and rheumatologic abnormalities. Regardless of the cause, for many patients the natural history of PH involves progressive elevation in pulmonary arterial resistance and pressure, right ventricular dysfunction, and eventually heart failure. In recent years, a number of pulmonary arterial hypertension (PAH)-targeted therapies have become available to reduce pulmonary artery pressure and improve outcome. A growing body of evidence in both the adult and pediatric literature demonstrates enhanced quality of life, functional status, and survival among treated patients. This review provides a description of select etiologies of PH seen in pediatrics and an update on the most recent data pertaining to evaluation and management of children with PH/PAH. The available evidence for specific classes of PAH-targeted therapies in pediatrics is additionally discussed.
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Affiliation(s)
- Benjamin S Frank
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - D Dunbar Ivy
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.
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5
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Ma L, Chung WK. The role of genetics in pulmonary arterial hypertension. J Pathol 2016; 241:273-280. [PMID: 27770446 DOI: 10.1002/path.4833] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 09/30/2016] [Accepted: 10/17/2016] [Indexed: 12/14/2022]
Abstract
Group 1 pulmonary hypertension or pulmonary arterial hypertension (PAH) is a rare disease characterized by proliferation and occlusion of small pulmonary arterioles, leading to progressive elevation of pulmonary artery pressure and pulmonary vascular resistance, and right ventricular failure. Historically, it has been associated with a high mortality rate, although, over the last decade, treatment has improved survival. PAH includes idiopathic PAH (IPAH), heritable PAH (HPAH), and PAH associated with certain medical conditions. The aetiology of PAH is heterogeneous, and genetics play an important role in some cases. Mutations in BMPR2, encoding bone morphogenetic protein receptor 2, a member of the transforming growth factor-β superfamily of receptors, have been identified in 70% of cases of HPAH, and in 10-40% of cases of IPAH. Other genetic causes of PAH include mutations in the genes encoding activin receptor-like type 1, endoglin, SMAD9, caveolin 1, and potassium two-pore-domain channel subfamily K member 3. Mutations in the gene encoding T-box 4 have been identified in 10-30% of paediatric PAH patients, but rarely in adults with PAH. PAH in children is much more heterogeneous than in adults, and can be associated with several genetic syndromes, congenital heart disease, pulmonary disease, and vascular disease. In addition to rare mutations as a monogenic cause of HPAH, common variants in the gene encoding cerebellin 2 increase the risk of PAH by approximately two-fold. A PAH panel of genes is available for clinical testing, and should be considered for use in clinical management, especially for patients with a family history of PAH. Copyright © 2016 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Lijiang Ma
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University, New York, NY, USA.,Department of Medicine, Columbia University, New York, NY, USA
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6
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Navas Tejedor P, Tenorio Castaño J, Palomino Doza J, Arias Lajara P, Gordo Trujillo G, López Meseguer M, Román Broto A, Lapunzina Abadía P, Escribano Subía P. An homozygous mutation in KCNK3 is associated with an aggressive form of hereditary pulmonary arterial hypertension. Clin Genet 2016; 91:453-457. [PMID: 27649371 DOI: 10.1111/cge.12869] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/30/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare devastating disease characterized by a high genetic heterogeneity with several related genes recently described, including BMPR2,TBX4 and KCNK3. The association between KCNK3 and PAH has been recently identified, but the prognosis and phenotype associated with these mutations have been poorly described. We studied a series of 136 idiopathic and hereditary PAH Spanish patients for BMPR2, TBX4 and KCNK3 mutations. We report the results of KCNK3 in which we were able to describe two new mutations (p.Gly106Arg and p.Leu214Arg) in three patients. The first one was found in a patient belonging to a consanguineous Romani family, who carried a homozygous mutation in KCNK3 and developed a severe and early form of the disease. To the best of our knowledge, this is the first time that a homozygous mutation in KCNK3 is reported in a PAH patient. The second one was found in a patient who presented at the young adult age a severe form of the disease. The present report supports the contribution of KCNK3 mutations to the genetic etiology of PAH and strongly suggests that mutations in KCNK3 follow incomplete dominance with worsening of the clinical features in homozygous patients.
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Affiliation(s)
- P Navas Tejedor
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain.,Red de Investigación Cardiovascular (RIC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - J Tenorio Castaño
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,INGEMM, Instituto de Genética Médica y Molecular, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - J Palomino Doza
- Unidad de Cardiopatías Familiares. Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - P Arias Lajara
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,INGEMM, Instituto de Genética Médica y Molecular, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - G Gordo Trujillo
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,INGEMM, Instituto de Genética Médica y Molecular, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - M López Meseguer
- Servicio de Neumología, Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - A Román Broto
- Servicio de Neumología, Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - P Lapunzina Abadía
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain.,INGEMM, Instituto de Genética Médica y Molecular, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.,Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - P Escribano Subía
- Red de Investigación Cardiovascular (RIC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.,Unidad Multidisciplinar de Hipertensión Pulmonar. Servicio de Cardiología, Hospital Doce de Octubre, Madrid, Spain
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7
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Abstract
The prevalence of PH is increasing in the pediatric population, because of improved recognition and increased survival of patients, and remains a significant cause of morbidity and mortality. Recent studies have improved the understanding of pediatric PH, but management remains challenging because of a lack of evidence-based clinical trials. The growing contribution of developmental lung disease requires dedicated research to explore the use of existing therapies as well as the creation of novel therapies. Adequate study of pediatric PH will require multicenter collaboration due to the small numbers of patients, multifactorial disease causes, and practice variability.
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Affiliation(s)
- Dunbar Ivy
- Section of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B100, Aurora, CO 80045, USA.
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8
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Soubrier F, Chung WK, Machado R, Grünig E, Aldred M, Geraci M, Loyd JE, Elliott CG, Trembath RC, Newman JH, Humbert M. Genetics and genomics of pulmonary arterial hypertension. J Am Coll Cardiol 2014; 62:D13-21. [PMID: 24355637 DOI: 10.1016/j.jacc.2013.10.035] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/22/2013] [Indexed: 12/24/2022]
Abstract
Major discoveries have been obtained within the last decade in the field of hereditary predisposition to pulmonary arterial hypertension (PAH). Among them, the identification of bone morphogenetic protein receptor type 2 (BMPR2) as the major predisposing gene and activin A receptor type II-like kinase-1 (ACVRL1, also known as ALK1) as the major gene when PAH is associated with hereditary hemorrhagic telangiectasia. The mutation detection rate for the known genes is approximately 75% in familial PAH, but the mutation shortfall remains unexplained even after careful molecular investigation of these genes. To identify additional genetic variants predisposing to PAH, investigators harnessed the power of next-generation sequencing to successfully identify additional genes that will be described in this report. Furthermore, common genetic predisposing factors for PAH can be identified by genome-wide association studies and are detailed in this paper. The careful study of families and routine genetic diagnosis facilitated natural history studies based on large registries of PAH patients to be set up in different countries. These longitudinal or cross-sectional studies permitted the clinical characterization of PAH in mutation carriers to be accurately described. The availability of molecular genetic diagnosis has opened up a new field for patient care, including genetic counseling for a severe disease, taking into account that the major predisposing gene has a highly variable penetrance between families. Molecular information can be drawn from the genomic study of affected tissues in PAH, in particular, pulmonary vascular tissues and cells, to gain insight into the mechanisms leading to the development of the disease. High-throughput genomic techniques, on the basis of next-generation sequencing, now allow the accurate quantification and analysis of ribonucleic acid, species, including micro-ribonucleic acids, and allow for a genome-wide investigation of epigenetic or regulatory mechanisms, which include deoxyribonucleic acid methylation, histone methylation, and acetylation, or transcription factor binding.
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Affiliation(s)
- Florent Soubrier
- Genetics Department, Hospital Pitié-Salpêtrière, Assistance Publique Hôpitaux de Paris (APHP), Unité Mixte de Recherche en Sante (UMRS) 956 Institut National de la Sante et de la Recherche Medicale INSERM, Université Pierre et Marie Curie Paris 06 (UPMC), and Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University Medical Center, New York, New York
| | - Rajiv Machado
- University of Lincoln, School of Life Sciences, Lincoln, United Kingdom
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension at University Hospital Heidelberg, Heidelberg, Germany
| | - Micheala Aldred
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mark Geraci
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - James E Loyd
- Pulmonary Hypertension Center, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center North, Nashville, Tennessee
| | - C Gregory Elliott
- Departments of Medicine at Intermountain Medical Center and the University of Utah, Salt Lake City, Utah
| | - Richard C Trembath
- Division of Genetics and Molecular Medicine, Kings College, London, United Kingdom
| | - John H Newman
- Pulmonary Hypertension Center, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center North, Nashville, Tennessee
| | - Marc Humbert
- Centre de Référence de l'Hypertension Pulmonaire Sévère, Service de Pneumologie, Hôpital de Bicêtre, APHP, Le Kremlin Bicêtre, Université Paris-Sud, Faculté de Médecine, Le Kremlin Bicêtre; Département Hospitalo-Universitaire (DHU) thorax Innovation, AP-HP, Le Kremlin Bicêtre; UMR_S 999, INSERM and Université Paris-Sud, LabEx LERMIT, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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9
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Abstract
Children and adults with pulmonary arterial hypertension (PAH) have similarities and differences in their background characteristics, hemodynamics, and clinical manifestations. Regarding genetic background, mutations in BMPR2-related pathways seem to be pivotal; however, it is likely that other modifier genes and bioactive mediators have roles in the various forms of PAH in children and adults. In pediatric PAH, there are no clear sex differences in incidence, age at onset, disease severity, or prognosis but, as compared with adults, syncope incidence, pulmonary vascular resistance, and mean pulmonary artery pressure are higher, and vasoreactivity to acute drug testing is more frequent, among children. Nevertheless, the pharmacokinetic effects of 3 major pulmonary vasodilators appear to be similar in children and adults with PAH. This review focuses on the specific pathophysiologic features of PAH in children.
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Affiliation(s)
- Tsutomu Saji
- Division of Pediatric Cardiology & Cardiac Surgery, Omori Hospital Medical Center, Toho University
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10
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Kerstjens-Frederikse WS, Bongers EMHF, Roofthooft MTR, Leter EM, Douwes JM, Van Dijk A, Vonk-Noordegraaf A, Dijk-Bos KK, Hoefsloot LH, Hoendermis ES, Gille JJP, Sikkema-Raddatz B, Hofstra RMW, Berger RMF. TBX4 mutations (small patella syndrome) are associated with childhood-onset pulmonary arterial hypertension. J Med Genet 2013; 50:500-6. [PMID: 23592887 PMCID: PMC3717587 DOI: 10.1136/jmedgenet-2012-101152] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Childhood-onset pulmonary arterial hypertension (PAH) is rare and differs from adult-onset disease in clinical presentation, with often unexplained mental retardation and dysmorphic features (MR/DF). Mutations in the major PAH gene, BMPR2, were reported to cause PAH in only 10–16% of childhood-onset patients. We aimed to identify more genes associated with childhood-onset PAH. Methods We studied 20 consecutive cases with idiopathic or heritable PAH. In patients with accompanying MR/DF (n=6) array-comparative genomic hybridisation analysis was performed, with the aim of finding common deletion regions containing candidate genes for PAH. Three patients had overlapping deletions of 17q23.2. TBX2 and TBX4 were selected from this area as candidate genes and sequenced in all 20 children. After identifying TBX4 mutations in these children, we subsequently sequenced TBX4 in a cohort of 49 adults with PAH. Because TBX4 mutations are known to cause small patella syndrome (SPS), all patients with newly detected TBX4 mutations were screened for features of SPS. We also screened a third cohort of 23 patients with SPS for PAH. Results TBX4 mutations (n=3) or TBX4-containing deletions (n=3) were detected in 6 out of 20 children with PAH (30%). All living patients and two parents with TBX4 mutations appeared to have previously unrecognised SPS. In the adult PAH-cohort, one TBX4 mutation (2%) was detected. Screening in the cohort of (predominantly adult) SPS patients revealed no PAH. Conclusions These data indicate that TBX4 mutations are associated with childhood-onset PAH, but that the prevalence of PAH in adult TBX4 mutation carriers is low.
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11
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Pfarr N, Fischer C, Ehlken N, Becker-Grünig T, López-González V, Gorenflo M, Hager A, Hinderhofer K, Miera O, Nagel C, Schranz D, Grünig E. Hemodynamic and genetic analysis in children with idiopathic, heritable, and congenital heart disease associated pulmonary arterial hypertension. Respir Res 2013; 14:3. [PMID: 23298310 PMCID: PMC3547748 DOI: 10.1186/1465-9921-14-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/26/2012] [Indexed: 11/10/2022] Open
Abstract
Background Aim of this prospective study was to compare clinical and genetic findings in children with idiopathic or heritable pulmonary arterial hypertension (I/HPAH) with children affected with congenital heart defects associated PAH (CHD-APAH). Methods Prospectively included were 40 consecutive children with invasively diagnosed I/HPAH or CHD-APAH and 117 relatives. Assessment of family members, pedigree analysis and systematic screening for mutations in TGFß genes were performed. Results Five mutations in the bone morphogenetic protein type II receptor (BMPR2) gene, 2 Activin A receptor type II-like kinase-1 (ACVRL1) mutations and one Endoglin (ENG) mutation were found in the 29 I/HPAH children. Two mutations in BMPR2 and one mutation in ACVRL1 and ENG, respectively, are described for the first time. In the 11 children with CHD-APAH one BMPR2 gene mutation and one Endoglin gene mutation were found. Clinical assessment of relatives revealed familial aggregation of the disease in 6 children with PAH (HPAH) and one CHD-APAH patient. Patients with mutations had a significantly lower PVR. Conclusion Mutations in different TGFß genes occurred in 8/29 (27.6%) I/HPAH patients and in 2/11 (18.2%) CHD-APAH patients and may influence the clinical status of the disease. Therefore, genetic analysis in children with PAH, especially in those with I/HPAH, may be of clinical relevance and shows the complexity of the genetic background.
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Affiliation(s)
- Nicole Pfarr
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
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12
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Abstract
Familial pulmonary arterial hypertension (FPAH) was described 60 years ago, but real progress in understanding its origins and pathogenesis is just beginning. Germline mutations in bone morphogenetic protein receptor type 2 (BMPR2) are responsible for the disease in most families, and also in many sporadic cases of idiopathic PAH. Heritable PAH refers to patients with a positive family history, or with a responsible genetic mutation, and is an autosomal dominant disease that affects females disproportionately, may occur at any age, and is characterized by reduced penetrance and variable expressivity. These characteristics suggest that other endogenous or exogenous factors modify its expression. Several different factors have recently been demonstrated to modify the clinical expression of BMPR2 mutation, including estrogen metabolites and functional polymorphisms in transforming growth factor-β1 and CYP1B1. Furthermore, a linkage study recently identified modifier loci for BMPR2 clinical expression, which suggests an oligogenic model. Clinical testing for BMPR2 mutations is available for families with heritable and idiopathic PAH, and is an evolving model of personalized medicine. Variable age of onset and decreased penetrance confound genetic counseling, because the majority of carriers of a BMPR2 mutation will never develop PAH, but often transmit the risk to their progeny.
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13
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Abstract
PURPOSE OF REVIEW Pulmonary artery hypertension (PAH) in children contributes significantly to morbidity and mortality in diverse pediatric cardiac, lung, hematologic and other diseases. Advances in pulmonary vascular biology over the past few decades have significantly expanded therapeutic strategies; however, many unique issues persist regarding our understanding of pediatric PAH. RECENT FINDINGS Recent studies of pediatric PAH include those that highlight gaps in our understanding of pediatric diseases associated with PAH from those of adult onset, emphasizing the strong need for specific studies regarding unique aspects of the pathogenesis and treatment of children with PAH. Registries have begun to provide new data showing differences in physiology, course, and genetics between adult and pediatric forms of PAH. Unfortunately, therapeutic strategies in pediatric pulmonary hypertension are often limited to small observational studies in children and are dependent on results from larger adult studies. In addition, clinical endpoints for studies and care remain poorly defined in infants and children. SUMMARY Despite many advances, long-term outcomes for children with PAH remain guarded and substantial challenges persist, especially with regard to understanding mechanisms and approach to severe PAH. Future studies are needed to develop novel biomarkers, clinical endpoints and interventions for young children with diverse causes of PAH.
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Affiliation(s)
- Steven H Abman
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital, Aurora, Colorado, USA
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14
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Saggar R, Khanna D, Furst DE, Shapiro S, Maranian P, Belperio JA, Chauhan N, Clements P, Gorn A, Weigt SS, Ross D, Lynch JP, Saggar R. Exercise-induced pulmonary hypertension associated with systemic sclerosis: four distinct entities. ACTA ACUST UNITED AC 2011; 62:3741-50. [PMID: 20722025 DOI: 10.1002/art.27695] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Exercise-induced pulmonary hypertension (PH) may represent an early but clinically relevant phase in the spectrum of pulmonary vascular disease. There are limited data on the prevalence of exercise-induced PH determined by right heart catheterization in scleroderma spectrum disorders. We undertook this study to describe the hemodynamic response to exercise in a homogeneous population of patients with scleroderma spectrum disorders at risk of developing pulmonary vascular disease. METHODS Patients with normal resting hemodynamics underwent supine lower extremity exercise testing. A classification and regression tree (CART) analysis was used to assess combinations of variables collected during resting right heart catheterization that best predicted abnormal exercise physiology, applicable to each individual subject. RESULTS Fifty-seven patients who had normal resting hemodynamics underwent subsequent exercise right heart catheterization. Four distinct hemodynamic groups were identified during exercise: a normal group, an exercise-induced pulmonary venous hypertension (ePVH) group, an exercise out of proportion PH (eoPH) group, and an exercise-induced PH (ePH) group. The eoPH and ePVH groups had higher pulmonary capillary wedge pressure (PCWP) than the ePH group (P < 0.05). The normal and ePH groups had exercise PCWP ≤18 mm Hg, which was lower than that in the ePVH and eoPH groups (P < 0.05). During submaximal exercise, the transpulmonary gradient and pulmonary vascular resistance (PVR) were elevated in the ePH and eoPH groups as compared with the normal and ePVH groups (P < 0.05). CART analysis suggested that resting mean pulmonary artery pressure (mPAP) ≥14 mm Hg and PVR ≥160 dynes/seconds/cm(-5) were associated with eoPH and ePH (positive predictive value 89% for mPAP 14-20 mm Hg and 100% for mPAP >20 mm Hg). CONCLUSION We characterized the exercise hemodynamic response in at-risk patients with scleroderma spectrum disorders who did not have resting PH. Four distinct hemodynamic groups were identified during exercise. These groups may have potentially different prognoses and treatment options.
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Affiliation(s)
- Rajeev Saggar
- David Geffen School of Medicine at University of California, Los Angeles, CA 90095-1690, USA.
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15
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Barst RJ, Ertel SI, Beghetti M, Ivy DD. Pulmonary arterial hypertension: a comparison between children and adults. Eur Respir J 2011; 37:665-77. [PMID: 21357924 PMCID: PMC3128436 DOI: 10.1183/09031936.00056110] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The characteristics of pulmonary arterial hypertension (PAH), including pathology, symptoms, diagnosis and treatment are reviewed in children and adults. The histopathology seen in adults is also observed in children, although children have more medial hypertrophy at presentation. Both populations have vascular and endothelial dysfunction. Several unique disease states are present in children, as lung growth abnormalities contribute to pulmonary hypertension. Although both children and adults present at diagnosis with elevations in pulmonary vascular resistance and pulmonary artery pressure, children have less heart failure. Dyspnoea on exertion is the most frequent symptom in children and adults with PAH, but heart failure with oedema occurs more frequently in adults. However, in idiopathic PAH, syncope is more common in children. Haemodynamic assessment remains the gold standard for diagnosis, but the definition of vasoreactivity in adults may not apply to young children. Targeted PAH therapies approved for adults are associated with clinically meaningful effects in paediatric observational studies; children now survive as long as adults with current treatment guidelines. In conclusion, there are more similarities than differences in the characteristics of PAH in children and adults, resulting in guidelines recommending similar diagnostic and therapeutic algorithms in children (based on expert opinion) and adults (evidence-based).
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Affiliation(s)
- R J Barst
- Division of Paediatric Cardiology, Columbia University College of Physicians and Surgeons, 31 Murray Hill Road, Scarsdale, New York, NY 10583, USA.
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16
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Yuan JXJ, Garcia JG, West JB, Hales CA, Rich S, Archer SL. High-Altitude Pulmonary Edema. TEXTBOOK OF PULMONARY VASCULAR DISEASE 2011. [PMCID: PMC7122766 DOI: 10.1007/978-0-387-87429-6_61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
High-altitude pulmonary edema (HAPE) is an uncommon form of pulmonary edema that occurs in healthy individuals within a few days of arrival at altitudes above 2,500–3,000 m. The crucial pathophysiology is an excessive hypoxia-mediated rise in pulmonary vascular resistance (PVR) or hypoxic pulmonary vasoconstriction (HPV) leading to increased microvascular hydrostatic pressures despite normal left atrial pressure. The resultant hydrostatic stress can cause both dynamic changes in the permeability of the alveolar capillary barrier and mechanical damage leading to leakage of large proteins and erythrocytes into the alveolar space in the absence of inflammation. Bronchoalveolar lavage (BAL) and pulmonary artery (PA) and microvascular pressure measurements in humans confirm that high capillary pressure induces a high-permeability non-inflammatory-type lung edema; a concept termed “capillary stress failure.” Measurements of endothelin and nitric oxide (NO) in exhaled air, NO metabolites in BAL fluid, and NO-dependent endothelial function in the systemic circulation all point to reduced NO availability and increased endothelin in hypoxia as a major cause of the excessive hypoxic PA pressure rise in HAPE-susceptible individuals. Other hypoxia-dependent differences in ventilatory control, sympathetic nervous system activation, endothelial function, and alveolar epithelial sodium and water reabsorption likely contribute additionally to the phenotype of HAPE susceptibility. Recent studies using magnetic resonance imaging in humans strongly suggest nonuniform regional hypoxic arteriolar vasoconstriction as an explanation for how HPV occurring predominantly at the arteriolar level can cause leakage. This compelling but not yet fully proven mechanism predicts that in areas of high blood flow due to lesser vasoconstriction edema will develop owing to pressures that exceed the structural and dynamic capacity of the alveolar capillary barrier to maintain normal alveolar fluid balance. Numerous strategies aimed at lowering HPV and possibly enhancing active alveolar fluid reabsorption are effective in preventing and treating HAPE. Much has been learned about HAPE in the past four decades such that what was once a mysterious alpine malady is now a well-characterized and preventable lung disease. This chapter will relate the history, pathophysiology, and treatment of HAPE, using it not only to illuminate the condition, but also for the broader lessons it offers in understanding pulmonary vascular regulation and lung fluid balance.
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Affiliation(s)
- Jason X. -J. Yuan
- Departments of Medicine, COMRB Rm. 3131 (MC 719), University of Illinois at Chicago, 909 South Wolcott Avenue, Chicago, 60612 Illinois USA
| | - Joe G.N. Garcia
- 310 Admin.Office Building (MC 672), University of Illinois at Chicago, 1737 W. Polk Street, Suite 310, Chicago, 60612 Illinois USA
| | - John B. West
- Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, 92093-0623 California USA
| | - Charles A. Hales
- Dept. Pulmonary & Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, 02114 Massachusetts USA
| | - Stuart Rich
- Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Ave., Chicago, 60637 Illinois USA
| | - Stephen L. Archer
- Department of Medicine, University of Chicago School of Medicine, 5841 S. Maryland Ave., Chicago, 60637 Illinois USA
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17
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Tissot C, Beghetti M. Advances in therapies for pediatric pulmonary arterial hypertension. Expert Rev Respir Med 2010; 3:265-82. [PMID: 20477321 DOI: 10.1586/ers.09.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterized by progressive obliteration of the pulmonary vasculature, leading to right heart failure and death if left untreated. Prior to the current treatment era, pulmonary hypertension carried a poor prognosis with a high mortality rate, but its prognosis has changed over the past decades in relation to new therapeutic agents. Nevertheless, pulmonary hypertension continues to be a serious condition, which is extremely challenging to manage. The data in children are often limited owing to the small number of patients, and extrapolation from adults to children is not straightforward. While none of these new therapeutic agents have been specifically approved for children, there is evidence that each can appropriately benefit the PAH child. We review the current understanding of pediatric pulmonary hypertension, classification, diagnostic evaluation and available treatment. A description of targeted pharmacological therapy and new treatments in children is outlined.
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Affiliation(s)
- Cecile Tissot
- The Children's University Hospital of Geneva, Pediatric Cardiology Unit, 6 rue Willy Donze, 1211 Geneva 14, Switzerland.
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18
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Abstract
Pulmonary arterial hypertension in children contributes significantly to morbidity and mortality in diverse pediatric cardiac, lung, hematologic, and other diseases. Pulmonary arterial hypertension is generally a disease of small pulmonary arteries characterized by vascular narrowing due to high-tone and abnormal vasoreactivity, structural remodeling of the vessel wall, intraluminal obstruction, and decreased vascular growth and surface area. Without therapy, high pulmonary vascular resistance contributes to progressive right ventricular failure, low cardiac output, and death. Advances in basic pulmonary vascular biology over the last few decades have led directly to several novel therapies, which have significantly expanded therapeutic choices and have led to improved survival and quality of life of many children with pulmonary arterial hypertension. Despite these improvements, long-term outcomes in many settings remain guarded and substantial challenges persist, especially with regard to understanding mechanisms and approach to structural remodeling of severe pulmonary arterial hypertension.
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19
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Ivy DD, Feinstein JA, Humpl T, Rosenzweig EB. Non-congenital heart disease associated pediatric pulmonary arterial hypertension. PROGRESS IN PEDIATRIC CARDIOLOGY 2009; 27:13-23. [PMID: 21852894 DOI: 10.1016/j.ppedcard.2009.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Recognition of causes of pulmonary hypertension other than congenital heart disease is increasing in children. Diagnosis and treatment of any underlying cause of pulmonary hypertension is crucial for optimal management of pulmonary hypertension. This article discusses the available knowledge regarding several disorders associated with pulmonary hypertension in children: idiopathic pulmonary arterial hypertension (IPAH), pulmonary capillary hemangiomatosis, pulmonary veno-occlusive disease, hemoglobinopathies, hepatopulmonary syndrome, portopulmonary hypertension and HIV. Three classes of drugs have been extensively studied for the treatment of IPAH in adults: prostanoids (epoprostenol, treprostinil, iloprost, beraprost), endothelin receptor antagonists (bosentan, sitaxsentan, ambrisentan), and phosphodiesterase inhibitors (Sildenafil, tadalafil). These medications have been used in treatment of children with pulmonary arterial hypertension, although randomized clinical trial data is lacking. As pulmonary vasodilator therapy in certain diseases may be associated with adverse outcomes, further study of these medications is needed before widespread use is encouraged.
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Affiliation(s)
- D D Ivy
- University of Colorado Denver School of Medicine and The Children's Hospital, United States
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20
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Rosenzweig EB, Morse JH, Knowles JA, Chada KK, Khan AM, Roberts KE, McElroy JJ, Juskiw NK, Mallory NC, Rich S, Diamond B, Barst RJ. Clinical Implications of Determining BMPR2 Mutation Status in a Large Cohort of Children and Adults With Pulmonary Arterial Hypertension. J Heart Lung Transplant 2008; 27:668-74. [DOI: 10.1016/j.healun.2008.02.009] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 02/08/2008] [Accepted: 02/17/2008] [Indexed: 11/30/2022] Open
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21
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Synthèse : Rôle du BMPR2 dans l’hypertension artérielle pulmonaire : de la mutation génique au dysfonctionnement protéique. Rev Mal Respir 2008. [DOI: 10.1016/s0761-8425(08)74834-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Assessment of Pulmonary Artery Systolic Pressures by Stress Doppler Echocardiography After Bilateral Lung Transplantation. J Heart Lung Transplant 2008; 27:66-71. [DOI: 10.1016/j.healun.2007.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 07/24/2007] [Accepted: 09/24/2007] [Indexed: 11/19/2022] Open
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23
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Pignone A, Mori F, Pieri F, Oddo A, Galeota G, Fiori G, Del Rosso A, Perfetto F, Becucci A, Livi R, Tempestini A, Benvenuti C, Gramigna L, Fedi R, Generini S, Minelli M, Cinelli M, Guiducci S, Arcangeli C, Conforti ML, Bernardo P, Cerinic MM. Exercise Doppler echocardiography identifies preclinic asymptomatic pulmonary hypertension in systemic sclerosis. Ann N Y Acad Sci 2007; 1108:291-304. [PMID: 17893993 DOI: 10.1196/annals.1422.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In systemic sclerosis (SSc), the involvement of the interstitium or vascular system of the lung may lead to pulmonary arterial hypertension (PAH). PAH is often asymptomatic or oligosymptomatic in early SSc and, when it becomes symptomatic, pulmonary vascular system is already damaged. Exercise echocardiography (ex-echo), measuring pulmonary artery pressure (PAP) during exercise and allowing to differentiate physiologic from altered PAP responses, may identify subclinical PAH. Our aims were (a) to evaluate by ex-echo the change of PAP in patients with SSc without lung involvement; and (b) to correlate PAP during exercise (ex-PAP) values to clinical and biohumoral parameters of PAH. Twenty-seven patients with limited SSc (ISSc) without interstitial lung involvement were studied. Patients underwent rest and exercise two-dimensional and Doppler echocardiography by supine cycloergometer. Systolic PAP was calculated using the maximum systolic velocity of the tricuspid regurgitant jet at rest and during exercise values of systolic PAP exceeding 40 mmHg at ex-echo were considered as abnormal, and biohumoral markers potentially related to PAH were assessed. Eighteen of 27 SSc patients presented an ex-PAP > 40 mmHg, while in 9 of 27 patients ex-PAP values remained < 40 mmHg (48.8 +/- 4.5 mmHg versus 36.2 +/- 3.1 mmHg; P < 0.001). Other echocardiographic and ergometric parameters, clinical tests, and biohumoral markers were not different in the two groups. Ex-PAP significantly correlated with D-dimer (P = 0.0125; r2 = 0.2029). Ex-echo identifies a cluster of SSc patients with subclinical PAH that may develop PAH. This group should be followed up and may be considered for specific therapies to prevent disease evolution.
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Affiliation(s)
- Alberto Pignone
- Department of Medicine, Division of Rheumatology, University of Florence, Florence, Italy
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24
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Olschewski H, Hoeper MM, Borst MM, Ewert R, Grünig E, Kleber FX, Kopp B, Opitz C, Reichenberger F, Schmeisser A, Schranz D, Schulze-Neick I, Wilkens H, Winkler J, Worth H. Diagnostik und Therapie der chronischen pulmonalen Hypertonie. Clin Res Cardiol 2007; 96:301-30. [PMID: 17468810 DOI: 10.1007/s00392-007-0508-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Horst Olschewski
- Department of Pulmonology, University Clinic of Internal Medicine, Medical University Graz, Auenbruggerplatz 20, Graz, Austria
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25
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Beghetti M. Current treatment options in children with pulmonary arterial hypertension and experiences with oral bosentan. Eur J Clin Invest 2006; 36 Suppl 3:16-24. [PMID: 16919006 DOI: 10.1111/j.1365-2362.2006.01681.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterized by vasoconstriction and progressive remodelling of the pulmonary arterial wall leading to right ventricular failure and death. Idiopathic PAH (IPAH) and PAH associated with congenital heart defects account for the majority of paediatric patients with PAH. During the last few decades, several pharmacological approaches have been introduced, including calcium channel-blockers (CCBs), prostacyclin analogues, endothelin receptor antagonists and, most recently, phosphodiesterase inhibitors. This paper reviews the treatment options available to children with a special focus on the initial experience with bosentan. Although CCBs have been shown to increase survival in IPAH, the beneficial effect appears to be limited to a small number of patients, defined as 'responders' to the vasoreactivity testing. With the availability of prostacyclin (intravenous epoprostenol) and then prostacyclin analogues, the treatment options have increased markedly and particularly in patients who have not responded to conventional therapy. Although epoprostenol has been shown to be efficacious in PAH, the drug is not ideal owing to serious complications arising from the invasive mode of application, particularly in children. Phosphodiesterase-5 inhibitors have also shown beneficial effects. Targeting the endothelin (ET) system with the oral, dual ET(A)/ET(B) receptor antagonist, bosentan has been demonstrated to improve the cardiopulmonary haemodynamics, exercise capacity, quality-of-life and survival in adult patients with PAH. Specific ET(A) antagonists may also present the same beneficial profile. Recent experience with bosentan in paediatric patients with PAH indicates that the results obtained in adult patients may be extrapolated to children, thus offering a safe and effective therapy that is easy to administer.
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Affiliation(s)
- M Beghetti
- Paediatric Cardiology Unit, Children's Hospital, Geneva, Switzerland.
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26
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27
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Grünig E, Dehnert C, Mereles D, Koehler R, Olschewski H, Bärtsch P, Janssen B. Enhanced Hypoxic Pulmonary Vasoconstriction in Families of Adults or Children With Idiopathic Pulmonary Arterial Hypertension. Chest 2005; 128:630S-633S. [PMID: 16373883 DOI: 10.1378/chest.128.6_suppl.630s-a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Ekkehard Grünig
- Department of Cardiology and Pneumology, University Hospital of Heidelberg, INF 410, 69120 Heidelberg, Germany.
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28
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Vachharajani A, Saunders S. Allelic variation in the serotonin transporter (5HTT) gene contributes to idiopathic pulmonary hypertension in children. Biochem Biophys Res Commun 2005; 334:376-9. [PMID: 16009349 DOI: 10.1016/j.bbrc.2005.06.107] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Accepted: 06/17/2005] [Indexed: 11/27/2022]
Abstract
Pulmonary hypertension is a potentially lethal condition, which affects adults and children alike. Genetic factors are implicated in the causation of primary pulmonary hypertension. We investigate the role of polymorphism in the 5HTT gene in the etiology of pulmonary hypertension in children aged 1-18.8 years. We have tested the hypothesis that the 5HTT gene does contribute to the pathogenesis of this disease in children by comparing the allelic frequencies of both the long and short variants between children with idiopathic pulmonary hypertension and pulmonary hypertension secondary to underlying pulmonary disease. We found that homozygosity for the long variant of 5HTT was highly associated with idiopathic pulmonary hypertension in children, suggesting perhaps a more important role for 5HTT gene function in the pathogenesis of early onset disease.
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Affiliation(s)
- Akshaya Vachharajani
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA
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29
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Harrison RE, Berger R, Haworth SG, Tulloh R, Mache CJ, Morrell NW, Aldred MA, Trembath RC. Transforming Growth Factor-β Receptor Mutations and Pulmonary Arterial Hypertension in Childhood. Circulation 2005; 111:435-41. [PMID: 15687131 DOI: 10.1161/01.cir.0000153798.78540.87] [Citation(s) in RCA: 175] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Pulmonary arterial hypertension (PAH) is a potentially fatal vasculopathy that can develop at any age. Adult-onset disease has previously been associated with mutations in
BMPR2
and
ALK-1
. Presentation in early life may be associated with congenital heart disease but frequently is idiopathic.
Methods and Results—
We performed mutation analysis in genes encoding receptor members of the transforming growth factor-β cell-signaling pathway in 18 children (age at presentation <6 years) with PAH. Sixteen children were initially diagnosed with idiopathic PAH and 2 with PAH in association with congenital heart defects. Germ-line mutations were observed in 4 patients (22%) (age at disease onset, 1 month to 6 years), all of whom presented with idiopathic PAH. The
BMPR2
mutations (n=2, 11%) included a partial gene deletion and a nonsense mutation, both arising de novo in the proband. Importantly, a missense mutation of
ALK-1
and a branch-site mutation of
endoglin
were also detected. Presenting clinical features or progression of pulmonary hypertension did not distinguish between patients with mutations in the different genes or between those without mutations.
Conclusions—
The cause of PAH presenting in childhood is heterogeneous in nature, with genetic defects of transforming growth factor-β receptors playing a critical role.
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MESH Headings
- Activin Receptors, Type I/genetics
- Activin Receptors, Type I/physiology
- Activin Receptors, Type II
- Amino Acid Motifs/genetics
- Amino Acid Substitution
- Antigens, CD
- Bone Morphogenetic Protein Receptors, Type II
- Child
- Child, Preschool
- Codon, Nonsense
- DNA Mutational Analysis
- Endoglin
- Exons/genetics
- Female
- Genetic Predisposition to Disease
- Genotype
- Germ-Line Mutation
- Heart Defects, Congenital/genetics
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Infant
- Infant, Newborn
- Male
- Mutation, Missense
- Protein Serine-Threonine Kinases/genetics
- Protein Serine-Threonine Kinases/physiology
- RNA Splicing
- Receptors, Cell Surface
- Receptors, Transforming Growth Factor beta/genetics
- Receptors, Transforming Growth Factor beta/physiology
- Sequence Deletion
- Signal Transduction/physiology
- Telangiectasia, Hereditary Hemorrhagic/complications
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Transforming Growth Factor beta/physiology
- Vascular Cell Adhesion Molecule-1/genetics
- Vascular Cell Adhesion Molecule-1/physiology
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Affiliation(s)
- Rachel E Harrison
- Division of Medical Genetics, University of Leicester, Leicester, UK
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30
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Morse JH. Defining the Role and Clinical Relevance of BMPR2 Mutations In Pulmonary Arterial Hypertension. ACTA ACUST UNITED AC 2005. [DOI: 10.21693/1933-088x-4.1.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jane H. Morse
- Professor Emerita of Clinical Medicine and Special Lecturer, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
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