Circulating von Willebrand factor antigen as a predictor of short-term prognosis in pulmonary hypertension

Biomarkers in Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a severe medical condition characterized by elevated pulmonary vascular resistance (PVR), right ventricular (RV) failure, and death in the absence of appropriate treatment. The progression and prognosis are strictly related to the etiology, biochemical parameters, and treatment response. The gold-standard test remains right-sided heart catheterization, but dynamic monitoring of systolic pressure in the pulmonary artery is performed using echocardiography. However, simple and easily accessible non-invasive assays are also required in order to monitor this pathology. In addition, research in this area is in continuous development. In recent years, more and more biomarkers have been studied and included in clinical guidelines. These biomarkers can be categorized based on their associations with inflammation, endothelial cell dysfunction, cardiac fibrosis, oxidative stress, and metabolic disorders. Moreover, biomarkers can be easily detected in blood and urine and correlated with disease severity, playing an important role in diagnosis, prognosis, and disease progression.

An Overview of Circulating Pulmonary Arterial Hypertension Biomarkers

Pulmonary arterial hypertension (PAH), also known as Group 1 Pulmonary Hypertension (PH), is a PH subset characterized by pulmonary vascular remodeling and pulmonary arterial obstruction. PAH has an estimated incidence of 15-50 people per million in the United States and Europe, and is associated with high mortality and morbidity, with patients' survival time after diagnosis being only 2.8 years. According to current guidelines, right heart catheterization is the gold standard for diagnostic and prognostic evaluation of PAH patients. However, this technique is highly invasive, so it is not used in routine clinical practice or patient follow-up. Thereby, it is essential to find new non-invasive strategies for evaluating disease progression. Biomarkers can be an effective solution for determining PAH patient prognosis and response to therapy, and aiding in diagnostic efforts, so long as their detection is non-invasive, easy, and objective. This review aims to clarify and describe some of the potential new candidates as circulating biomarkers of PAH.

Von Willebrand Factor, Factor VIII, and Other Acute Phase Reactants as Biomarkers of Inflammation and Endothelial Dysfunction in Chronic Graft-Versus-Host Disease

Chronic graft-versus-host disease (cGvHD) is an immune mediated late complication of allogeneic hematopoietic stem cell transplantation (alloHSCT). Discovery of adequate biomarkers could identify high-risk patients and provide an effective pre-emptive intervention or early modification of therapeutic strategy, thus reducing prevalence and severity of the disease among long-term survivors of alloHSCT. Inflammation, endothelial injury, and endothelial dysfunction are involved in cGvHD development. Altered levels of acute phase reactants have shown a strong correlation with the activity of several immune mediated disorders and are routinely used in clinical practice. Since elevated von Willebrand factor (VWF) and factor VIII (FVIII) levels have been described as acute phase reactants that may indicate endothelial dysfunction and inflammation in different settings, including chronic autoimmune diseases, they could serve as potential candidate biomarkers of cGvHD. In this review we focused on reported data regarding VWF and FVIII as well as other markers of inflammation and endothelial dysfunction, evaluating their potential role in cGvHD.

Pulmonary hypertension: Proteins in the blood

The plasma proteome is rich in information. It comprises proteins that are secreted or lost from cells as they respond to their local environment. Changes in the constitution of the plasma proteome offer a relatively non-invasive report on the health of tissues. This is particularly true of the lung in pulmonary hypertension, given the large surface area of the pulmonary vasculature in direct communication with blood. So far, this is relatively untapped; we have relied on proteins released from the heart, specifically brain natriuretic peptide and troponin, to inform clinical management. New technology allows the measurement of a larger number of proteins that cover a broad range of molecular pathways in a single small aliquot. The emerging data will yield more than just new biomarkers of pulmonary hypertension for clinical use. Integrated with genomics and with the help of new bioinformatic tools, the plasma proteome can provide insight into the causative drivers of pulmonary vascular disease and guide drug development.

Prognostic Significance of Biomarkers in Pulmonary Arterial Hypertension

RATIONALE

Pulmonary arterial hypertension (PAH) is a rare progressive disease of the pulmonary vasculature that is characterized by endothelial dysfunction, inflammation, and right ventricular dysfunction.

OBJECTIVES

The main objective was to determine whether endothelial, inflammatory, and cardiac biomarkers would be associated with the World Health Organization functional assessment and survival in patients with PAH.

METHODS

We performed a retrospective cohort study of patients with PAH enrolled in the Randomized Clinical Trial of Aspirin and Simvastatin for Pulmonary Arterial Hypertension (ASA-STAT). Biomarkers (N-terminal fragment of pro-BNP [NT-pro-BNP], von Willebrand factor [vWF], soluble P selectin, C-reactive protein, total and high-density lipoprotein cholesterol, triglycerides, tumor necrosis factor, IL-6, β-thromboglobulin, and thromboxane B2) were measured at baseline. Patients from the study were followed until lung transplantation, death, or August 1, 2013. Ordinal logistic regression and Cox regression analyses were performed.

MEASUREMENTS AND MAIN RESULTS

Sixty-five patients with PAH were enrolled. The mean age was 51 years, and 86% were women. Higher vWF activity, lower high-density lipoprotein cholesterol, and higher thromboxane B2 levels were associated with worse World Health Organization functional class after adjustment for age, sex, and etiology of PAH. Higher NT-pro-BNP levels, lower vWF activity, and lower total cholesterol were associated with an increased risk of death or lung transplant after adjustment for age, sex, etiology of PAH, and 6-minute-walk distance.

CONCLUSIONS

In patients with PAH, lower vWF activity and cholesterol levels and higher NT-pro-BNP levels at baseline were associated with an increased risk of death or transplantation. Clinical trial registered with www.clinicaltrials.gov (NCT00384865).

Determination of von Willebrand Factor Activity: Evaluation of the HaemosIL™ Assay in Comparison With Established Procedures

Determination of von Willebrand factor activity is required for diagnosis and classification of von Willebrand disease. In addition, von Willebrand factor activity can be of prognostic relevance in several clinical entities including thromboembolic and cardiovascular disorders in which elevated activity correlates with a poor prognosis. The HaemosIL™ assay (Instrumentation Laboratory GmbH, Munich, Germany) provides a new fully automated procedure for determination of von Willebrand factor activity. This assay measures binding of the von Willebrand factor to GP Ibα of the platelet glycoprotein complex Ib-V-IX. In our study, we analyzed 300 samples including those of patients with hereditary von Willebrand disease. The results obtained with the HaemosIL™ assay were compared to von Willebrand factor activities determined by established procedures. Activities determined with HaemosIL™ correlated with those activities determined as ristocetin cofactor (r = 0.88, p < 0.0001), collagen-binding (r = 0.93, p < 0.0001), and GP Ib-binding (r = 0.91, p < 0.0001). The comparability of results obtained by HaemosIL™ and the GP Ib-binding ELISA were excellent ([HaemosIL™] = 0.96 ∞ activity [GP Ib-binding ELISA] + 10.7), whereas activities determined by ristocetin cofactor or collagen-binding revealed more variance. Like the other assays, the HaemosIL™ failed to indicate a loss of high-molecular-weight von Willebrand factor multimers. The HaemosIL™ assay can replace the GP Ib-binding ELISA for the determination of von Willebrand factor activity. Advantages of this assay include accuracy of results, full automation, and, thus, broad availability. Since the assay does not predict the absence of high-molecular-weight multimers, multimeric analysis remains the procedure of choice for the differentiation of functional defects.

Recognizing Pulmonary Hypertension and Right Ventricular Dysfunction in Heart Failure

Pulmonary hypertension (PH) in the setting of left heart disease (LHD) or heart failure (HF) is the most common form of PH, yet its prevalence is underappreciated. Varying terminology possibly leads to misconceptions in pathophysiology, diagnosis and management. The accurate diagnosis of PH due to LHD is contingent upon hemodynamic assessment via right heart catheterization, however due to limitations in access, comprehensive echocardiography and integrative scoring systems are frequently used. When present in the setting of PH due to LHD, right ventricular dysfunction (RVD) confers a poor clinical prognosis. The management of RVD is directed towards treating underlying HF and/or valvular disease. Implantable hemodynamic monitors may offer opportunity to obtain longitudinal information to increase diagnostic accuracy as well as monitor the effect of treatment of PH in the setting of HF with and without the presence of RVD.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Biomarkers in pulmonary arterial hypertension

The biomarker is an indicaror of a biological or pathological process.

Clinical observations, measures or environmental events, or measured laboratory values can all be biomarkers in the appropriate setting. An ideal biomarker reflects the underlying biological process, predicts clinical events, is easily obtainable, is reproducible and is not prohibitively expensive. This typically requires validation in longitudinal cohort studies. Biomarkers may help understand the pathological mechanisms responsible for the disease, help as screening tools, predict disease worsening or decline, and determine adequacy of response to therapeutic interventions.

The responses of endothelial cells to Zr₆ ₁Ti ₂Cu₂₅Al₁₂ metallic glass in vitro and in vivo

The goal of this study was to evaluate the biocompatibility of newly developed Zr61Ti2Cu25Al12 metallic glass (denoted ZT1) and its parallel material, commercially pure titanium (CP-Ti), as dental implants. To this end, we evaluated their cytotoxicity in vitro using human umbilical vein endothelial cells (HUVECs) and in vivo by performing an oral mucosa irritation test in hamsters. Specifically, cytotoxicity was determined in HUVECs by evaluating their cell morphology using scanning electron microscopy (SEM) and their cell viability using CCK-8 assays. Moreover, we examined the mRNA levels of vascular endothelial growth factor and von Willebrand factor by quantitative PCR (qPCR). In the early stages of proliferation and differentiation, no differences were observed between HUVECs inoculated on ZT1 compared to those on CP-Ti. However, in the later stages of proliferation and differentiation, the HUVECs inoculated on ZT1 were significantly better than the cells cultured on CP-Ti. In the oral mucosa irritation test, we sutured sample discs into the cheek pouch of hamsters. After 2, 3, and 4weeks, we harvested the corresponding mucosal tissues, stained them with hematoxylin and eosin, obtained blood samples for biochemical analysis, and finally, observed the topography of the sample discs by SEM. Immunohistochemistry and hematology analyses showed no differences in the biocompatibility of ZT1 and CP-Ti, and neither of these compounds caused irritation of the mucosa. In addition, SEM images showed that no pitting occurred on the sample discs. Together, these data indicate that ZT1 may be a good candidate for dental implants and should be further studied.

Assessment of operability of patients with pulmonary arterial hypertension associated with congenital heart disease

Pulmonary arterial hypertension (PAH) is a common complication of congenital heart disease, and is now predominantly among patients with uncorrected left-to-right shunts. A growing population is characterized by persistent or recurrent PAH after surgical or interventional correction of left-to-right shunts; the latter having a worse prognosis than other forms of PAH associated with congenital heart disease. New treatments for PAH have been shown to be effective in improving PAH exercise capacity and hemodynamics, raising the hope for making previously inoperable congenital heart defects operable and shifting the framework for the assessment of operability. This review focuses on current methods for assessing operability in PAH associated with congenital heart disease, and the possibility of "treat-and-repair" vs. "repair-and-treat" strategies for patients with inoperable or borderline PAH.

Standard nonspecific therapies in the management of pulmonary arterial hypertension

Recent advances in pulmonary arterial hypertension (PAH) research have created a new era of PAH-specific therapies. Although these therapeutics have revolutionized PAH therapy, their innovation was predated by supportive but nonspecific medical therapies adapted from their use in more common cardiopulmonary diseases. These therapies include oxygen therapy, diuretics, digoxin, anticoagulation, and high-dose calcium channel blockers. Expert opinion continues to support the use of adjunct therapies based on current pathologic understandings of PAH combined with some evidence extrapolated from small studies. This article discusses why these therapies continue to play an important role in the treatment of patients with PAH.

Markers of vascular perturbation correlate with airway structural change in asthma

RATIONALE

Air trapping and ventilation defects on imaging are characteristics of asthma. Airway wall thickening occurs in asthma and is associated with increased bronchial vascularity and vascular permeability. Vascular endothelial cell products have not been explored as a surrogate to mark structural airway changes in asthma.

OBJECTIVES

Determine whether reporters of vascular endothelial cell perturbation correlate with airway imaging metrics in patients with asthma of varying severity.

METHODS

Plasma from Severe Asthma Research Program subjects was analyzed by ELISAs for soluble von Willebrand factor mature protein (VWF:Ag) and propeptide (VWFpp), P-selectin, and platelet factor 4. Additional subjects were analyzed over 48 hours after whole-lung antigen challenge. We calculated ventilation defect volume by hyperpolarized helium-3 magnetic resonance imaging and areas of low signal density by multidetector computed tomography (less than -856 Hounsfield units [HU] at functional residual capacity and -950 HU at total lung capacity [TLC]).

MEASUREMENTS AND MAIN RESULTS

VWFpp and VWFpp/Ag ratio correlated with and predicted greater percentage defect volume on hyperpolarized helium-3 magnetic resonance imaging. P-selectin correlated with and predicted greater area of low density on chest multidetector computed tomography less than -950 HU at TLC. Platelet factor 4 did not correlate. Following whole-lung antigen challenge, variation in VWFpp, VWFpp/Ag, and P-selectin among time-points was less than that among subjects, indicating stability and repeatability of the measurements.

CONCLUSIONS

Plasma VWFpp and P-selectin may be useful as surrogates of functional and structural defects that are evident on imaging. The results raise important questions about why VWFpp and P-selectin are associated specifically with different imaging abnormalities.

Updating clinical endpoint definitions

The 6-Minute Walk Distance (6-MWD) has been the most utilized endpoint for judging the efficacy of pulmonary arterial hypertension (PAH) therapy in clinical trials conducted over the past two decades. Despite its simplicity, widespread use in recent trials and overall prognostic value, the 6-MWD has often been criticized over the past several years and pleas from several PAH experts have emerged from the literature to find alternative endpoints that would be more reliable in reflecting the pulmonary vascular resistance as well as cardiac status in PAH and their response to therapy. A meeting of PAH experts and representatives from regulatory agencies and pharmaceutical companies was convened in early 2012 to discuss the validity of current as well as emerging valuable endpoints. The current work represents the proceedings of the conference.

Hypoxia results in upregulation and de novo activation of von Willebrand factor expression in lung endothelial cells

OBJECTIVE

Increased von Willebrand factor (VWF) levels in lungs are associated with diseases such as pulmonary hypertension. The objective of our study was to determine the mechanism of increased VWF levels in conditions, such as hypoxia, which contribute to pulmonary hypertension.

APPROACH AND RESULTS

We have previously reported generation of transgenic mice that express LacZ transgene under the regulation of lung- and brain-specific transcriptional regulatory elements of the VWF gene. Hypoxia exposure of these transgenic mice resulted in increased VWF and LacZ mRNA levels as well as redistribution of their expression from primarily larger vessels in the lungs to microvessels. Exposure of cultured lung microvascular endothelial cells to hypoxia demonstrated that VWF upregulation was accompanied by increased platelet binding. Transcription upregulation was mediated through inhibition of the repressor nuclear factor-IB association with the VWF promoter, and increased nuclear translocation of the transcription factor YY1 and association with its cognate binding site on the VWF gene. Knockdown of YY1 expression abolished the hypoxia-induced upregulation and reduced basal level of VWF.

CONCLUSIONS

These analyses demonstrate that hypoxia induces a phenotypic shift, accompanied by modulation of nuclear factor-IB and YY1 activities, in microvascular endothelial cells of the lungs to support VWF promoter activation.

The potential of biomarkers in pulmonary arterial hypertension

Effective management of patients with pulmonary arterial hypertension (PAH) requires comprehensive prognostic evaluation in order to determine optimal management strategies. Although a number of clinical and hemodynamic parameters linked to PAH prognosis have been identified, some are associated with significant limitations (eg, invasive techniques, subjective measures). There is a need for noninvasive and objective measures to be established that function as biomarkers for the diagnosis and assessment of disease prognosis, and that determine response to therapy in patients with PAH. Reflecting the highly complex etiology of the disease, a large number of potential biomarkers have been, and continue to be, investigated in PAH, including those reflecting right heart function, endothelial dysfunction, and markers of inflammation and second organ failure. However, it has become clear that scientifically interesting biomarkers may not necessarily be clinically useful. Of the range of biomarkers investigated in PAH to date, only brain natriuretic peptide and its N-terminal cleavage product have been included as prognostic parameters in treatment guidelines. It is unlikely that any single biomarker will provide all the relevant information required for an individual patient, and the potential for combining markers is currently of considerable interest. Future studies are required to determine the optimal combination of existing and emerging biomarkers in the clinical setting.

Pulmonary vascular disease in mice xenografted with human BM progenitors from patients with pulmonary arterial hypertension

Hematopoietic myeloid progenitors released into the circulation are able to promote vascular remodeling through endothelium activation and injury. Endothelial injury is central to the development of pulmonary arterial hypertension (PAH), a proliferative vasculopathy of the pulmonary circulation, but the origin of vascular injury is unknown. In the present study, mice transplanted with BM-derived CD133(+) progenitor cells from patients with PAH, but not from healthy controls, exhibited morbidity and/or death due to features of PAH: in situ thrombi and endothelial injury, angioproliferative remodeling, and right ventricular hypertrophy and failure. Myeloid progenitors from patients with heritable and/or idiopathic PAH all produced disease in xenografted mice. Analyses of hematopoietic transcription factors and colony formation revealed underlying abnormalities of progenitors that skewed differentiation toward the myeloid-erythroid lineage. The results of the present study suggest a causal role for hematopoietic stem cell abnormalities in vascular injury, right ventricular hypertrophy, and morbidity associated with PAH.

Biomarkers in pulmonary arterial hypertension

Despite recent advances in medical treatment, pulmonary arterial hypertension (PAH) continues to be associated with high morbidity and mortality. While the diagnosis is established via a right heart catheterisation, current non-invasive measures of disease severity and response to treatment used in clinical practice are the 6-min walk distance and the World Health Organization functional class. Although both parameters correlate with disease severity and prognosis, they have significant limitations. A major shortcoming in assessing PAH is lack of standardised, non-invasive, objective parameters that function as biomarkers to help assess the severity and prognosis of disease and to follow patients' response to treatment. In this article, we will review current knowledge on potential biomarkers associated with diagnosis, prognosis and response to treatment of PAH. Most biomarkers are either being evaluated for potential use in clinical practice, or being used as research tools.

Senescent endothelial progenitor cells from dogs with pulmonary arterial hypertension: a before-after self-controlled study

Previous studies have underlined the importance of endothelial dysfunction and microvascular occlusion in the pathogenesis of pulmonary artery hypertension (PAH). Since the endothelial progenitor cells (EPCs) are involved in maintaining endothelial homeostasis, we observed the change of peripheral EPCs in canines before and after PAH onset. PAH was induced by intra-pulmonary artery injection of dehydromonocrotaline (DHMC) in nine beagles. Before and 48 h and 6 weeks after DHMC injection, 40 ml peripheral blood was obtained from the femoral vein. Circulating EPCs were identified as CD133 + KDR + cells and numerated by fluorescence-activated cell sorter; the EPCs functional capacity was determined by in vitro tubule-forming assay. The senescence of EPCs was determined by beta-galactosidase staining. At each time point, 2 ml blood from femoral artery was obtained for arterial oxygen pressure (PaO(2)). Forty-eight hours after DHMC injection, treated beagles suffered from hypoxemia; however, both the number and the tubule-forming capacity of EPCs were transiently raised. Six weeks later, PAH was confirmed by obviously high mean pulmonary arterial pressure (20.2 +/- 1.64 vs. 11.3 +/- 2.0 mmHg, p < 0.05) and low PaO(2) (69.30 +/- 9.15 vs. 95.94 +/- 1.43 mmHg, p < 0.01) in beagles after DHMC treatment, and their EPCs exhibited a predominant decrease in either the number (206.1 +/- 26.8 vs. 632.8 +/- 42.8 cells/ml blood, p < 0.01) or the tubule-forming capacity (21.1 +/- 2.8 vs. 11.2 +/- 2.8 tubules/x200 field, p < 0.01). Additionally, senescence-associated beta-galactosidase-positive EPCs were significantly increased. Our data suggested that, after the acute stage of DHMC injury to pulmonary vessels, the EPCs from PAH beagles suffered from exhaustion and senescence.

Von Willebrand factor, red cell fragmentation, and disease activity in systemic lupus erythematosus

This study sought to determine whether the plasma levels of Von Willebrand factor (vWf) and the degree of red blood cell (RBC) fragmentation on peripheral smear correlate with disease activity in systemic lupus erythematosus (SLE). Forty consecutive patients who fulfilled the criteria for SLE were studied prospectively for 1 year. Patients were categorized according to the SLE Disease Activity Index (SLEDAI) as either active (>2) or inactive disease and followed up monthly (active) or quarterly (inactive). At each visit, patients were examined fully and had complete blood count, tests on antibodies to double-stranded DNA, C3, and C4 levels, and urinalysis. Citrated plasma was analyzed for vWf antigen by standard enzyme-linked immunosorbent assay. A Wright's stained blood smear was obtained and schistocytes were quantitated on blood smear. The number of schistocytes per 500 RBCs was determined and a schistocyte index (SI) was calculated. At baseline, vWf correlated with SLEDAI (r = 0.64, p < 0.01), SI correlated with SLEDAI (r = 0.62, p < 0.01), and vWf and SI correlated with each other (r = 0.41, p = 0.01). There was an inverse correlation between baseline C3 levels and vWf (r = 0.49, p = 0.0013) and C3 levels and SI (r = 0.40, p = 0.01). Over time, there was also a correlation of SLEDAI with vWf (r = 0.53, p = 0.002) and SI (r = 0.57;p = 0.002). The relation of vWf with SI approached but did not reach statistical significance (r = 0.37, p = 0.06). We found that the plasma levels of vWf and the degree of RBC fragmentation correlate with lupus disease activity over time. Therefore, inflammation in SLE may be associated with endothelial injury.

Surrogate end points in pulmonary arterial hypertension: assessing the response to therapy

Recent discoveries in the disease pathophysiology of pulmonary arterial hypertension have been translated into effective therapies tested in clinical trials. The studies have focused on surrogate and intermediate end points, thought to reflect quantity and quality of life, respectively. The authors present the necessary requirements for establishing the reliability and validity of such end points before they may be used dependably. The authors also review the available data, strengths, and weaknesses of potential end points in pulmonary arterial hypertension.

Acquired and Reversible von Willebrand Disease With High Shear Stress Aortic Valve Stenosis

BACKGROUND

Severe aortic valve stenosis is relatively more prevalent in patients with repeated bleeding episodes. The goal of the present study was to determine the effect of aortic valve replacement on von Willebrand factor levels in patients with aortic stenosis.

METHODS

von Willebrand factor levels were assessed by using immunoblotting electrophoresis techniques before and 1 month after surgery in 29 consecutive patients with severe aortic valve stenosis.

RESULTS

Eight of 29 patients reported episodes of bleeding, including three episodes of major bleeding, in the 6 months before surgery. None of the patients were receiving anticoagulation therapy. Although there was no difference in platelet count before and after surgery, von Willebrand factor levels were significantly greater at 1 month after surgery (p = 0.05) when compared with preoperative values. Further, von Willebrand factor levels were significantly lower in patients with aortic valve prosthesis mismatch than in those patients without this phenomenon (p < 0.05). Electrophoresis experiments showed a deficit in large multimers of von Willebrand factor preoperatively but not postoperatively, except for in those patients with aortic valve prosthesis mismatch.

CONCLUSIONS

In conclusion, valve replacement can result in increases in von Willebrand factor in patients with aortic valve stenosis.

von Willebrand factor independently predicts long-term survival in patients with pulmonary arterial hypertension

OBJECTIVES

We hypothesized that higher plasma levels of von Willebrand factor (vWF) and reduced ristocetin cofactor activity (RCA)/vWF ratios at baseline and follow-up would be associated with an increased risk of death in patients with pulmonary arterial hypertension (PAH).

BACKGROUND

Endothelial injury and dysfunction cause increased vWF levels in patients with cardiovascular disease. Increased vWF is associated with a higher risk of death in patients with coronary artery disease, congestive heart failure, and ARDS. In PAH, vWF is elevated and functions abnormally, resulting in reduced platelet binding. The ability of vWF to bind platelets is reflected by RCA.

METHODS

We performed a retrospective cohort study of 66 PAH patients who underwent initial evaluation at our center from January 1994 to June 2002. The primary outcome was death or lung transplantation.

RESULTS

vWF level was directly associated with Factor VIII activity, RCA, fibrinogen, and prothrombin time (p < or = 0.01). vWF levels at baseline and follow-up were associated with the risk of death (hazard ratio [HR] per 50% increase, 1.4; 95% confidence interval [CI], 1.1 to 1.8 [p = 0.02]; and HR per 50% increase, 1.5; 95% CI, 1.1 to 2.0 [p = 0.011]; n = 48, respectively). RCA/vWF ratios were not associated with outcome. These results were unaffected by adjustment for demographics, baseline hemodynamics, laboratory results, or PAH therapy in multivariate analyses.

CONCLUSIONS

Increased vWF levels at baseline and follow-up are associated with worse survival in patients with PAH; however, RCA/vWF ratios are not. The hemostatic effects of vWF do not account for these findings. This suggests that endothelial injury and dysfunction may persist despite treatment and may impact on disease course. Therapies that target endothelial injury may therefore improve outcomes for patients with PAH.

Immunohistochemical expression of endothelial markers CD31, CD34, von Willebrand factor, and Fli-1 in normal human tissues

Few systematic studies have been published comparing the expression and distribution of endothelial cell (EC) markers in different vascular beds in normal human tissues. We investigated by immunohistochemistry the expression of CD31, CD34, von Willebrand factor (vWF), and Fli-1 in EC of the major organs and large vessels. Tissue samples obtained from autopsies and biopsy specimens were routinely processed and stained immunohistochemically for CD31, CD34, and vWF. Biopsy material was also stained immunohistochemically for Fli-1, D2-40, and Lyve-1. The expression pattern of the markers was heterogeneous in some of the organs studied. In the kidney, fenestrated endothelium of the glomeruli strongly expressed CD31 and CD34 but was only focally positive or completely negative for vWF. Alveolar wall capillaries of the lung strongly stained for CD31 and CD34 but were usually negative for vWF. The staining intensity for vWF increased gradually with the vessel caliber in the lung. Sinusoids of the spleen and liver were diffusely positive for CD31. They were negative for CD34 in the spleen and only expressed CD34 in the periportal area in the liver. Fli-1 was expressed in all types of EC but also in lymphocytes. D2-40 stained lymphatic endothelium only. Lyve-1 immunostaining was too variable to be applied to routinely processed tissues. The expression of EC markers CD31, CD34, and vWF in the vascular tree is heterogeneous with a specific pattern for individual vessel types and different anatomic compartments of the same organ. D2-40 labels lymphatic EC only.

[Biomarkers as prognostic factors in pulmonary arterial hypertension. Rationale and study design]

CURRENT SITUATION

Pulmonary arterial hypertension (PAH) is a serious disease. Its prognostic is based on the functional status quantified by the NYHA class and the 6-min walking test, and the hemodynamic data. The algorithms of treatment are solely based on the hemodynamic data and the functional status. The main objective is to test whether basal concentrations of isoprostanes, Big endotheline 1, ADMA, high sensitivity CRP, NT-Pro-BNP and cardiac troponin T are a 3-year prognostic factor in PAH using a combined criterion: death from any cause and pulmonary or cardiopulmonary transplantation.

MATERIALS AND METHODS

This is a multicenter, prospective, prognostic, single blinded study (plasma and urinary samples being blinded). The study started in november 2003, running for 2 years, with a 3 year follow-up for each patient. The main inclusion criterion is PAH. The data analysis will use a multivariable Cox model, taking into account the functional and hemodynamic parameters.

EXPECTED RESULTS

This study will determine whether any of the biomarkers tested provides additional prognostic information in PAH in addition to the functional and hemodynamic parameters.

Cellular and molecular mechanisms of pulmonary vascular remodeling: role in the development of pulmonary hypertension

Pulmonary artery vasoconstriction and vascular remodeling greatly contribute to a sustained elevation of pulmonary vascular resistance (PVR) and pulmonary arterial pressure (PAP) in patients with pulmonary arterial hypertension (PAH). The development of PAH involves a complex and heterogeneous constellation of multiple genetic, molecular, and humoral abnormalities, which interact in a complicated manner, presenting a final manifestation of vascular remodeling in which fibroblasts, smooth muscle and endothelial cells, and platelets all play a role. Vascular remodeling is characterized largely by medial hypertrophy due to enhanced vascular smooth muscle cell proliferation or attenuated apoptosis and to endothelial cell over-proliferation, which can result in lumen obliteration. In addition to other factors, cytoplasmic Ca2+ in particular seems to play a central role as it is involved in both the generation of force through its effects on the contractile machinery, and the initiation and propagation of cell proliferation via its effects on transcription factors, mitogens, and cell cycle components. This review focuses on the role played by cellular factors, circulating factors, and genetic molecular signaling factors that promote a proliferative, antiapoptotic, and vasoconstrictive physiological milieu leading to vascular remodeling.

Molecular biology of primary pulmonary hypertension

Primary pulmonary hypertension (PPH) is a rare but often fatal condition characterized by pulmonary artery remodeling leading to chronic elevation of pulmonary artery pressure in the absence of causes. The pathophysiology of PPH is not completely understood, but a number of recent studies have elucidated many possible gentic, hormonal, and environmental factors. Current treatment options slow the progression of the disease but do not halt it. The study of molecular mechanisms that result from mutations in onmental and hormonal modifiers holds great promise for the development of novel therapies that may halt the progression of the disease.

Recipient selection

Since international recommendations for lung transplant recipients were made in 1998, newer tools for predicting mortality in patients who have end-stage lung disease have been investigated. This article reviews studies for predicting mortality in obstructive, restrictive, pulmonary vascular, and suppurative/bronchiectatic lung disease. Newer considerations for alternative treatments, postoperative risks, and contraindications are also examined. The article aims to provide more accurate data for selecting patients who will benefit from lung transplantation.

Significance of a plasma D-dimer test in patients with primary pulmonary hypertension

BACKGROUND

D-dimer, a degradation product of fibrin, has been increasingly used as a marker or prognostic factor in various thrombotic diseases.

OBJECTIVE

To assess the significance of a d-dimer test in patients with primary pulmonary hypertension (PPH).

PATIENTS AND METHODS

Fourteen patients with PPH (12 women and 2 men) aged 25 to 68 years (mean +/- SD age, 50 +/- 14 years) entered the study. Plasma d-dimer was determined by Miniquant assay (Biopool International; Venture, CA) 3 +/- 5 months after the disease onset, and patients were followed up for 1 year. We compared the d-dimer levels to the demographic, clinical, and hemodynamic data of the patients.

RESULTS

D-dimer levels were positively correlated with New York Heart Association classification (r = 0.59, p = 0.01) and pulmonary artery pressure (r = 0.43, p = 0.03) and were negatively correlated with oxygen saturation (r = - 0.45, p = 0.03) and 6-min walk distance (r = - 0.49, p = 0.04). One-year survival was also negatively correlated with d-dimer (point-biserial r = - 0.71, p = 0.004), with a higher d-dimer value associated with poorer survival. No significant correlations were found between d-dimer values and sex, age, diffusing capacity of the lung for carbon monoxide, or cardiac index.

CONCLUSION

D-dimer levels may have a role in the evaluation of patients with PPH. This simple, noninvasive test may be helpful for identifying patients who are at a higher risk for severe disease.

Ion channels in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a hemodynamic abnormality that ultimately results in mortality due to right heart failure. Although the clinical manifestations of primary and secondary PAH are diverse, medial hypertrophy and arterial vasoconstriction are key components in the vascular remodeling leading to PAH. Abnormalities in the homeostasis of intracellular Ca(2+), transmembrane flux of ions, and membrane potential may play significant roles in the processes leading to pulmonary vascular remodeling. Decreased activity of K(+) channels causes membrane depolarization, leading to Ca(2+) influx. The elevated cytoplasmic Ca(2+) is a major trigger for pulmonary vasoconstriction and an important stimulus for vascular smooth muscle proliferation. Dysfunctional K(+) channels have also been linked to inhibition of apoptosis and contribute further to the medial hypertrophy. This review focuses on the relative role of K(+) and Ca(2+) ions and channels in human pulmonary artery smooth muscle cells in the development of PAH.

Expression of the endothelial markers PECAM-1, vWf, and CD34 in vivo and in vitro

EC culture models are essential to study pathological alterations of endothelial cells (ECs) in pulmonary vascular diseases under standardized conditions. Nevertheless, little is known about the spectrum of alterations of vessel-specific endothelial phenotypes in monolayer cultures. For the comparative study of endothelial markers in vivo and in vitro we investigated immunohistochemically the expression of PECAM-1, vWf, and CD34 by pulmonary ECs in vivo and in stimulated/unstimulated human umbilical vein endothelial cells (HU-VEC) and human pulmonary microvascular endothelial cells (HPMEC). In vivo, vessel type-specific expression patterns were found for vWf and CD34, while PECAM-1 was homogeneously and strongly expressed. While all HUVEC showed a marked vWf staining, about two-thirds of HPMEC exhibited a strong and the rest a moderate vWf staining. In both in vitro models all ECs were clearly PECAM-1-positive. However, only about 20% of the HUVEC and HPMEC were CD34-positive. Our results demonstrate the reduced expression of vessel type-specific endothelial phenotypes by endothelial monolayer cultures, stressing the need to improve culture conditions as well as develop cocultures and three-dimensional culture models. Moreover, the need for endothelial markers specific for single microvascular type ECs becomes obvious in order to establish cultures consisting of only one microvascular ECs subpopulation.

Correlation of age with in vivo expression of endothelial markers

The importance of endothelial senescence as a pathogenetic factor in age-related vascular alterations has almost exclusively been studied in vitro. However, the in vitro-findings have rarely been compared with histomorphological changes in aging human tissue or in age-related degenerative diseases. Therefore, we compared the expression of the endothelial marker CD34 and the procoagulant protein von Willebrand factor (vWf) in lung endothelium by conventional immunohistochemistry and confocal laser scan microscopy (CLSM), taking the age of the patients into consideration. The staining reactions were statistically analysed by covariance analysis. With age the endothelial staining intensity of CD34 increased in arteries and veins, but decreased in arterioles, capillaries and venules. For vWf, on the contrary, the endothelial staining intensity increased with age in all types of vessels. CLSM confirmed a mosaic staining pattern. This study demonstrates age-associated phenotypical alterations of CD34 and vWf. Whether the down-regulation of CD34 correlates with an age-associated reduction of the angiogenetic properties of EC or an age-related over-expression of vWf as a relevant cofactor for the raised coagulatory activity and the increase in thrombotic diseases resp coronary heart disease in older patients, remains subject to debate.

Chemokine RANTES in severe pulmonary arterial hypertension

The recent discovery that sporadic and familial primary pulmonary hypertension can be associated with germline mutations of genes encoding receptor members of the transforming growth factor-beta family has focused much attention on cytokines and growth factors in pulmonary vascular disorders. Production of several cytokines has been demonstrated in severe pulmonary arterial hypertension, emphasizing the possible influence of inflammatory mechanisms in this condition. Moreover, perivascular inflammatory cell infiltrates composed of macrophages and lymphocytes have been detected in plexiform lesions of primary pulmonary hypertension. Chemokine RANTES is an important chemoattractant for monocytes and T cells. We therefore hypothesize that chemokine RANTES promotes cell recruitment in the lungs of patients displaying severe pulmonary arterial hypertension. Reverse transcriptase polymerase chain reaction demonstrated elevated RANTES mRNA expression in 10 lung samples from patients with severe pulmonary arterial hypertension, as compared with seven control subjects. In situ hybridization and immunohistochemistry confirmed that endothelial cells were the major source of RANTES within the pulmonary artery wall of the patients. Serial sections analysis showed that RANTES expression was associated with CD45+ inflammatory cell infiltrates. These results support the concept that inflammatory mechanisms play a role in the natural history of pulmonary arterial hypertension.

Improvement of von Willebrand factor proteolysis after prostacyclin infusion in severe pulmonary arterial hypertension

BACKGROUND

The presence of dysfunctional von Willebrand factor (vWF) in pulmonary arterial hypertension (PAH) was suggested to be related to increased proteolysis.

METHODS AND RESULTS

In 10 patients with severe PAH, we studied the proteolysis of plasma vWF (vWF levels, multimeric distribution, proteolytic pattern, and cleaving protease activity) and hemodynamic variables (mean pulmonary artery pressure, cardiac index, and total pulmonary vascular resistance) at baseline and 30 days after initiation of continuous prostacyclin infusion. At baseline, vWF levels were significantly increased, vWF proteolysis was excessive, and vWF-cleaving protease activity remained normal. These biological abnormalities were reversible and paralleled the improvement of hemodynamics under vasodilator treatment with prostacyclin.

CONCLUSIONS

The excessive proteolysis of vWF in PAH is likely to be related to an increased susceptibility of vWF to proteases induced by high shear rates rather than to an enhanced release of enzymes.

Characterization of von Willebrand factor in primary pulmonary hypertension

The aim of this study was to determine the value of von Willebrand factor (vWF), a well-characterized endothelial cell protein secretion, as a marker for prognosis in patients with primary pulmonary hypertension (PPH). Venous and arterial blood samples were obtained from 18 clinically diagnosed PPH patients and 12 case controls matched for age and sex. Plasma vWF antigen was determined by enzyme-linked immunosorbent assay (ELISA). The patients' multimeric vWF pattern was analyzed by sodium dodecylsulfate (SDS)-agarose-acrylamide electrophoresis, Western blot, and densitometric analysis. vWF sialic acid content was determined by a lectin-based ELISA. The PPH patients showed a higher content of vWF antigen in venous (P = 0.0026) and arterial (P = 0.0094) blood samples than controls. The mean vWF sialic acid content of the PPH patients corresponded to 37.7% of the mean value for the control group. On the basis of the hemodynamic response to vasodilator trial, the PPH patients were grouped as responders or nonresponders. The latter group showed a significantly higher plasma vWF antigen antecubital vein/radial artery ratio, an increased number of unusually large vWF multimers, and a diminished content of vWF sialic acid in comparison with the first group. We believe that our results establish the nature of vWF alterations that are related to endothelial cell damage in patients with primary pulmonary hypertension and that this could be of value when establishing the prognosis in this group of patients.