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Xiong J, Peng Y, Li J, Cai S, Wu R. Total iron binding capacity: an independent predictor of prognosis for pulmonary arterial hypertension in systemic lupus erythematosus. Scand J Rheumatol 2024; 53:44-48. [PMID: 37605880 DOI: 10.1080/03009742.2023.2240586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/21/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE To investigate the role of parameters of iron metabolism in systemic lupus erythematosus (SLE) patients with pulmonary arterial hypertension (PAH). METHOD This was a prospective observational study recruiting patients diagnosed with systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH). Patients with other factors that might lead to PAH were excluded from the study. All patients were assessed for PAH every 1-3 months and were followed up for 6 months. The primary outcome was considered improved if the grade of risk stratification declined at the endpoint; otherwise, it was considered unimproved. RESULTS In total, 29 patients with SLE-PAH were included in this study. The mean of serum ferritin was higher than normal, and total iron binding capacity (TIBC) decreased in 48% of patients. Correlation analyses showed that serum iron (SI) was negatively correlated with World Health Organization functional class (WHO-FC) (r = -0.409, p = 0.028), and positively correlated with Six-Minute Walk Test distance (6MWD) (r = 0.427, p = 0.021) and tricuspid annular plane systolic excursion (TAPSE) (r = 0.388, p = 0.037). Primary outcomes improved in 12 patients at the endpoint, and univariate logistic regression analyses indicated that TIBC was associated with improved primary outcomes in patients with SLE-PAH (odds ratio 12.00, 95% confidence interval 1.90-75.72). CONCLUSION SI was negatively correlated with WHO-FC, and positively correlated with 6MWD and TAPSE. Furthermore, TIBC was associated with improved outcomes of patients with SLE-PAH, which could be an independent predictor of prognosis. Further research is needed to verify the findings.
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Affiliation(s)
- J Xiong
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Y Peng
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - J Li
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - S Cai
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - R Wu
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
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New Drugs and Therapies in Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24065850. [PMID: 36982922 PMCID: PMC10058689 DOI: 10.3390/ijms24065850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive disorder of the pulmonary vasculature with associated pulmonary and cardiac remodeling. PAH was a uniformly fatal disease until the late 1970s, but with the advent of targeted therapies, the life expectancy of patients with PAH has now considerably improved. Despite these advances, PAH inevitably remains a progressive disease with significant morbidity and mortality. Thus, there is still an unmet need for the development of new drugs and other interventional therapies for the treatment of PAH. One shortcoming of currently approved vasodilator therapies is that they do not target or reverse the underlying pathogenesis of the disease process itself. A large body of evidence has evolved in the past two decades clarifying the role of genetics, dysregulation of growth factors, inflammatory pathways, mitochondrial dysfunction, DNA damage, sex hormones, neurohormonal pathways, and iron deficiency in the pathogenesis of PAH. This review focuses on newer targets and drugs that modify these pathways as well as novel interventional therapies in PAH.
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Upton PD, Dunmore BJ, Li W, Morrell NW. An emerging class of new therapeutics targeting TGF, Activin, and BMP ligands in pulmonary arterial hypertension. Dev Dyn 2023; 252:327-342. [PMID: 35434863 PMCID: PMC10952790 DOI: 10.1002/dvdy.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/21/2022] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is an often fatal condition, the primary pathology of which involves loss of pulmonary vascular perfusion due to progressive aberrant vessel remodeling. The reduced capacity of the pulmonary circulation places increasing strain on the right ventricle of the heart, leading to death by heart failure. Currently, licensed therapies are primarily vasodilators, which have increased the median post-diagnosis life expectancy from 2.8 to 7 years. Although this represents a substantial improvement, the search continues for transformative therapeutics that reverse established disease. The genetics of human PAH heavily implicates reduced endothelial bone morphogenetic protein (BMP) signaling as a causal role for the disease pathobiology. Recent approaches have focused on directly enhancing BMP signaling or removing the inhibitory influence of pathways that repress BMP signaling. In this critical commentary, we review the evidence underpinning the development of two approaches: BMP-based agonists and inhibition of activin/GDF signaling. We also address the key considerations and questions that remain regarding these approaches.
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Affiliation(s)
- Paul D. Upton
- Department of MedicineUniversity of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth HospitalsCambridgeUK
| | - Benjamin J. Dunmore
- Department of MedicineUniversity of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth HospitalsCambridgeUK
| | - Wei Li
- Department of MedicineUniversity of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth HospitalsCambridgeUK
| | - Nicholas W. Morrell
- Department of MedicineUniversity of Cambridge School of Clinical Medicine, Addenbrooke's and Royal Papworth HospitalsCambridgeUK
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Abstract
The cardiovascular system requires iron to maintain its high energy demands and metabolic activity. Iron plays a critical role in oxygen transport and storage, mitochondrial function, and enzyme activity. However, excess iron is also cardiotoxic due to its ability to catalyze the formation of reactive oxygen species and promote oxidative damage. While mammalian cells have several redundant iron import mechanisms, they are equipped with a single iron-exporting protein, which makes the cardiovascular system particularly sensitive to iron overload. As a result, iron levels are tightly regulated at many levels to maintain homeostasis. Iron dysregulation ranges from iron deficiency to iron overload and is seen in many types of cardiovascular disease, including heart failure, myocardial infarction, anthracycline-induced cardiotoxicity, and Friedreich's ataxia. Recently, the use of intravenous iron therapy has been advocated in patients with heart failure and certain criteria for iron deficiency. Here, we provide an overview of systemic and cellular iron homeostasis in the context of cardiovascular physiology, iron deficiency, and iron overload in cardiovascular disease, current therapeutic strategies, and future perspectives.
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Affiliation(s)
- Konrad Teodor Sawicki
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Adam De Jesus
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
| | - Hossein Ardehali
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
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Cuthbertson I, Morrell NW, Caruso P. BMPR2 Mutation and Metabolic Reprogramming in Pulmonary Arterial Hypertension. Circ Res 2023; 132:109-126. [PMID: 36603064 DOI: 10.1161/circresaha.122.321554] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pulmonary arterial hypertension forms the first and most severe of the 5 categories of pulmonary hypertension. Disease pathogenesis is driven by progressive remodeling of peripheral pulmonary arteries, caused by the excessive proliferation of vascular wall cells, including endothelial cells, smooth muscle cells and fibroblasts, and perivascular inflammation. Compelling evidence from animal models suggests endothelial cell dysfunction is a key initial trigger of pulmonary vascular remodeling, which is characterised by hyperproliferation and early apoptosis followed by enrichment of apoptosis-resistant populations. Dysfunctional pulmonary arterial endothelial cells lose their ability to produce vasodilatory mediators, together leading to augmented pulmonary arterial smooth muscle cell responses, increased pulmonary vascular pressures and right ventricular afterload, and progressive right ventricular hypertrophy and heart failure. It is recognized that a range of abnormal cellular molecular signatures underpin the pathophysiology of pulmonary arterial hypertension and are enhanced by loss-of-function mutations in the BMPR2 gene, the most common genetic cause of pulmonary arterial hypertension and associated with worse disease prognosis. Widespread metabolic abnormalities are observed in the heart, pulmonary vasculature, and systemic tissues, and may underpin heterogeneity in responsivity to treatment. Metabolic abnormalities include hyperglycolytic reprogramming, mitochondrial dysfunction, aberrant polyamine and sphingosine metabolism, reduced insulin sensitivity, and defective iron handling. This review critically discusses published mechanisms linking metabolic abnormalities with dysfunctional BMPR2 (bone morphogenetic protein receptor 2) signaling; hypothesized mechanistic links requiring further validation; and their relevance to pulmonary arterial hypertension pathogenesis and the development of potential therapeutic strategies.
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Affiliation(s)
- Iona Cuthbertson
- Department of Medicine, University of Cambridge School of Clinical Medicine, Heart and Lung Research Institute, United Kingdom
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge School of Clinical Medicine, Heart and Lung Research Institute, United Kingdom
| | - Paola Caruso
- Department of Medicine, University of Cambridge School of Clinical Medicine, Heart and Lung Research Institute, United Kingdom
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Yu H, Alruwaili N, Kelly MR, Zhang B, Liu A, Wang Y, Sun D, Wolin MS. Endothelin-1 depletion of cartilage oligomeric matrix protein modulates pulmonary artery superoxide and iron metabolism-associated mitochondrial heme biosynthesis. Am J Physiol Lung Cell Mol Physiol 2022; 323:L400-L409. [PMID: 35943724 PMCID: PMC9484992 DOI: 10.1152/ajplung.00534.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/22/2022] Open
Abstract
This study examines if heme biosynthesis-associated iron metabolism is regulated in pulmonary arteries by endothelin-1 (ET1) potentially through modulating cartilage oligomeric matrix protein (COMP) availability. Our studies in organoid-cultured endothelium-rubbed bovine pulmonary arteries (BPAs) observed COMP depletion by siRNA or hypoxia increases NOX2 and superoxide and depletes mitochondrial SOD2. ET1 also increases superoxide in a manner that potentially impairs mitochondrial heme biosynthesis. In this study, organoid culture of BPA with ET1 (10 nM) increases superoxide in the mitochondrial matrix and extramitochondrial regions associated with COMP depletion, and COMP (0.5 μM) inhibited these superoxide increases. As mitochondrial matrix superoxide could impair heme biosynthesis from protoporphyrin IX (PpIX) by decreasing Fe2+ availability and/or ferrochelatase (FECH), we studied ET1, COMP, and COMP siRNA effects on the expression of FECH, transferrin receptor-1 (TfR1, an indicator of iron availability) and soluble guanylate cyclase (sGC, a key heme-dependent protein), and on measurements of PpIX (HPLC) and heme content. ET1 decreased FECH, heme, and sGC, and increased TfR1 and iron. COMP reversed these effects of ET1, and COMP decreased PpIX and increased heme in the absence of ET1. COMP siRNA increased PpIX detection and TfR1 expression and decreased the expression of FECH and sGC. Nitric oxide (spermine NONOate) relaxation of BPA was inhibited by ET1, and this was attenuated by COMP during exposure to ET1. Thus, COMP depletion by ET1 or siRNA modulates pulmonary artery iron metabolism, which results in loss of heme biosynthesis and heme-dependent cGMP mechanisms.
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Affiliation(s)
- Hang Yu
- Department of Physiology, Harbin Medical University-Daqing, Daqing, China
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Norah Alruwaili
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Melissa R Kelly
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Bin Zhang
- Department of Physiology, New York Medical College, Valhalla, New York
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Aijing Liu
- Department of Physiology, Harbin Medical University-Daqing, Daqing, China
| | - Yingqi Wang
- Department of Physiology, Harbin Medical University-Daqing, Daqing, China
| | - Dong Sun
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Michael S Wolin
- Department of Physiology, New York Medical College, Valhalla, New York
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Chang H, Zhang D, Xin Z, Zhang P, Ding W, Chang YZ. Influence of prazosin on systemic iron levels and the associated iron metabolic alterations in spontaneously hypertensive rats. Pharmacol Res Perspect 2022; 10:e00991. [PMID: 35892277 PMCID: PMC9326454 DOI: 10.1002/prp2.991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 12/23/2022] Open
Abstract
The relationship between cardiovascular diseases and iron disorders has gained increasing attention; however, the effects of hypotensive drugs on iron metabolic alterations in hypertension are not well understood. The purpose of this study was to investigate iron metabolic changes after prazosin treatment of spontaneously hypertensive rats (SHRs) and Wistar–Kyoto (WKY) rats. Our second objective was to examine the effects of hypertension and anti‐hypertensive drugs on bone formation and resorption. SHRs and WKY rats were randomized into either prazosin‐treated groups (WKY + PZ and SHR + PZ) or untreated groups (WKY and SHR). After 7 days of intragastric prazosin administration, the rats were sacrificed for analysis; blood samples and organs (the duodenum, liver, kidneys, spleen, and femur) were collected. Both WKY + PZ and SHR groups exhibited iron deficiency in the serum and liver. Prazosin increased the iron levels in the bone tissue of SHRs. Prazosin stimulated the expression of hepcidin mRNA in the liver of SHRs and inhibited the expression of this iron‐regulatory hormone in WKY rats. FPN1 expression in the duodenum was increased significantly in SHRs, however markedly decreased after prazosin treatment. The expression of TLR4 and Ctsk was enhanced in the bone tissue of SHRs, whereas CLC‐7 expression was inhibited. Both hypotension and hypertension can lead to iron deficiency. Treatment with prazosin restored iron homeostasis in SHRs. The inverse impacts of prazosin on hepatic hepcidin expression in SHRs versus WKY rats indicates differing iron regulatory mechanisms between hypertensive and normal animals. The osteoclast activity was found to be enhanced in SHRs. Further study is needed to address whether the changes in osteoblast and osteoclast activity in SHRs correlates with the effects on iron metabolism.
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Affiliation(s)
- Hengrui Chang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,College of Life Science, Hebei Normal University, Shijiazhuang, Hebei, People's Republic of China
| | - Dong Zhang
- College of Life Science, Hebei Normal University, Shijiazhuang, Hebei, People's Republic of China
| | - Zhen Xin
- College of Life Science, Hebei Normal University, Shijiazhuang, Hebei, People's Republic of China
| | - Pengfei Zhang
- College of Life Science, Hebei Normal University, Shijiazhuang, Hebei, People's Republic of China
| | - Wenyuan Ding
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Yan-Zhong Chang
- College of Life Science, Hebei Normal University, Shijiazhuang, Hebei, People's Republic of China
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8
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Neumann M, Wong KA, Lazo K, Stover D. Iron therapy as a novel treatment of scleroderma-related pulmonary hypertension: A case report and literature review. Respirol Case Rep 2022; 10:e0904. [PMID: 35079404 PMCID: PMC8767940 DOI: 10.1002/rcr2.904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 11/06/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is the leading cause of death in patients with systemic sclerosis (SSc), with a 3-year mortality of 40%-50% despite optimal therapy. Treatment mirrors that of idiopathic PAH and is often ineffective. This is a case report of a patient with SSc evaluated for progressive dyspnoea with exertion and found to have elevated pulmonary artery systolic pressures (PASPs). She received ferritin-targeted iron infusions as a novel treatment of suspected SSc-associated PAH, with subsequent resolution of respiratory symptoms and PASPs that normalized. We review PAH especially associated with SSc, its treatment and identify a possible novel therapeutic approach for those with PAH-SSc.
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Affiliation(s)
| | - Karen A. Wong
- Pulmonary ServiceMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Kevin Lazo
- Pulmonary ServiceMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Diane Stover
- Pulmonary ServiceMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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9
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Prevalence of Micronutrient Deficiencies and Relationship with Clinical and Patient-Related Outcomes in Pulmonary Hypertension Types I and IV. Nutrients 2021; 13:nu13113923. [PMID: 34836178 PMCID: PMC8617670 DOI: 10.3390/nu13113923] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 01/24/2023] Open
Abstract
Background: Pulmonary hypertension (PH) is a rare progressive and lethal disease affecting pulmonary arteries and heart function. The disease may compromise the nutritional status of the patient, which impairs their physical performance. This study aimed to determine the prevalence of micronutrient deficiencies in pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH) patients. Methods: Eighty-one blood samples from a prospective observational cohort study were analyzed for concentrations of micronutrients and inflammation-related factors. The samples consisted of newly diagnosed (treatment-naive) PAH and CTEPH patients and patients treated for 1.5 years according to ERS/ESC guidelines. Results: In the newly diagnosed group, 42% of PAH patients and 21% of CTEPH patients were iron deficient compared to 29% of PAH patients and 20% of CTEPH patients in the treatment group. Vitamin D deficiency occurred in 42% of the newly diagnosed PAH patients, 71% of the newly diagnosed CTEPH patients, 68% of the treated PAH patients, and 70% of the treated CTEPH patients. Iron levels correlated with the 6 min walking distance (6MWD). Conclusions: Iron and vitamin D deficiencies are highly prevalent in PAH and CTEPH patients, underlining the need for monitoring their status. Studies evaluating the effects of supplementation strategies for iron and vitamin D are necessary.
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Zou HX, Qiu BQ, Lai SQ, Zhou XL, Gong CW, Wang LJ, Yuan MM, He AD, Liu JC, Huang H. Iron Metabolism and Idiopathic Pulmonary Arterial Hypertension: New Insights from Bioinformatic Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5669412. [PMID: 34722766 PMCID: PMC8556088 DOI: 10.1155/2021/5669412] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/14/2021] [Accepted: 09/22/2021] [Indexed: 12/16/2022]
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is a rare vascular disease with a poor prognosis, and the mechanism of its development remains unclear. Further molecular pathology studies may contribute to a comprehensive understanding of IPAH and provide new insights into diagnostic markers and potential therapeutic targets. Iron deficiency has been reported in 43-63% of patients with IPAH and is associated with reduced exercise capacity and higher mortality, suggesting that dysregulated iron metabolism may play an unrecognized role in influencing the development of IPAH. In this study, we explored the regulatory mechanisms of iron metabolism in IPAH by bioinformatic analysis. The molecular function of iron metabolism-related genes (IMRGs) is mainly enriched in active transmembrane transporter activity, and they mainly affect the biological process of response to oxidative stress. Ferroptosis and fluid shear stress and atherosclerosis pathways may be the critical pathways regulating iron metabolism in IPAH. We further identified 7 key genes (BCL2, GCLM, MSMO1, SLC7A11, SRXN1, TSPAN5, and TXNRD1) and 5 of the key genes (BCL2, MSMO1, SLC7A11, TSPAN5, and TXNRD1) as target genes may be regulated by 6 dysregulated miRNAs (miR-483-5p, miR-27a-3p, miR-27b-3p, miR-26b-5p, miR-199a-5p, and miR-23b-3p) in IPAH. In addition, we predicted potential IPAH drugs-celastrol and cinnamaldehyde-that target iron metabolism based on our results. These results provide insights for further definition of the role of dysregulated iron metabolism in IPAH and contribute to a deeper understanding of the molecular mechanisms and potential therapeutic targets of IPAH.
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Affiliation(s)
- Hua-Xi Zou
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
- Department of Cardiothoracic Surgery, Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Bai-Quan Qiu
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
- Department of Cardiothoracic Surgery, Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Song-Qing Lai
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Xue-Liang Zhou
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Cheng-Wu Gong
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
- Department of Cardiothoracic Surgery, Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Li-Jun Wang
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
- Department of Cardiothoracic Surgery, Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Ming-Ming Yuan
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - An-Di He
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Ji-Chun Liu
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
- Department of Cardiothoracic Surgery, Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
| | - Huang Huang
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi 330006, China
- Institute of Cardiovascular Diseases, Jiangxi Academy of Clinical Medical Sciences, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
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Duarte TL, Talbot NP, Drakesmith H. NRF2 and Hypoxia-Inducible Factors: Key Players in the Redox Control of Systemic Iron Homeostasis. Antioxid Redox Signal 2021; 35:433-452. [PMID: 32791852 DOI: 10.1089/ars.2020.8148] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Significance: Oxygen metabolism and iron homeostasis are closely linked. Iron facilitates the oxygen-carrying capacity of blood, and its deficiency causes anemia. Conversely, excess free iron is detrimental for stimulating the formation of reactive oxygen species, causing tissue damage. The amount and distribution of iron thus need to be tightly regulated by the liver-expressed hormone hepcidin. This review analyzes the roles of key oxygen-sensing pathways in cellular and systemic regulation of iron homeostasis; specifically, the prolyl hydroxylase domain (PHD)/hypoxia-inducible factor (HIF) and the Kelch-like ECH-associated protein 1/NF-E2 p45-related factor 2 (KEAP1/NRF2) pathways, which mediate tissue adaptation to low and high oxygen, respectively. Recent Advances: In macrophages, NRF2 regulates genes involved in hemoglobin catabolism, iron storage, and iron export. NRF2 was recently identified as the molecular sensor of iron-induced oxidative stress and is responsible for BMP6 expression by liver sinusoidal endothelial cells, which in turn activates hepcidin synthesis by hepatocytes to restore systemic iron levels. Moreover, NRF2 orchestrates the activation of antioxidant defenses that are crucial to protect against iron toxicity. On the contrary, low iron/hypoxia stabilizes renal HIF2a via inactivation of iron-dependent PHD dioxygenases, causing an erythropoietic stimulus that represses hepcidin via an inhibitory effect of erythroferrone on bone morphogenetic proteins. Intestinal HIF2a is also stabilized, increasing the expression of genes involved in dietary iron absorption. Critical Issues: An intimate crosstalk between oxygen-sensing pathways and iron regulatory mechanisms ensures that fluctuations in systemic iron levels are promptly detected and restored. Future Directions: The realization that redox-sensitive transcription factors regulate systemic iron levels suggests novel therapeutic approaches. Antioxid. Redox Signal. 35, 433-452.
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Affiliation(s)
- Tiago L Duarte
- Instituto de Biologia Molecular e Celular, Instituto de Investigação e Inovação em Saúde (i3S), Universidade do Porto, Porto, Portugal
| | - Nick P Talbot
- Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, United Kingdom
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
- Haematology Theme, Oxford Biomedical Research Centre, Oxford, United Kingdom
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12
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Wang X, Li Y, Han L, Li J, Liu C, Sun C. Role of Flavonoids in the Treatment of Iron Overload. Front Cell Dev Biol 2021; 9:685364. [PMID: 34291050 PMCID: PMC8287860 DOI: 10.3389/fcell.2021.685364] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022] Open
Abstract
Iron overload, a high risk factor for many diseases, is seen in almost all human chronic and common diseases. Iron chelating agents are often used for treatment but, at present, most of these have a narrow scope of application, obvious side effects, and other disadvantages. Recent studies have shown that flavonoids can affect iron status, reduce iron deposition, and inhibit the lipid peroxidation process caused by iron overload. Therefore, flavonoids with iron chelating and antioxidant activities may become potential complementary therapies. In this study, we not only reviewed the research progress of iron overload and the regulation mechanism of flavonoids, but also studied the structural basis and potential mechanism of their function. In addition, the advantages and disadvantages of flavonoids as plant iron chelating agents are discussed to provide a foundation for the prevention and treatment of iron homeostasis disorders using flavonoids.
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Affiliation(s)
- Xiaomin Wang
- College of First Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ye Li
- College of First Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Li Han
- Shandong Academy of Chinese Medicine, Jinan, China
| | - Jie Li
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Cun Liu
- College of First Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Changgang Sun
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, China.,Qingdao Academy of Chinese Medical Sciences, Shandong University of Traditional Chinese Medicine, Qingdao, China
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Santer P, McGahey A, Frise MC, Petousi N, Talbot NP, Baskerville R, Bafadhel M, Nickol AH, Robbins PA. Intravenous iron and chronic obstructive pulmonary disease: a randomised controlled trial. BMJ Open Respir Res 2021; 7:7/1/e000577. [PMID: 32565444 PMCID: PMC7311010 DOI: 10.1136/bmjresp-2020-000577] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/24/2020] [Accepted: 05/29/2020] [Indexed: 12/16/2022] Open
Abstract
Background Increased iron availability modifies cardiorespiratory function in healthy volunteers and improves exercise capacity and quality of life in patients with heart failure or pulmonary hypertension. We hypothesised that intravenous iron would produce improvements in oxygenation, exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD). Methods We performed a randomised, placebo-controlled, double-blind trial in 48 participants with COPD (mean±SD: age 69±8 years, haemoglobin 144.8±13.2 g/L, ferritin 97.1±70.0 µg/L, transferrin saturation 31.3%±15.2%; GOLD grades II–IV), each of whom received a single dose of intravenous ferric carboxymaltose (FCM; 15 mg/kg bodyweight) or saline placebo. The primary endpoint was peripheral oxygen saturation (SpO2) at rest after 1 week. The secondary endpoints included daily SpO2, overnight SpO2, exercise SpO2, 6 min walk distance, symptom and quality of life scores, serum iron indices, spirometry, echocardiographic measures, and exacerbation frequency. Results SpO2 was unchanged 1 week after FCM administration (difference between groups 0.8%, 95% CI −0.2% to 1.7%). However, in secondary analyses, exercise capacity increased significantly after FCM administration, compared with placebo, with a mean difference in 6 min walk distance of 12.6 m (95% CI 1.6 to 23.5 m). Improvements of ≥40 m were observed in 29.2% of iron-treated and 0% of placebo-treated participants after 1 week (p=0.009). Modified MRC Dyspnoea Scale score was also significantly lower after FCM, and fewer participants reported scores ≥2 in the FCM group, compared with placebo (33.3% vs 66.7%, p=0.02). No significant differences were observed in other secondary endpoints. Adverse event rates were similar between groups, except for hypophosphataemia, which occurred more frequently after FCM (91.7% vs 8.3%, p<0.001). Conclusions FCM did not improve oxygenation over 8 weeks in patients with COPD. However, this treatment was well tolerated and produced improvements in exercise capacity and functional limitation caused by breathlessness. These effects on secondary endpoints require confirmation in future studies. Trial registration number ISRCTN09143837.
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Affiliation(s)
- Peter Santer
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Anne McGahey
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Nayia Petousi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nick P Talbot
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Richard Baskerville
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mona Bafadhel
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Annabel H Nickol
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Peter A Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
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14
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Impact of Nutrition on Pulmonary Arterial Hypertension. Nutrients 2020; 12:nu12010169. [PMID: 31936113 PMCID: PMC7019983 DOI: 10.3390/nu12010169] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/26/2019] [Accepted: 01/03/2020] [Indexed: 02/07/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by sustained vasoconstriction, vascular remodeling, inflammation, and in situ thrombosis. Although there have been important advances in the knowledge of the pathophysiology of PAH, it remains a debilitating, limiting, and rapidly progressive disease. Vitamin D and iron deficiency are worldwide health problems of pandemic proportions. Notably, these nutritional alterations are largely more prevalent in PAH patients than in the general population and there are several pieces of evidence suggesting that they may trigger or aggravate disease progression. There are also several case reports associating scurvy, due to severe vitamin C deficiency, with PAH. Flavonoids such as quercetin, isoflavonoids such as genistein, and other dietary polyphenols including resveratrol slow the progression of the disease in animal models of PAH. Finally, the role of the gut microbiota and its interplay with the diet, host immune system, and energy metabolism is emerging in multiple cardiovascular diseases. The alteration of the gut microbiota has also been reported in animal models of PAH. It is thus possible that in the near future interventions targeting the nutritional status and the gut dysbiosis will improve the outcome of these patients.
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15
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Hester J, Ventetuolo C, Lahm T. Sex, Gender, and Sex Hormones in Pulmonary Hypertension and Right Ventricular Failure. Compr Physiol 2019; 10:125-170. [PMID: 31853950 DOI: 10.1002/cphy.c190011] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary hypertension (PH) encompasses a syndrome of diseases that are characterized by elevated pulmonary artery pressure and pulmonary vascular remodeling and that frequently lead to right ventricular (RV) failure and death. Several types of PH exhibit sexually dimorphic features in disease penetrance, presentation, and progression. Most sexually dimorphic features in PH have been described in pulmonary arterial hypertension (PAH), a devastating and progressive pulmonary vasculopathy with a 3-year survival rate <60%. While patient registries show that women are more susceptible to development of PAH, female PAH patients display better RV function and increased survival compared to their male counterparts, a phenomenon referred to as the "estrogen paradox" or "estrogen puzzle" of PAH. Recent advances in the field have demonstrated that multiple sex hormones, receptors, and metabolites play a role in the estrogen puzzle and that the effects of hormone signaling may be time and compartment specific. While the underlying physiological mechanisms are complex, unraveling the estrogen puzzle may reveal novel therapeutic strategies to treat and reverse the effects of PAH/PH. In this article, we (i) review PH classification and pathophysiology; (ii) discuss sex/gender differences observed in patients and animal models; (iii) review sex hormone synthesis and metabolism; (iv) review in detail the scientific literature of sex hormone signaling in PAH/PH, particularly estrogen-, testosterone-, progesterone-, and dehydroepiandrosterone (DHEA)-mediated effects in the pulmonary vasculature and RV; (v) discuss hormone-independent variables contributing to sexually dimorphic disease presentation; and (vi) identify knowledge gaps and pathways forward. © 2020 American Physiological Society. Compr Physiol 10:125-170, 2020.
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Affiliation(s)
- James Hester
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Corey Ventetuolo
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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16
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Alruwaili N, Kandhi S, Sun D, Wolin MS. Metabolism and Redox in Pulmonary Vascular Physiology and Pathophysiology. Antioxid Redox Signal 2019; 31:752-769. [PMID: 30403147 PMCID: PMC6708269 DOI: 10.1089/ars.2018.7657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Significance: This review considers how some systems controlling pulmonary vascular function are potentially regulated by redox processes to examine how and why conditions such as prolonged hypoxia, pathological mediators, and other factors promoting vascular remodeling contribute to the development of pulmonary hypertension (PH). Recent Advances and Critical Issues: Aspects of vascular remodeling induction mechanisms described are associated with shifts in glucose metabolism through the pentose phosphate pathway and increased cytosolic NADPH generation by glucose-6-phosphate dehydrogenase, increased glycolysis generation of cytosolic NADH and lactate, mitochondrial dysfunction associated with superoxide dismutase-2 depletion, changes in reactive oxygen species and iron metabolism, and redox signaling. Future Directions: The regulation and impact of hypoxia-inducible factor and the function of cGMP-dependent and redox regulation of protein kinase G are considered for their potential roles as key sensors and coordinators of redox and metabolic processes controlling the progression of vascular pathophysiology in PH, and how modulating aspects of metabolic and redox regulatory systems potentially function in beneficial therapeutic approaches.
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Affiliation(s)
- Norah Alruwaili
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Sharath Kandhi
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Dong Sun
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Michael S Wolin
- Department of Physiology, New York Medical College, Valhalla, New York
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17
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Litton E, Lim J. Iron Metabolism: An Emerging Therapeutic Target in Critical Illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:81. [PMID: 30850005 PMCID: PMC6408790 DOI: 10.1186/s13054-019-2373-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia. .,School of Medicine, University of Western Australia, Perth, Australia.
| | - Jolene Lim
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
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18
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Iron Homeostasis in the Lungs-A Balance between Health and Disease. Pharmaceuticals (Basel) 2019; 12:ph12010005. [PMID: 30609678 PMCID: PMC6469191 DOI: 10.3390/ph12010005] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/23/2018] [Accepted: 12/25/2018] [Indexed: 12/15/2022] Open
Abstract
A strong mechanistic link between the regulation of iron homeostasis and oxygen sensing is evident in the lung, where both systems must be properly controlled to maintain lung function. Imbalances in pulmonary iron homeostasis are frequently associated with respiratory diseases, such as chronic obstructive pulmonary disease and with lung cancer. However, the underlying mechanisms causing alterations in iron levels and the involvement of iron in the development of lung disorders are incompletely understood. Here, we review current knowledge about the regulation of pulmonary iron homeostasis, its functional importance, and the link between dysregulated iron levels and lung diseases. Gaining greater knowledge on how iron contributes to the pathogenesis of these diseases holds promise for future iron-related therapeutic strategies.
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19
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Ramakrishnan L, Pedersen SL, Toe QK, West LE, Mumby S, Casbolt H, Issitt T, Garfield B, Lawrie A, Wort SJ, Quinlan GJ. The Hepcidin/Ferroportin axis modulates proliferation of pulmonary artery smooth muscle cells. Sci Rep 2018; 8:12972. [PMID: 30154413 PMCID: PMC6113242 DOI: 10.1038/s41598-018-31095-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 08/10/2018] [Indexed: 12/22/2022] Open
Abstract
Studies were undertaken to examine any role for the hepcidin/ferroportin axis in proliferative responses of human pulmonary artery smooth muscle cells (hPASMCs). Entirely novel findings have demonstrated the presence of ferroportin in hPASMCs. Hepcidin treatment caused increased proliferation of these cells most likely by binding ferroportin resulting in internalisation and cellular iron retention. Cellular iron content increased with hepcidin treatment. Stabilisation of ferroportin expression and activity via intervention with the therapeutic monoclonal antibody LY2928057 reversed proliferation and cellular iron accumulation. Additionally, IL-6 treatment was found to enhance proliferation and iron accumulation in hPASMCs; intervention with LY2928057 prevented this response. IL-6 was also found to increase hepcidin transcription and release from hPASMCs suggesting a potential autocrine response. Hepcidin or IL-6 mediated iron accumulation contributes to proliferation in hPASMCs; ferroportin mediated cellular iron excretion limits proliferation. Haemoglobin also caused proliferation of hPASMCs; in other novel findings, CD163, the haemoglobin/haptoglobin receptor, was found on these cells and offers a means for cellular uptake of iron via haemoglobin. Il-6 was also found to modulate CD163 on these cells. These data contribute to a better understanding of how disrupted iron homeostasis may induce vascular remodelling, such as in pulmonary arterial hypertension.
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MESH Headings
- Antibodies, Monoclonal/pharmacology
- Antigens, CD/metabolism
- Antigens, Differentiation, Myelomonocytic/metabolism
- Autocrine Communication/drug effects
- Autocrine Communication/physiology
- Cation Transport Proteins/biosynthesis
- Cell Proliferation
- Cells, Cultured
- Gene Expression Regulation/drug effects
- Gene Expression Regulation/physiology
- Hepcidins/biosynthesis
- Humans
- Interleukin-6/metabolism
- Iron/metabolism
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/metabolism
- Myocytes, Smooth Muscle/cytology
- Myocytes, Smooth Muscle/metabolism
- Pulmonary Artery/cytology
- Pulmonary Artery/metabolism
- Receptors, Cell Surface/metabolism
- Transcription, Genetic/drug effects
- Transcription, Genetic/physiology
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Affiliation(s)
- Latha Ramakrishnan
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Sofia L Pedersen
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Quezia K Toe
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Laura E West
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, S10 2RX, Sheffield, UK
| | - Sharon Mumby
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Helen Casbolt
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, S10 2RX, Sheffield, UK
| | - Theo Issitt
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Benjamin Garfield
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Allan Lawrie
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, S10 2RX, Sheffield, UK
| | - S John Wort
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK
| | - Gregory J Quinlan
- Vascular Biology Group, National Heart and Lung Institute, Imperial College London, Faculty of Medicine, Guy Scadding Building, London, SW3 6LY, UK.
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