1
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Ivy D, Rosenzweig EB, Abman SH, Beghetti M, Bonnet D, Douwes JM, Manes A, Berger RMF. Embracing the challenges of neonatal and paediatric pulmonary hypertension. Eur Respir J 2024:2401345. [PMID: 39209483 DOI: 10.1183/13993003.01345-2024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features with adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for caring for infants and children with PAH, as presented by the paediatric task force of the 7th World Symposium on Pulmonary Hypertension. We provide updates on diagnosing, classifying, risk-stratifying and treating paediatric pulmonary hypertension (PH) and identify critical knowledge gaps. An updated risk stratification tool and treatment algorithm is provided, now also including strategies for patients with associated cardiopulmonary conditions. Treatment of paediatric PH continues to be hindered by the lack of randomised controlled clinical trials. The challenging management of children failing targeted PAH therapy is discussed, including balloon atrial septostomy, lung transplantation and pulmonary-to-systemic shunt (Potts). A novel strategy using a multimodal approach for the management of PAH associated with congenital heart diseases with borderline pulmonary vascular resistance is included. Advances in diagnosing neonatal PH, especially signs and interpretation of PH by echocardiography, are highlighted. A team approach to the rapidly changing physiology of neonatal PH is emphasised. Challenges in drug approval are discussed, particularly the challenges of designing accurate paediatric clinical trials with age-appropriate end-points and adequate enrolment.
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Affiliation(s)
- Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, and Children's Hospital Colorado, Aurora, CO, USA
| | - Erika B Rosenzweig
- Department of Pediatrics, Maria Fareri Children's Hospital at WMC Health and New York Medical College of Touro University, Valhalla, NY, USA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine, and Children's Hospital Colorado, Aurora, CO, USA
| | - Maurice Beghetti
- Paediatric Cardiology Unit, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Damien Bonnet
- Centre de Référence Malformations Cardiaques Congénitales Complexes, M3C, Necker Hospital for Sick Children, Assistance Publique des Hôpitaux de Paris, Paediatric Cardiology, Paris, France
| | - Johannes Menno Douwes
- Center for Congenital Heart Diseases, Paediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alessandra Manes
- Cardiology Unit IRCCS, S. Orsola University Hospital, Bologna, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Paediatric and Congenital Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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2
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Szafranski P, Patrizi S, Gambin T, Afzal B, Schlotterbeck E, Karolak JA, Deutsch G, Roberts D, Stankiewicz P. Diminished TMEM100 Expression in a Newborn With Acinar Dysplasia and a Novel TBX4 Variant: A Case Report. Pediatr Dev Pathol 2024; 27:255-259. [PMID: 38044468 PMCID: PMC11087193 DOI: 10.1177/10935266231213464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Acinar dysplasia (AcDys) of the lung is a rare lethal developmental disorder in neonates characterized by severe respiratory failure and pulmonary arterial hypertension refractory to treatment. Recently, abnormalities of TBX4-FGF10-FGFR2-TMEM100 signaling regulating lung development have been reported in patients with AcDys due to heterozygous single-nucleotide variants or copy-number variant deletions involving TBX4, FGF10, or FGFR2. Here, we describe a female neonate who died at 4 hours of life due to severe respiratory distress related to AcDys diagnosed by postmortem histopathologic evaluation. Genomic analyses revealed a novel deleterious heterozygous missense variant c.728A>C (p.Asn243Thr) in TBX4 that arose de novo on paternal chromosome 17. We also identified 6 candidate hypomorphic rare variants in the TBX4 enhancer in trans to TBX4 coding variant. Gene expression analyses of proband's lung tissue showed a significant reduction of TMEM100 expression with near absence of TMEM100 within the endothelium of arteries and capillaries by immunohistochemistry. These results support the pathogenicity of the detected TBX4 variant and provide further evidence that disrupted signaling between TBX4 and TMEM100 may contribute to severe lung phenotypes in humans, including AcDys.
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Affiliation(s)
| | - Silvia Patrizi
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital and Newton-Wellesley Hospital, Harvard Medical School, Boston, MA
| | - Tomasz Gambin
- Institute of Computer Science, Warsaw University of Technology, Warsaw, Poland
| | - Bushra Afzal
- Division of Neonatology, Department of Pediatrics, Harvard University School of Medicine, Boston, MA
| | - Emily Schlotterbeck
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St. WRN 219, Boston, MA
| | - Justyna A. Karolak
- Chair and Department of Genetics and Pharmaceutical Microbiology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Gail Deutsch
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA
| | - Drucilla Roberts
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St. WRN 219, Boston, MA
| | - Paweł Stankiewicz
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX
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3
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Mani S, Mirza H, Ziegler J, Chandrasekharan P. Early Pulmonary Hypertension in Preterm Infants. Clin Perinatol 2024; 51:171-193. [PMID: 38325940 PMCID: PMC10850766 DOI: 10.1016/j.clp.2023.11.005] [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] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in preterm neonates has multifactorial pathogenesis with unique characteristics. Premature surfactant-deficient lungs are injured following exposure to positive pressure ventilation and high oxygen concentrations resulting in variable phenotypes of PH. The prevalence of early PH is variable and reported to be between 8% and 55% of extremely preterm infants. Disruption of the lung development and vascular signaling pathway could lead to abnormal pulmonary vascular transition. The management of early PH and the off-label use of selective pulmonary vasodilators continue to be controversial.
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Affiliation(s)
- Srinivasan Mani
- Section of Neonatology, Department of Pediatrics, The University of Toledo/ ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH 43606, USA
| | - Hussnain Mirza
- Section of Neonatology, Department of Pediatrics, Advent Health for Children/ UCF College of Medicine, Orlando, FL 32408, USA
| | - James Ziegler
- Division of Cardiovascular Diseases, Department of Pediatrics, Hasbro Children's Hospital/ Brown University, Providence, RI 02903, USA
| | - Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 32408, USA; Oishei Children's Hospital, 818 Ellicott Street, Buffalo, NY 14203, USA.
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4
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Montani D, Eichstaedt CA, Belge C, Chung WK, Gräf S, Grünig E, Humbert M, Quarck R, Tenorio-Castano JA, Soubrier F, Trembath RC, Morrell NW. [Genetic counselling and testing in pulmonary arterial hypertension - A consensus statement on behalf of the International Consortium for Genetic Studies in PAH - French version]. Rev Mal Respir 2023; 40:838-852. [PMID: 37923650 DOI: 10.1016/j.rmr.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/11/2023] [Indexed: 11/07/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease that can be caused by (likely) pathogenic germline genomic variants. In addition to the most prevalent disease gene, BMPR2 (bone morphogenetic protein receptor 2), several genes, some belonging to distinct functional classes, are also now known to predispose to the development of PAH. As a consequence, specialist and non-specialist clinicians and healthcare professionals are increasingly faced with a range of questions regarding the need for, approaches to and benefits/risks of genetic testing for PAH patients and/or related family members. We provide a consensus-based approach to recommendations for genetic counselling and assessment of current best practice for disease gene testing. We provide a framework and the type of information to be provided to patients and relatives through the process of genetic counselling, and describe the presently known disease causal genes to be analysed. Benefits of including molecular genetic testing within the management protocol of patients with PAH include the identification of individuals misclassified by other diagnostic approaches, the optimisation of phenotypic characterisation for aggregation of outcome data, including in clinical trials, and importantly through cascade screening, the detection of healthy causal variant carriers, to whom regular assessment should be offered.
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Affiliation(s)
- D Montani
- French Referral Center for Pulmonary Hypertension, Pulmonary Department, hôpital de Bicêtre, AP-HP, université Paris-Saclay, Le Kremlin-Bicêtre, France; Inserm UMR_S999, hôpital Marie-Lannelongue, Le Plessis-Robinson, France.
| | - C A Eichstaedt
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Allemagne; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Allemagne; Laboratory for Molecular Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Allemagne
| | - C Belge
- Department of Chronic Diseases & Metabolism (CHROMETA), Clinical Department of Respiratory Diseases, University Hospitals, Laboratory of Respiratory Diseases & Thoracic Surgery (BREATHE), University of Leuven, 3000 Leuven, Belgique
| | - W K Chung
- Department of Pediatrics, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, États-Unis
| | - S Gräf
- Department of Medicine, University of Cambridge, Heart and Lung Research Institute, Cambridge Biomedical Campus, Cambridge CB2 0BB, Royaume-Uni; Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0PT, Royaume-Uni; NIHR BioResource, for Translational Research - Rare Diseases, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, Royaume-Uni
| | - E Grünig
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Allemagne; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Allemagne
| | - M Humbert
- French Referral Center for Pulmonary Hypertension, Pulmonary Department, hôpital de Bicêtre, AP-HP, université Paris-Saclay, Le Kremlin-Bicêtre, France; Inserm UMR_S999, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - R Quarck
- Department of Chronic Diseases & Metabolism (CHROMETA), Clinical Department of Respiratory Diseases, University Hospitals, Laboratory of Respiratory Diseases & Thoracic Surgery (BREATHE), University of Leuven, 3000 Leuven, Belgique
| | - J A Tenorio-Castano
- INGEMM, Instituto de Genética Médica y Molecular, IdiPAZ, Hospital Universitario La Paz, Madrid, Espagne; CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Espagne; ITHACA, European Reference Network, Brussels, Belgique
| | - F Soubrier
- Département de génétique, Inserm UMR_S1166, AP-HP, hôpital Pitié-Salpêtrière, Institute for Cardio-metabolism and Nutrition (ICAN), Sorbonne université, Paris, France
| | - R C Trembath
- Department of Medical & Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, London SE1 9RT, Royaume-Uni
| | - N W Morrell
- Department of Medicine, University of Cambridge, Heart and Lung Research Institute, Cambridge Biomedical Campus, Cambridge CB2 0BB, Royaume-Uni; Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0PT, Royaume-Uni
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5
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Karolak JA, Welch CL, Mosimann C, Bzdęga K, West JD, Montani D, Eyries M, Mullen MP, Abman SH, Prapa M, Gräf S, Morrell NW, Hemnes AR, Perros F, Hamid R, Logan MPO, Whitsett J, Galambos C, Stankiewicz P, Chung WK, Austin ED. Molecular Function and Contribution of TBX4 in Development and Disease. Am J Respir Crit Care Med 2023; 207:855-864. [PMID: 36367783 PMCID: PMC10111992 DOI: 10.1164/rccm.202206-1039tr] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022] Open
Abstract
Over the past decade, recognition of the profound impact of the TBX4 (T-box 4) gene, which encodes a member of the evolutionarily conserved family of T-box-containing transcription factors, on respiratory diseases has emerged. The developmental importance of TBX4 is emphasized by the association of TBX4 variants with congenital disorders involving respiratory and skeletal structures; however, the exact role of TBX4 in human development remains incompletely understood. Here, we discuss the developmental, tissue-specific, and pathological TBX4 functions identified through human and animal studies and review the published TBX4 variants resulting in variable disease phenotypes. We also outline future research directions to fill the gaps in our understanding of TBX4 function and of how TBX4 disruption affects development.
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Affiliation(s)
- Justyna A. Karolak
- Chair and Department of Genetics and Pharmaceutical Microbiology, Poznan University of Medical Sciences, Poznan, Poland
| | | | | | - Katarzyna Bzdęga
- Chair and Department of Genetics and Pharmaceutical Microbiology, Poznan University of Medical Sciences, Poznan, Poland
| | - James D. West
- Division of Allergy, Pulmonary and Critical Care Medicine, and
| | - David Montani
- Université Paris-Saclay, Assistance Publique–Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Mélanie Eyries
- Sorbonne Université, AP-HP, Département de Génétique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Mary P. Mullen
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Matina Prapa
- St. George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Stefan Gräf
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Heart and Lung Research Institute, Cambridge, United Kingdom
| | - Nicholas W. Morrell
- Department of Medicine, School of Clinical Medicine, University of Cambridge, Heart and Lung Research Institute, Cambridge, United Kingdom
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, and
| | - Frédéric Perros
- Université Paris-Saclay, Assistance Publique–Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, DMU 5 Thorinno, Inserm UMR_S999, Le Kremlin-Bicêtre, France
| | - Rizwan Hamid
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Malcolm P. O. Logan
- Randall Centre for Cell and Molecular Biophysics, King’s College London, London, United Kingdom
| | - Jeffrey Whitsett
- Division of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Perinatal Institute, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Csaba Galambos
- Department of Pathology, University of Colorado School of Medicine, and Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Paweł Stankiewicz
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Wendy K. Chung
- Department of Pediatrics and
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Eric D. Austin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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6
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Flanagan FO, Holtz AM, Vargas SO, Genetti CA, Schmitz-Abe K, Casey A, Kennedy JC, Raby BA, Mullen MP, Fishman MP, Agrawal PB. An intronic variant in TBX4 in a single family with variable and severe pulmonary manifestations. NPJ Genom Med 2023; 8:7. [PMID: 36878902 PMCID: PMC9988848 DOI: 10.1038/s41525-023-00350-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/09/2023] [Indexed: 03/08/2023] Open
Abstract
A male infant presented at term with neonatal respiratory failure and pulmonary hypertension. His respiratory symptoms improved initially, but he exhibited a biphasic clinical course, re-presenting at 15 months of age with tachypnea, interstitial lung disease, and progressive pulmonary hypertension. We identified an intronic TBX4 gene variant in close proximity to the canonical donor splice site of exon 3 (hg 19; chr17:59543302; c.401 + 3 A > T), also carried by his father who had a typical TBX4-associated skeletal phenotype and mild pulmonary hypertension, and by his deceased sister who died shortly after birth of acinar dysplasia. Analysis of patient-derived cells demonstrated a significant reduction in TBX4 expression resulting from this intronic variant. Our study illustrates the variable expressivity in cardiopulmonary phenotype conferred by TBX4 mutation and the utility of genetic diagnostics in enabling accurate identification and classification of more subtly affected family members.
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Affiliation(s)
- Frances O Flanagan
- Division of Pulmonary Medicine, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Alexander M Holtz
- Division of Genetics & Genomics, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Sara O Vargas
- Department of Pathology, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Casie A Genetti
- Division of Genetics & Genomics, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, USA
| | - Klaus Schmitz-Abe
- Division of Genetics & Genomics, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Alicia Casey
- Division of Pulmonary Medicine, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - John C Kennedy
- Division of Pulmonary Medicine, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Benjamin A Raby
- Division of Pulmonary Medicine, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA.
| | - Martha P Fishman
- Division of Pulmonary Medicine, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pankaj B Agrawal
- Division of Genetics & Genomics, Department of Pediatrics, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA.
- Department of Pathology, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA.
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, USA.
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA.
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7
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Eichstaedt CA, Belge C, Chung WK, Gräf S, Grünig E, Montani D, Quarck R, Tenorio-Castano JA, Soubrier F, Trembath RC, Morrell NW. Genetic counselling and testing in pulmonary arterial hypertension: a consensus statement on behalf of the International Consortium for Genetic Studies in PAH. Eur Respir J 2023; 61:2201471. [PMID: 36302552 PMCID: PMC9947314 DOI: 10.1183/13993003.01471-2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease that can be caused by (likely) pathogenic germline genomic variants. In addition to the most prevalent disease gene, BMPR2 (bone morphogenetic protein receptor 2), several genes, some belonging to distinct functional classes, are also now known to predispose to the development of PAH. As a consequence, specialist and non-specialist clinicians and healthcare professionals are increasingly faced with a range of questions regarding the need for, approaches to and benefits/risks of genetic testing for PAH patients and/or related family members. We provide a consensus-based approach to recommendations for genetic counselling and assessment of current best practice for disease gene testing. We provide a framework and the type of information to be provided to patients and relatives through the process of genetic counselling, and describe the presently known disease causal genes to be analysed. Benefits of including molecular genetic testing within the management protocol of patients with PAH include the identification of individuals misclassified by other diagnostic approaches, the optimisation of phenotypic characterisation for aggregation of outcome data, including in clinical trials, and importantly through cascade screening, the detection of healthy causal variant carriers, to whom regular assessment should be offered.
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Affiliation(s)
- Christina A Eichstaedt
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Catharina Belge
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), Clinical Department of Respiratory Diseases, University Hospitals, University of Leuven, Leuven, Belgium
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Stefan Gräf
- Department of Medicine, Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
- NIHR BioResource for Translational Research - Rare Diseases, University of Cambridge, Cambridge, UK
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - David Montani
- Université Paris-Saclay, AP-HP, French Referral Center for Pulmonary Hypertension, Pulmonary Department, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Rozenn Quarck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), Clinical Department of Respiratory Diseases, University Hospitals, University of Leuven, Leuven, Belgium
| | - Jair A Tenorio-Castano
- INGEMM, Instituto de Genética Médica y Molecular, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
- CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), Madrid, Spain
- ITHACA, European Reference Network, Brussels, Belgium
| | - Florent Soubrier
- Sorbonne Université, AP-HP, Département de Génétique, INSERM UMR_S1166, Sorbonne Université, Institute for Cardiometabolism and Nutrition (ICAN), Hôpital Pitié-Salpêtrière, Paris, France
| | - Richard C Trembath
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nicholas W Morrell
- Department of Medicine, Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
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8
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Ishizuka M, Zou W, Whalen E, Ely E, Coleman RD, Lopez-Terrada DH, Penny DJ, Fan Y, Varghese NP. Hereditary pulmonary arterial hypertension burden in pediatrics: A single referral center experience. Front Pediatr 2023; 11:1050706. [PMID: 37063688 PMCID: PMC10090688 DOI: 10.3389/fped.2023.1050706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/24/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction Hereditary pulmonary arterial hypertension (HPAH) is a rare yet serious type of pulmonary arterial hypertension (PAH). The burden in the pediatric population remains high yet underreported. The objective of this study is to describe the distribution of mutations found on targeted PAH panel testing at a large pediatric referral center. Methods Children with PAH panel administered by the John Welsh Cardiovascular Diagnostic Laboratory at Texas Children's Hospital and Baylor College of Medicine in Houston, Texas between October 2012 to August 2021 were included into this study. Medical records were retrospectively reviewed for clinical correlation. Results Sixty-six children with PAH underwent PAH genetic testing. Among those, 9 (14%) children were found to have pathogenic mutations, 16 (24%) children with variant of unknown significance and 41 (62%) children with polymorphism (classified as likely benign and benign). BMPR2 mutation was the most common pathogenic mutation, seen in 6 of the 9 children with detected mutations. Hemodynamic studies showed higher pulmonary vascular resistance among those with pathogenic mutations than those without (17.4 vs. 4.6 Wood units). All children with pathogenic mutations had severe PAH requiring triple therapy. There were tendencies for higher lung transplantation rate but lower mortality among those with pathogenic mutations. Conclusions Abnormalities on genetic testing are not uncommon among children with PAH, although majority are of unclear significance. However, children with pathogenic mutations tended to present with more severe PAH requiring aggressive medical and surgical therapies. Genetic testing should be routinely considered due to consequences for treatment and prognostic implications. Larger scale population studies and registries are warranted to characterize the burden of HPAH in the pediatric population specifically.
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Affiliation(s)
- Maki Ishizuka
- Department of Pediatrics, Critical Care, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Wenxin Zou
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
- John Welsh Cardiovascular Diagnostic Laboratory, Division of Genomic Medicine, Department of Pathology, Texas Children’s Hospital, Houston, TX, United States
| | - Elise Whalen
- Department of Pediatrics, Pulmonology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Erin Ely
- Department of Pediatrics, Pulmonology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Ryan D. Coleman
- Department of Pediatrics, Critical Care, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Dolores H. Lopez-Terrada
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
- Division of Genomic Medicine, Department of Pathology, Texas Children’s Hospital, Houston, TX, United States
| | - Daniel J. Penny
- Department of Pediatrics, Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Yuxin Fan
- John Welsh Cardiovascular Diagnostic Laboratory, Division of Genomic Medicine, Department of Pathology, Texas Children’s Hospital, Houston, TX, United States
- Departments of Pathology & Immunology and Pediatrics-Cardiology, Baylor College of Medicine, Houston, TX, United States
- Correspondence: Yuxin Fan
| | - Nidhy P. Varghese
- John Welsh Cardiovascular Diagnostic Laboratory, Division of Genomic Medicine, Department of Pathology, Texas Children’s Hospital, Houston, TX, United States
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9
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Upton P, Richards S, Bates A, Niederhoffer KY, Morrell NW, Christian S. A rare homozygous missense GDF2 (BMP9) mutation causing PAH in siblings: Does BMP10 status contribute? Am J Med Genet A 2023; 191:228-233. [PMID: 36259599 PMCID: PMC10092753 DOI: 10.1002/ajmg.a.62996] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a disease characterized by pathological remodeling of the pulmonary vasculature causing elevated pulmonary artery pressures and ultimately, right ventricular failure from chronic pressure overload. Heterozygous pathogenic GDF2 (encoding bone morphogenetic protein 9 (BMP9)) variants account for some (>1%) adult PAH cases. Only three pediatric PAH cases, harboring homozygous or compound heterozygous variants, are reported to date. Ultra-rare pathogenic GDF2 variants are reported in hereditary hemorrhagic telangiectasia and overlapping disorders characterized by telangiectasias and arteriovenous malformations (AVMs). Here, we present two siblings with PAH homozygous for a GDF2 mutation that impairs BMP9 proprotein processing and reduces growth factor domain availability. We confirm an absence of measurable plasma BMP9 whereas BMP10 levels are detectable and serum-dependent endothelial BMP activity is evident. This contrasts with the absence of activity which we reported in two children with homozygous pathogenic GDF2 nonsense variants, one with PAH and one with pulmonary AVMs, both with telangiectasias, suggesting loss of BMP10 and endothelial BMP activity in the latter may precipitate telangiectasia development. An absence of phenotype in related heterozygous GDF2 variant carriers suggests incomplete penetrance in PAH and AVM-related diseases, indicating that additional somatic and/or genetic modifiers may be necessary for disease precipitation.
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Affiliation(s)
- Paul Upton
- Department of Medicine, Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Susan Richards
- Pediatric Pulmonary Hypertension Service, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Angela Bates
- Pediatric Pulmonary Hypertension Service, Stollery Children's Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Y Niederhoffer
- Department of Medical Genetics, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Nicholas W Morrell
- Department of Medicine, Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Susan Christian
- Pediatric Pulmonary Hypertension Service, Stollery Children's Hospital, Edmonton, Alberta, Canada
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10
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Prapa M, Lago-Docampo M, Swietlik EM, Montani D, Eyries M, Humbert M, Welch CL, Chung WK, Berger RMF, Bogaard HJ, Danhaive O, Escribano-Subías P, Gall H, Girerd B, Hernandez-Gonzalez I, Holden S, Hunt D, Jansen SMA, Kerstjens-Frederikse W, Kiely DG, Lapunzina P, McDermott J, Moledina S, Pepke-Zaba J, Polwarth GJ, Schotte G, Tenorio-Castaño J, Thompson AAR, Wharton J, Wort SJ, Megy K, Mapeta R, Treacy CM, Martin JM, Li W, Swift AJ, Upton PD, Morrell NW, Gräf S, Valverde D. First Genotype-Phenotype Study in TBX4 Syndrome: Gain-of-Function Mutations Causative for Lung Disease. Am J Respir Crit Care Med 2022; 206:1522-1533. [PMID: 35852389 PMCID: PMC9757087 DOI: 10.1164/rccm.202203-0485oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/18/2022] [Indexed: 02/02/2023] Open
Abstract
Rationale: Despite the increased recognition of TBX4 (T-BOX transcription factor 4)-associated pulmonary arterial hypertension (PAH), genotype-phenotype associations are lacking and may provide important insights. Objectives: To compile and functionally characterize all TBX4 variants reported to date and undertake a comprehensive genotype-phenotype analysis. Methods: We assembled a multicenter cohort of 137 patients harboring monoallelic TBX4 variants and assessed the pathogenicity of missense variation (n = 42) using a novel luciferase reporter assay containing T-BOX binding motifs. We sought genotype-phenotype correlations and undertook a comparative analysis with patients with PAH with BMPR2 (Bone Morphogenetic Protein Receptor type 2) causal variants (n = 162) or no identified variants in PAH-associated genes (n = 741) genotyped via the National Institute for Health Research BioResource-Rare Diseases. Measurements and Main Results: Functional assessment of TBX4 missense variants led to the novel finding of gain-of-function effects associated with older age at diagnosis of lung disease compared with loss-of-function effects (P = 0.038). Variants located in the T-BOX and nuclear localization domains were associated with earlier presentation (P = 0.005) and increased incidence of interstitial lung disease (P = 0.003). Event-free survival (death or transplantation) was shorter in the T-BOX group (P = 0.022), although age had a significant effect in the hazard model (P = 0.0461). Carriers of TBX4 variants were diagnosed at a younger age (P < 0.001) and had worse baseline lung function (FEV1, FVC) (P = 0.009) than the BMPR2 and no identified causal variant groups. Conclusions: We demonstrated that TBX4 syndrome is not strictly the result of haploinsufficiency but can also be caused by gain of function. The pleiotropic effects of TBX4 in lung disease may be in part explained by the differential effect of pathogenic mutations located in critical protein domains.
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Affiliation(s)
- Matina Prapa
- Department of Medicine and
- St. George’s University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Mauro Lago-Docampo
- CINBIO, Universidade de Vigo, Vigo, Spain
- Rare Diseases and Pediatric Medicine, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
| | - Emilia M. Swietlik
- Department of Medicine and
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David Montani
- Université Paris-Saclay, AP-HP, Service de Pneumologie, Centre de référence de l’hypertension pulmonaire, INSERM UMR_S 999, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Mélanie Eyries
- Département de génétique, hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, and UMR_S 1166-ICAN, INSERM, UPMC Sorbonne Universités, Paris, France
| | - Marc Humbert
- Université Paris-Saclay, AP-HP, Service de Pneumologie, Centre de référence de l’hypertension pulmonaire, INSERM UMR_S 999, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | | | - Wendy K. Chung
- Department of Pediatrics and
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Rolf M. F. Berger
- Centre for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children’s Hospital, and
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands
| | - Olivier Danhaive
- Division of Neonatology, St.-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Pilar Escribano-Subías
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, ISCIII, Madrid, Spain
| | - Henning Gall
- Centre for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children’s Hospital, and
| | - Barbara Girerd
- Université Paris-Saclay, AP-HP, Service de Pneumologie, Centre de référence de l’hypertension pulmonaire, INSERM UMR_S 999, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | | | - Simon Holden
- Department of Clinical Genetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David Hunt
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, United Kingdom
| | - Samara M. A. Jansen
- Department of Pulmonary Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands
| | | | - David G. Kiely
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Pablo Lapunzina
- Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz-UAM, Madrid, Spain
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain
- ITHACA, European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability, Brussels, Belgium
| | - John McDermott
- Manchester Centre for Genomic Medicine, St. Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, United Kingdom
| | | | - Joanna Pepke-Zaba
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Gary J. Polwarth
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Gwen Schotte
- Department of Pulmonary Medicine, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, the Netherlands
| | - Jair Tenorio-Castaño
- Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz-UAM, Madrid, Spain
- CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII, Madrid, Spain
- ITHACA, European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability, Brussels, Belgium
| | - A. A. Roger Thompson
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - John Wharton
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephen J. Wort
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Karyn Megy
- Department of Medicine and
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Rutendo Mapeta
- Department of Medicine and
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | | | | | - Wei Li
- Department of Medicine and
| | - Andrew J. Swift
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | | | - Nicholas W. Morrell
- Department of Medicine and
- Addenbrooke’s Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
- National Institute of Health Research (NIHR) BioResource for Translational Research, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Stefan Gräf
- Department of Medicine and
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
- National Institute of Health Research (NIHR) BioResource for Translational Research, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Diana Valverde
- CINBIO, Universidade de Vigo, Vigo, Spain
- Rare Diseases and Pediatric Medicine, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
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11
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Taha F, Southgate L. Molecular genetics of pulmonary hypertension in children. Curr Opin Genet Dev 2022; 75:101936. [PMID: 35772304 PMCID: PMC9763127 DOI: 10.1016/j.gde.2022.101936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/20/2022] [Accepted: 05/19/2022] [Indexed: 12/24/2022]
Abstract
Until recently, the molecular aetiology of paediatric pulmonary hypertension (PH) was relatively poorly understood. While the TGF-β/BMP pathway was recognised as central to disease progression, genetic analyses in children were largely confined to targeted screening of risk genes in small cohorts, with clinical management extrapolated from adult data. In recent years, next-generation sequencing has highlighted notable differences in the genetic architecture underlying childhood-onset cases, with a higher genetic burden in children partly explained by comorbidities such as congenital heart disease. Here, we review recent genetic advances in paediatric PH and highlight important risk factors such as dysregulation of the transcription factors SOX17 and TBX4. Given the poorer prognosis in paediatric cases, molecular diagnosis offers a vital tool to enhance clinical care of children with PH.
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Affiliation(s)
- Fatima Taha
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Laura Southgate
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
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12
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Aldred MA, Morrell NW, Guignabert C. New Mutations and Pathogenesis of Pulmonary Hypertension: Progress and Puzzles in Disease Pathogenesis. Circ Res 2022; 130:1365-1381. [PMID: 35482831 PMCID: PMC9897592 DOI: 10.1161/circresaha.122.320084] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a complex multifactorial disease with poor prognosis characterized by functional and structural alterations of the pulmonary circulation causing marked increase in pulmonary vascular resistance, ultimately leading to right heart failure and death. Mutations in the gene encoding BMPRII-a receptor for the TGF-β (transforming growth factor-beta) superfamily-account for over 70% of families with PAH and ≈20% of sporadic cases. In recent years, however, less common or rare mutations in other genes have been identified. This review will consider how these newly discovered PAH genes could help to provide a better understanding of the molecular and cellular bases of the maintenance of the pulmonary vascular integrity, as well as their role in the PAH pathogenesis underlying occlusion of arterioles in the lung. We will also discuss how insights into the genetic contributions of these new PAH-related genes may open up new therapeutic targets for this, currently incurable, cardiopulmonary disorder.
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Affiliation(s)
- Micheala A Aldred
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas W Morrell
- University of Cambridge School of Clinical Medicine, Addenbrooke's and Papworth Hospitals, Cambridge, UK
| | - Christophe Guignabert
- INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France,Université Paris-Saclay, Faculté de Médecine, 94270 Le Kremlin-Bicêtre, France
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13
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Padhye AA, Sahay S. An Adult Case of NOTCH3 Mutation in Pulmonary Artery Hypertension. Pulm Circ 2022; 12:e12050. [PMID: 35506080 PMCID: PMC9052997 DOI: 10.1002/pul2.12050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/04/2021] [Accepted: 02/07/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - Sandeep Sahay
- Houston Methodist Lung Center, Division of Pulmonary, Critical Care and Sleep Medicine, Houston Methodist Hospital Houston Texas
- Assistant Professor, Weill Cornell Medical College New York NY
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14
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Welch CL, Chung WK. Channelopathy Genes in Pulmonary Arterial Hypertension. Biomolecules 2022; 12:265. [PMID: 35204766 PMCID: PMC8961593 DOI: 10.3390/biom12020265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare, progressive vasculopathy with significant cardiopulmonary morbidity and mortality. The underlying pathogenetic mechanisms are heterogeneous and current therapies aim to decrease pulmonary vascular resistance but no curative treatments are available. Causal genetic variants can be identified in ~13% of adults and 43% of children with PAH. Knowledge of genetic diagnoses can inform clinical management of PAH, including multimodal medical treatment, surgical intervention and transplantation decisions, and screening for associated conditions, as well as risk stratification for family members. Roles for rare variants in three channelopathy genes-ABCC8, ATP13A3, and KCNK3-have been validated in multiple PAH cohorts, and in aggregate explain ~2.7% of PAH cases. Complete or partial loss of function has been demonstrated for PAH-associated variants in ABCC8 and KCNK3. Channels can be excellent targets for drugs, and knowledge of mechanisms for channel mutations may provide an opportunity for the development of PAH biomarkers and novel therapeutics for patients with hereditary PAH but also potentially more broadly for all patients with PAH.
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Affiliation(s)
- Carrie L. Welch
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Wendy K. Chung
- Department of Pediatrics, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY 10032, USA
- Department of Medicine, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY 10032, USA
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15
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Stevens L, Colglazier E, Parker C, Amin EK, Nawaytou H, Teitel D, Reddy VM, Welch CL, Chung WK, Fineman JR. Genetics dictating therapeutic decisions in pediatric pulmonary hypertension? A case report suggesting we are getting closer. Pulm Circ 2022; 12:e12033. [PMID: 35506084 PMCID: PMC9052973 DOI: 10.1002/pul2.12033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/20/2021] [Accepted: 12/26/2021] [Indexed: 12/28/2022] Open
Abstract
Despite therapeutic advances over the past decades, pulmonary arterial hypertension (PAH) and related pulmonary vascular diseases continue to cause significant morbidity and mortality in neonates, infants, and children. Unfortunately, an adequate understanding of underlying biology is lacking. There has been a growing interest in the role that genetic factors influence pulmonary vascular disease, with the hope that genetic information may aid in identifying disease etiologies, guide therapeutic decisions, and ultimately identify novel therapeutic targets. In fact, current data suggest that genetic factors contribute to ~42% of pediatric‐onset PH compared to ~12.5% of adult‐onset PAH. We report a case in which the knowledge that biallelic ATP13A3 mutations are associated with malignant progression of PAH in young childhood, led us to alter our traditional treatment plan for a 21‐month‐old PAH patient. In this case, we elected to perform a historically high‐risk Potts shunt before expected rapid deterioration. Short‐term follow‐up is encouraging, and the patient remains the only known surviving pediatric PAH patient with an associated biallelic ATP13A3 mutation in the literature. We speculate that an increased use of comprehensive genetic testing can aid in identifying the underlying pathobiology and the expected natural history, and guide treatment plans among PAH patients.
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Affiliation(s)
- Leah Stevens
- Department of Pediatrics University of California San Francisco San Francisco California USA
| | - Elizabeth Colglazier
- Department of Nursing University of California San Francisco San Francisco California USA
| | - Claire Parker
- Department of Nursing University of California San Francisco San Francisco California USA
| | - Elena K. Amin
- Department of Pediatrics University of California San Francisco San Francisco California USA
| | - Hythem Nawaytou
- Department of Pediatrics University of California San Francisco San Francisco California USA
| | - David Teitel
- Department of Pediatrics University of California San Francisco San Francisco California USA
- Cardiovascular Research Institute University of California San Francisco San Francisco California USA
| | - Vadiyala M. Reddy
- Department of Surgery University of California San Francisco San Francisco California USA
| | - Carrie L. Welch
- Department of Pediatrics and Medicine Columbia University Irving Medical Center New York New York USA
| | - Wendy K. Chung
- Department of Pediatrics and Medicine Columbia University Irving Medical Center New York New York USA
| | - Jeffrey R. Fineman
- Department of Pediatrics University of California San Francisco San Francisco California USA
- Cardiovascular Research Institute University of California San Francisco San Francisco California USA
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16
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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17
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Machado RD, Southgate L. Pulmonary Arterial Hypertension: A Deeper Evaluation of Genetic Risk in the -Omics Era. Genes (Basel) 2021; 12:genes12111798. [PMID: 34828405 PMCID: PMC8619860 DOI: 10.3390/genes12111798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rajiv D. Machado
- Institute of Medical and Biomedical Education, St George’s University of London, London SW17 0RE, UK;
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London SW17 0RE, UK
| | - Laura Southgate
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London SW17 0RE, UK
- Correspondence:
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18
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Machado RD, Welch CL, Haimel M, Bleda M, Colglazier E, Coulson JD, Debeljak M, Ekstein J, Fineman JR, Golden WC, Griffin EL, Hadinnapola C, Harris MA, Hirsch Y, Hoover-Fong JE, Nogee L, Romer LH, Vesel S, Gräf S, Morrell NW, Southgate L, Chung WK. Biallelic variants of ATP13A3 cause dose-dependent childhood-onset pulmonary arterial hypertension characterised by extreme morbidity and mortality. J Med Genet 2021; 59:906-911. [PMID: 34493544 PMCID: PMC9411922 DOI: 10.1136/jmedgenet-2021-107831] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/12/2021] [Indexed: 11/25/2022]
Abstract
Background The molecular genetic basis of pulmonary arterial hypertension (PAH) is heterogeneous, with at least 26 genes displaying putative evidence for disease causality. Heterozygous variants in the ATP13A3 gene were recently identified as a new cause of adult-onset PAH. However, the contribution of ATP13A3 risk alleles to child-onset PAH remains largely unexplored. Methods and results We report three families with a novel, autosomal recessive form of childhood-onset PAH due to biallelic ATP13A3 variants. Disease onset ranged from birth to 2.5 years and was characterised by high mortality. Using genome sequencing of parent–offspring trios, we identified a homozygous missense variant in one case, which was subsequently confirmed to cosegregate with disease in an affected sibling. Independently, compound heterozygous variants in ATP13A3 were identified in two affected siblings and in an unrelated third family. The variants included three loss of function variants (two frameshift, one nonsense) and two highly conserved missense substitutions located in the catalytic phosphorylation domain. The children were largely refractory to treatment and four died in early childhood. All parents were heterozygous for the variants and asymptomatic. Conclusion Our findings support biallelic predicted deleterious ATP13A3 variants in autosomal recessive, childhood-onset PAH, indicating likely semidominant dose-dependent inheritance for this gene.
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Affiliation(s)
- Rajiv D Machado
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Carrie L Welch
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthias Haimel
- NIHR Bioresource - Rare Diseases, University of Cambridge, Cambridge, Cambridgeshire, UK.,Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Marta Bleda
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Elizabeth Colglazier
- Department of Nursing, University of California San Francisco, San Francisco, California, USA
| | - John D Coulson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marusa Debeljak
- Clinical Institute of Special Laboratory Diagnostics, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, Institute of Cell Biology, University of Ljubljana, Ljubljana, Slovenia
| | - Josef Ekstein
- Dor Yeshorim, Committee for Prevention of Jewish Genetic Diseases, Brooklyn, New York, USA
| | - Jeffrey R Fineman
- Department of Pediatrics and Cardiovascular Research Institute, University of California San Francisco, San Francisco, California, USA
| | | | - Emily L Griffin
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Charaka Hadinnapola
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | | | - Yoel Hirsch
- Dor Yeshorim, Committee for Prevention of Jewish Genetic Diseases, Brooklyn, New York, USA
| | | | - Lawrence Nogee
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lewis H Romer
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Cell Biology, Biomedical Engineering, and the Center for Cell Dynamics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samo Vesel
- Department of Cardiology, University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia.,Department of Paediatrics, Teaching Hospital Celje, Celje, Slovenia
| | | | - Stefan Gräf
- NIHR Bioresource - Rare Diseases, University of Cambridge, Cambridge, Cambridgeshire, UK.,Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Nicholas W Morrell
- NIHR Bioresource - Rare Diseases, University of Cambridge, Cambridge, Cambridgeshire, UK.,Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Laura Southgate
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA .,Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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19
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Karolak JA, Gambin T, Szafranski P, Maywald RL, Popek E, Heaney JD, Stankiewicz P. Perturbation of semaphorin and VEGF signaling in ACDMPV lungs due to FOXF1 deficiency. Respir Res 2021; 22:212. [PMID: 34315444 PMCID: PMC8314029 DOI: 10.1186/s12931-021-01797-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/01/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV) is a rare lethal congenital lung disorder in neonates characterized by severe progressive respiratory failure and refractory pulmonary hypertension, resulting from underdevelopment of the peripheral pulmonary tree. Causative heterozygous single nucleotide variants (SNVs) or copy-number variant (CNV) deletions involving FOXF1 or its distant lung-specific enhancer on chromosome 16q24.1 have been identified in 80-90% of ACDMPV patients. FOXF1 maps closely to and regulates the oppositely oriented FENDRR, with which it also shares regulatory elements. METHODS To better understand the transcriptional networks downstream of FOXF1 that are relevant for lung organogenesis, using RNA-seq, we have examined lung transcriptomes in 12 histopathologically verified ACDMPV patients with or without pathogenic variants in the FOXF1 locus and analyzed gene expression profile in FENDRR-depleted fetal lung fibroblasts, IMR-90. RESULTS RNA-seq analyses in ACDMPV neonates revealed changes in the expression of several genes, including semaphorins (SEMAs), neuropilin 1 (NRP1), and plexins (PLXNs), essential for both epithelial branching and vascular patterning. In addition, we have found deregulation of the vascular endothelial growth factor (VEGF) signaling that also controls pulmonary vasculogenesis and a lung-specific endothelial gene TMEM100 known to be essential in vascular morphogenesis. Interestingly, we have observed a substantial difference in gene expression profiles between the ACDMPV samples with different types of FOXF1 defect. Moreover, partial overlap between transcriptome profiles of ACDMPV lungs with FOXF1 SNVs and FENDRR-depleted IMR-90 cells suggests contribution of FENDRR to ACDMPV etiology. CONCLUSIONS Our transcriptomic data imply potential crosstalk between several lung developmental pathways, including interactions between FOXF1-SHH and SEMA-NRP or VEGF/VEGFR2 signaling, and provide further insight into complexity of lung organogenesis in humans.
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Affiliation(s)
- Justyna A Karolak
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Rm ABBR-R809, Houston, TX, 77030, USA.,Chair and Department of Genetics and Pharmaceutical Microbiology, Poznan University of Medical Sciences, 60-781, Poznań, Poland
| | - Tomasz Gambin
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Rm ABBR-R809, Houston, TX, 77030, USA.,Institute of Computer Science, Warsaw University of Technology, 00-665, Warsaw, Poland
| | - Przemyslaw Szafranski
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Rm ABBR-R809, Houston, TX, 77030, USA
| | - Rebecca L Maywald
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Rm ABBR-R809, Houston, TX, 77030, USA
| | - Edwina Popek
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Jason D Heaney
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Rm ABBR-R809, Houston, TX, 77030, USA
| | - Paweł Stankiewicz
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Rm ABBR-R809, Houston, TX, 77030, USA.
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20
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Zhu N, Swietlik EM, Welch CL, Pauciulo MW, Hagen JJ, Zhou X, Guo Y, Karten J, Pandya D, Tilly T, Lutz KA, Martin JM, Treacy CM, Rosenzweig EB, Krishnan U, Coleman AW, Gonzaga-Jauregui C, Lawrie A, Trembath RC, Wilkins MR, Morrell NW, Shen Y, Gräf S, Nichols WC, Chung WK. Rare variant analysis of 4241 pulmonary arterial hypertension cases from an international consortium implicates FBLN2, PDGFD, and rare de novo variants in PAH. Genome Med 2021; 13:80. [PMID: 33971972 PMCID: PMC8112021 DOI: 10.1186/s13073-021-00891-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 04/19/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a lethal vasculopathy characterized by pathogenic remodeling of pulmonary arterioles leading to increased pulmonary pressures, right ventricular hypertrophy, and heart failure. PAH can be associated with other diseases (APAH: connective tissue diseases, congenital heart disease, and others) but often the etiology is idiopathic (IPAH). Mutations in bone morphogenetic protein receptor 2 (BMPR2) are the cause of most heritable cases but the vast majority of other cases are genetically undefined. METHODS To identify new risk genes, we utilized an international consortium of 4241 PAH cases with exome or genome sequencing data from the National Biological Sample and Data Repository for PAH, Columbia University Irving Medical Center, and the UK NIHR BioResource - Rare Diseases Study. The strength of this combined cohort is a doubling of the number of IPAH cases compared to either national cohort alone. We identified protein-coding variants and performed rare variant association analyses in unrelated participants of European ancestry, including 1647 IPAH cases and 18,819 controls. We also analyzed de novo variants in 124 pediatric trios enriched for IPAH and APAH-CHD. RESULTS Seven genes with rare deleterious variants were associated with IPAH with false discovery rate smaller than 0.1: three known genes (BMPR2, GDF2, and TBX4), two recently identified candidate genes (SOX17, KDR), and two new candidate genes (fibulin 2, FBLN2; platelet-derived growth factor D, PDGFD). The new genes were identified based solely on rare deleterious missense variants, a variant type that could not be adequately assessed in either cohort alone. The candidate genes exhibit expression patterns in lung and heart similar to that of known PAH risk genes, and most variants occur in conserved protein domains. For pediatric PAH, predicted deleterious de novo variants exhibited a significant burden compared to the background mutation rate (2.45×, p = 2.5e-5). At least eight novel pediatric candidate genes carrying de novo variants have plausible roles in lung/heart development. CONCLUSIONS Rare variant analysis of a large international consortium identified two new candidate genes-FBLN2 and PDGFD. The new genes have known functions in vasculogenesis and remodeling. Trio analysis predicted that ~ 15% of pediatric IPAH may be explained by de novo variants.
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Affiliation(s)
- Na Zhu
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA
- Department of Systems Biology, Columbia University, New York, NY, USA
| | - Emilia M Swietlik
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Carrie L Welch
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA
| | - Michael W Pauciulo
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jacob J Hagen
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA
- Department of Systems Biology, Columbia University, New York, NY, USA
| | - Xueya Zhou
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA
- Department of Systems Biology, Columbia University, New York, NY, USA
| | - Yicheng Guo
- Department of Systems Biology, Columbia University, New York, NY, USA
| | | | - Divya Pandya
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Tobias Tilly
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Katie A Lutz
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jennifer M Martin
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- NIHR BioResource for Translational Research, Cambridge Biomedical Campus, Cambridge, UK
| | - Carmen M Treacy
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Erika B Rosenzweig
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA
| | - Usha Krishnan
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA
| | - Anna W Coleman
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Richard C Trembath
- Department of Medical and Molecular Genetics, King's College London, London, UK
| | - Martin R Wilkins
- National Heart & Lung Institute, Imperial College London, London, UK
| | | | | | | | | | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- NIHR BioResource for Translational Research, Cambridge Biomedical Campus, Cambridge, UK
- Addenbrooke's Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
- Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Yufeng Shen
- Department of Systems Biology, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Stefan Gräf
- Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- NIHR BioResource for Translational Research, Cambridge Biomedical Campus, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - William C Nichols
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY, 10032, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA.
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
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