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Kim D, Tian W, Wu TTH, Xiang M, Vinh R, Chang JL, Gu S, Lee S, Zhu Y, Guan T, Schneider EC, Bao E, Dixon JB, Kao P, Pan J, Rockson SG, Jiang X, Nicolls MR. Abnormal Lymphatic Sphingosine-1-Phosphate Signaling Aggravates Lymphatic Dysfunction and Tissue Inflammation. Circulation 2023; 148:1231-1249. [PMID: 37609838 PMCID: PMC10592179 DOI: 10.1161/circulationaha.123.064181] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Lymphedema is a global health problem with no effective drug treatment. Enhanced T-cell immunity and abnormal lymphatic endothelial cell (LEC) signaling are promising therapeutic targets for this condition. Sphingosine-1-phosphate (S1P) mediates a key signaling pathway required for normal LEC function, and altered S1P signaling in LECs could lead to lymphatic disease and pathogenic T-cell activation. Characterizing this biology is relevant for developing much needed therapies. METHODS Human and mouse lymphedema was studied. Lymphedema was induced in mice by surgically ligating the tail lymphatics. Lymphedematous dermal tissue was assessed for S1P signaling. To verify the role of altered S1P signaling effects in lymphatic cells, LEC-specific S1pr1-deficient (S1pr1LECKO) mice were generated. Disease progression was quantified by tail-volumetric and -histopathologic measurements over time. LECs from mice and humans, with S1P signaling inhibition, were then cocultured with CD4 T cells, followed by an analysis of CD4 T-cell activation and pathway signaling. Last, animals were treated with a monoclonal antibody specific to P-selectin to assess its efficacy in reducing lymphedema and T-cell activation. RESULTS Human and experimental lymphedema tissues exhibited decreased LEC S1P signaling through S1P receptor 1 (S1PR1). LEC S1pr1 loss-of-function exacerbated lymphatic vascular insufficiency, tail swelling, and increased CD4 T-cell infiltration in mouse lymphedema. LECs, isolated from S1pr1LECKO mice and cocultured with CD4 T cells, resulted in augmented lymphocyte differentiation. Inhibiting S1PR1 signaling in human dermal LECs promoted T-helper type 1 and 2 (Th1 and Th2) cell differentiation through direct cell contact with lymphocytes. Human dermal LECs with dampened S1P signaling exhibited enhanced P-selectin, an important cell adhesion molecule expressed on activated vascular cells. In vitro, P-selectin blockade reduced the activation and differentiation of Th cells cocultured with shS1PR1-treated human dermal LECs. P-selectin-directed antibody treatment improved tail swelling and reduced Th1/Th2 immune responses in mouse lymphedema. CONCLUSIONS This study suggests that reduction of the LEC S1P signaling aggravates lymphedema by enhancing LEC adhesion and amplifying pathogenic CD4 T-cell responses. P-selectin inhibitors are suggested as a possible treatment for this pervasive condition.
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Affiliation(s)
- Dongeon Kim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Wen Tian
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Timothy Ting-Hsuan Wu
- Stanford University School of Medicine, Stanford, California, USA
- Department of Biochemistry, Stanford Bio-X, Stanford, California, USA
| | - Menglan Xiang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Ryan Vinh
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Jason Lon Chang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Shenbiao Gu
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Seunghee Lee
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Yu Zhu
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Torrey Guan
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Emilie Claire Schneider
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Evan Bao
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Peter Kao
- Stanford University School of Medicine, Stanford, California, USA
| | - Junliang Pan
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Mark Robert Nicolls
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
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Kim D, Tian W, Wu TTH, Xiang M, Vinh R, Chang J, Gu S, Lee S, Zhu Y, Guan T, Schneider EC, Bao E, Dixon JB, Kao P, Pan J, Rockson SG, Jiang X, Nicolls MR. Abnormal lymphatic S1P signaling aggravates lymphatic dysfunction and tissue inflammation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.08.23291175. [PMID: 37398237 PMCID: PMC10312855 DOI: 10.1101/2023.06.08.23291175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND Lymphedema is a global health problem with no effective drug treatment. Enhanced T cell immunity and abnormal lymphatic endothelial cell (LEC) signaling are promising therapeutic targets for this condition. Sphingosine-1-phosphate (S1P) mediates a key signaling pathway required for normal LEC function, and altered S1P signaling in LECs could lead to lymphatic disease and pathogenic T cell activation. Characterizing this biology is relevant for developing much-needed therapies. METHODS Human and mouse lymphedema was studied. Lymphedema was induced in mice by surgically ligating the tail lymphatics. Lymphedematous dermal tissue was assessed for S1P signaling. To verify the role of altered S1P signaling effects in lymphatic cells, LEC-specific S1pr1 -deficient ( S1pr1 LECKO ) mice were generated. Disease progression was quantified by tail-volumetric and -histopathological measurements over time. LECs from mice and humans, with S1P signaling inhibition, were then co-cultured with CD4 T cells, followed by an analysis of CD4 T cell activation and pathway signaling. Finally, animals were treated with a monoclonal antibody specific to P-selectin to assess its efficacy in reducing lymphedema and T cell activation. RESULTS Human and experimental lymphedema tissues exhibited decreased LEC S1P signaling through S1PR1. LEC S1pr1 loss-of-function exacerbated lymphatic vascular insufficiency, tail swelling, and increased CD4 T cell infiltration in mouse lymphedema. LECs, isolated from S1pr1 LECKO mice and co-cultured with CD4 T cells, resulted in augmented lymphocyte differentiation. Inhibiting S1PR1 signaling in human dermal LECs (HDLECs) promoted T helper type 1 and 2 (Th1 and Th2) cell differentiation through direct cell contact with lymphocytes. HDLECs with dampened S1P signaling exhibited enhanced P-selectin, an important cell adhesion molecule expressed on activated vascular cells. In vitro , P-selectin blockade reduced the activation and differentiation of Th cells co-cultured with sh S1PR1 -treated HDLECs. P-selectin-directed antibody treatment improved tail swelling and reduced Th1/Th2 immune responses in mouse lymphedema. CONCLUSION This study suggests that reduction of the LEC S1P signaling aggravates lymphedema by enhancing LEC adhesion and amplifying pathogenic CD4 T cell responses. P-selectin inhibitors are suggested as a possible treatment for this pervasive condition. Clinical Perspective What is New?: Lymphatic-specific S1pr1 deletion exacerbates lymphatic vessel malfunction and Th1/Th2 immune responses during lymphedema pathogenesis. S1pr1 -deficient LECs directly induce Th1/Th2 cell differentiation and decrease anti-inflammatory Treg populations. Peripheral dermal LECs affect CD4 T cell immune responses through direct cell contact.LEC P-selectin, regulated by S1PR1 signaling, affects CD4 T cell activation and differentiation.P-selectin blockade improves lymphedema tail swelling and decreases Th1/Th2 population in the diseased skin.What Are the Clinical Implications?: S1P/S1PR1 signaling in LECs regulates inflammation in lymphedema tissue.S1PR1 expression levels on LECs may be a useful biomarker for assessing predisposition to lymphatic disease, such as at-risk women undergoing mastectomyP-selectin Inhibitors may be effective for certain forms of lymphedema.
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Affiliation(s)
- Dongeon Kim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Wen Tian
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Timothy Ting-Hsuan Wu
- Stanford University School of Medicine, Stanford, California, USA
- Department of Biochemistry, Stanford Bio-X, Stanford, California, USA
| | - Menglan Xiang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Ryan Vinh
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Jason Chang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Shenbiao Gu
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Seunghee Lee
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Yu Zhu
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Torrey Guan
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Emilie Claire Schneider
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Evan Bao
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Peter Kao
- Stanford University School of Medicine, Stanford, California, USA
| | - Junliang Pan
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Mark Robert Nicolls
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
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Piña IL, Gibson GT, Zieroth S, Kataria R. Reflecting on the advancements of HFrEF therapies over the last two decades and predicting what is yet to come. Eur Heart J Suppl 2022; 24:L2-L9. [PMID: 36545229 PMCID: PMC9762889 DOI: 10.1093/eurheartjsupp/suac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
What was once considered a topic best avoided, managing heart failure with reduced ejection fraction (HFrEF) has become the focus of many drug and device therapies. While the four pillars of guideline-directed medical therapies have successfully reduced heart failure hospitalizations, and some have even impacted cardiovascular mortality in randomized controlled trials (RCTs), patient-reported outcomes have emerged as important endpoints that merit greater emphasis in future studies. The prospect of an oral inotrope seems more probable now as targets for drug therapies have moved from neurohormonal modulation to intracellular mechanisms and direct cardiac myosin stimulation. While we have come a long way in safely providing durable mechanical circulatory support to patients with advanced HFrEF, several percutaneous device therapies have emerged, and many are under investigation. Biomarkers have shown promise in not only improving our ability to diagnose incident heart failure but also our potential to implicate specific pathophysiological pathways. The once-forgotten concept of discordance between pressure and volume, the forgotten splanchnic venous and lymphatic compartments, have all emerged as promising targets for diagnosing and treating heart failure in the not-so-distant future. The increase in heart failure-related cardiogenic shock (CS) has revived interest in defining optimal perfusion targets and designing RCTs in CS. Rapid developments in remote monitoring, telemedicine, and artificial intelligence promise to change the face of heart failure care. In this state-of-the-art review, we reminisce about the past, highlight the present, and predict what might be the future of HFrEF therapies.
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Affiliation(s)
- Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, 4201 Henry Ave, Philadelphia, PA 19144, USA
| | - Gregory T Gibson
- Division of Cardiology, Thomas Jefferson University, 4201 Henry Ave, Philadelphia, PA 19144, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB R3E 0W2, Canada
| | - Rachna Kataria
- Corresponding author. Tel: +1 (401)4445803, Fax: +1 (401)7937200,
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Houck P, Dandapantula H, Wilkinson D. Cost to Save a Life in Heart Failure: Health Disparity Costs Lives. Cureus 2020; 12:e10081. [PMID: 32999794 PMCID: PMC7522045 DOI: 10.7759/cureus.10081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this paper is to assign a dollar value to life-saving medication, surgical procedures, and medical devices. The knowledge of the wide variation in the cost of drugs, surgery, and devices allows providers and patients to choose higher-valued therapies. Cost is a significant barrier to health. The current reimbursement system is complicated, representing a significant barrier to saving lives by promoting health disparity. Background The cost analysis of heart failure therapies is an important tool in the education of physicians, patients, and vendors of the intervention. The analysis demonstrates disparities between heart failure therapies. The cost to save a single life is calculated from annualized absolute mortality risk reduction, trial length, and estimated 10-year costs. The method allows comparisons of drugs, devices, and surgery. Methods The 10-year cost of drugs is 120 months times the cost of a drug/month as listed by the website GoodRX.com. The 10-year cost of surgery or device therapy was determined from a cost analysis found by a Google search of the literature. When wide ranges were reported, the mean value was selected. 1/absolute mortality risk reduction X 100 is the number needed to treat to save a life annualized for the mean length of the study. The cost to save a life can then be computed by the following formula: Cost/life saved = (10-year cost/annualized absolute mortality risk reduction) X (100) Results Beta-blockers and spironolactone had the lowest cost per life saved at $13,333 and $21,818, respectively. Defibrillators are the most expensive at $6,417,856. Valsartan/sacubitril has a cost of $1,127,733. Dapagliflozin, the newest class of heart failure drug, costs $4,853,200. Conclusions Calculating the cost to save a life gives insight into the value of therapies and demonstrates disparities. It is a means of comparing drugs and devices. New drug therapies are costly, not affordable, and serve as a barrier to the successful treatment of heart failure.
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Affiliation(s)
- Philip Houck
- Medicine/Cardiology, Texas A&M Health Sciences Center, Temple, USA.,Medicine/Cardiology, Baylor Scott & White Health, Temple, USA
| | - Hari Dandapantula
- Medicine/Cardiology, Texas A&M Health Sciences Center, Temple, USA.,Medicine/Cardiology, Baylor Scott & White Health, Temple, USA
| | - Donna Wilkinson
- Cardiology/Nursing, Baylor Scott & White Health, Temple, USA
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