1
|
Pasupneti S, Tian W, Tu AB, Dahms P, Granucci E, Gandjeva A, Xiang M, Butcher EC, Semenza GL, Tuder RM, Jiang X, Nicolls MR. Endothelial HIF-2α as a Key Endogenous Mediator Preventing Emphysema. Am J Respir Crit Care Med 2020; 202:983-995. [PMID: 32515984 DOI: 10.1164/rccm.202001-0078oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rationale: Endothelial injury may provoke emphysema, but molecular pathways of disease development require further discernment. Emphysematous lungs exhibit decreased expression of HIF-2α (hypoxia-inducible factor-2α)-regulated genes, and tobacco smoke decreases pulmonary HIF-2α concentrations. These findings suggest that decreased HIF-2α expression is important in the development of emphysema.Objectives: The objective of this study was to evaluate the roles of endothelial-cell (EC) HIF-2α in the pathogenesis of emphysema in mice.Methods: Mouse lungs were examined for emphysema after either the loss or the overexpression of EC Hif-2α. In addition, SU5416, a VEGFR2 inhibitor, was used to induce emphysema. Lungs were evaluated for HGF (hepatocyte growth factor), a protein involved in alveolar development and homeostasis. Lungs from patients with emphysema were measured for endothelial HIF-2α expression.Measurements and Main Results: EC Hif-2α deletion resulted in emphysema in association with fewer ECs and pericytes. After SU5416 exposure, EC Hif-2α-knockout mice developed more severe emphysema, whereas EC Hif-2α-overexpressing mice were protected. EC Hif-2α-knockout mice demonstrated lower levels of HGF. Human emphysema lung samples exhibited reduced EC HIF-2α expression.Conclusions: Here, we demonstrate a unique protective role for pulmonary endothelial HIF-2α and how decreased expression of this endogenous factor causes emphysema; its pivotal protective function is suggested by its ability to overcome VEGF antagonism. HIF-2α may maintain alveolar architecture by promoting vascular survival and associated HGF production. In summary, HIF-2α may be a key endogenous factor that prevents the development of emphysema, and its upregulation has the potential to foster lung health in at-risk patients.
Collapse
Affiliation(s)
- Shravani Pasupneti
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Wen Tian
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Allen B Tu
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Petra Dahms
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Eric Granucci
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Aneta Gandjeva
- School of Medicine, University of Colorado, Colorado; and
| | - Menglan Xiang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Eugene C Butcher
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Gregg L Semenza
- Vascular Program, Institute for Cell Engineering.,Sidney Kimmel Comprehensive Cancer Center.,Department of Genetic Medicine.,Department of Pediatrics.,Department of Medicine.,Department of Oncology.,Department of Radiation Oncology, and.,Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rubin M Tuder
- School of Medicine, University of Colorado, Colorado; and
| | - Xinguo Jiang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| | - Mark R Nicolls
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,School of Medicine, Stanford University, Stanford, California
| |
Collapse
|
2
|
Jiang X, Tian W, Granucci EJ, Tu AB, Kim D, Dahms P, Pasupneti S, Peng G, Kim Y, Lim AH, Espinoza FH, Cribb M, Dixon JB, Rockson SG, Semenza GL, Nicolls MR. Decreased lymphatic HIF-2α accentuates lymphatic remodeling in lymphedema. J Clin Invest 2020; 130:5562-5575. [PMID: 32673288 PMCID: PMC7524470 DOI: 10.1172/jci136164] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/09/2020] [Indexed: 12/22/2022] Open
Abstract
Pathologic lymphatic remodeling in lymphedema evolves during periods of tissue inflammation and hypoxia through poorly defined processes. In human and mouse lymphedema, there is a significant increase of hypoxia inducible factor 1 α (HIF-1α), but a reduction of HIF-2α protein expression in lymphatic endothelial cells (LECs). We questioned whether dysregulated expression of these transcription factors contributes to disease pathogenesis and found that LEC-specific deletion of Hif2α exacerbated lymphedema pathology. Even without lymphatic vascular injury, the loss of LEC-specific Hif2α caused anatomic pathology and a functional decline in fetal and adult mice. These findings suggest that HIF-2α is an important mediator of lymphatic health. HIF-2α promoted protective phosphorylated TIE2 (p-TIE2) signaling in LECs, a process also replicated by upregulating TIE2 signaling through adenovirus-mediated angiopoietin-1 (Angpt1) gene therapy. Our study suggests that HIF-2α normally promotes healthy lymphatic homeostasis and raises the exciting possibility that restoring HIF-2α pathways in lymphedema could mitigate long-term pathology and disability.
Collapse
Affiliation(s)
- Xinguo Jiang
- 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
| | - Eric J. Granucci
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Allen B. Tu
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Dongeon Kim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Petra Dahms
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Shravani Pasupneti
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Gongyong Peng
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Yesl Kim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Amber H. Lim
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Matthew Cribb
- Georgia Institute of Technology, Atlanta, Georgia, USA
| | | | | | - Gregg L. Semenza
- Vascular Biology, Institute for Cell Engineering
- Department of Pediatrics
- Department of Medicine
- Department of Oncology
- Department of Radiation Oncology, and
- Department of Biological Chemistry, and
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark R. Nicolls
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
3
|
Jiang X, Tian W, Tu AB, Pasupneti S, Shuffle E, Dahms P, Zhang P, Cai H, Dinh TT, Liu B, Cain C, Giaccia AJ, Butcher EC, Simon MC, Semenza GL, Nicolls MR. Endothelial Hypoxia-Inducible Factor-2α Is Required for the Maintenance of Airway Microvasculature. Circulation 2019; 139:502-517. [PMID: 30586708 DOI: 10.1161/circulationaha.118.036157] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypoxia-inducible factors (HIFs), especially HIF-1α and HIF-2α, are key mediators of the adaptive response to hypoxic stress and play essential roles in maintaining lung homeostasis. Human and animal genetics studies confirm that abnormal HIF correlates with pulmonary vascular pathology and chronic lung diseases, but it remains unclear whether endothelial cell HIF production is essential for microvascular health. The large airway has an ideal circulatory bed for evaluating histological changes and physiology in genetically modified rodents. METHODS The tracheal microvasculature of mice, with conditionally deleted or overexpressed HIF-1α or HIF-2α, was evaluated for anatomy, perfusion, and permeability. Angiogenic signaling studies assessed vascular changes attributable to dysregulated HIF expression. An orthotopic tracheal transplantation model further evaluated the contribution of individual HIF isoforms in airway endothelial cells. RESULTS The genetic deletion of Hif-2α but not Hif-1α caused tracheal endothelial cell apoptosis, diminished pericyte coverage, reduced vascular perfusion, defective barrier function, overlying epithelial abnormalities, and subepithelial fibrotic remodeling. HIF-2α promoted microvascular integrity in airways through endothelial angiopoietin-1/TIE2 signaling and Notch activity. In functional tracheal transplants, HIF-2α deficiency in airway donors accelerated graft microvascular loss, whereas HIF-2α or angiopoietin-1 overexpression prolonged transplant microvascular perfusion. Augmented endothelial HIF-2α in transplant donors promoted airway microvascular integrity and diminished alloimmune inflammation. CONCLUSIONS Our findings reveal that the constitutive expression of endothelial HIF-2α is required for airway microvascular health.
Collapse
Affiliation(s)
- Xinguo Jiang
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Wen Tian
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Allen B Tu
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Shravani Pasupneti
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Eric Shuffle
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Petra Dahms
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Patrick Zhang
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Haoliang Cai
- School of Information, University of Michigan, Ann Arbor (H.C.)
| | - Thanh T Dinh
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Bo Liu
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Corey Cain
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.)
| | - Amato J Giaccia
- School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - Eugene C Butcher
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| | - M Celeste Simon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia (M.C.S.)
| | - Gregg L Semenza
- School of Medicine, Johns Hopkins University, Baltimore, MD (G.L.S.)
| | - Mark R Nicolls
- Veterans Affairs Palo Alto Health Care System, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., C.C., E.C.B., M.R.N.).,School of Medicine, Stanford University, CA (X.J., W.T., A.B.T., S.P., E.S., P.D., P.Z., T.T.D., B.L., A.J.G., E.C.B., M.R.N.)
| |
Collapse
|
4
|
Tian W, Jiang X, Sung YK, Shuffle E, Wu TH, Kao PN, Tu AB, Dorfmüller P, Cao A, Wang L, Peng G, Kim Y, Zhang P, Chappell J, Pasupneti S, Dahms P, Maguire P, Chaib H, Zamanian R, Peters-Golden M, Snyder MP, Voelkel NF, Humbert M, Rabinovitch M, Nicolls MR. Phenotypically Silent Bone Morphogenetic Protein Receptor 2 Mutations Predispose Rats to Inflammation-Induced Pulmonary Arterial Hypertension by Enhancing the Risk for Neointimal Transformation. Circulation 2019; 140:1409-1425. [PMID: 31462075 DOI: 10.1161/circulationaha.119.040629] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bmpr2 (bone morphogenetic protein receptor 2) mutations are critical risk factors for hereditary pulmonary arterial hypertension (PAH) with approximately 20% of carriers developing disease. There is an unmet medical need to understand how environmental factors, such as inflammation, render Bmpr2 mutants susceptible to PAH. Overexpressing 5-LO (5-lipoxygenase) provokes lung inflammation and transient PAH in Bmpr2+/- mice. Accordingly, 5-LO and its metabolite, leukotriene B4, are candidates for the second hit. The purpose of this study was to determine how 5-LO-mediated pulmonary inflammation synergized with phenotypically silent Bmpr2 defects to elicit significant pulmonary vascular disease in rats. METHODS Monoallelic Bmpr2 mutant rats were generated and found phenotypically normal for up to 1 year of observation. To evaluate whether a second hit would elicit disease, animals were exposed to 5-LO-expressing adenovirus, monocrotaline, SU5416, SU5416 with chronic hypoxia, or chronic hypoxia alone. Bmpr2-mutant hereditary PAH patient samples were assessed for neointimal 5-LO expression. Pulmonary artery endothelial cells with impaired BMPR2 signaling were exposed to increased 5-LO-mediated inflammation and were assessed for phenotypic and transcriptomic changes. RESULTS Lung inflammation, induced by intratracheal delivery of 5-LO-expressing adenovirus, elicited severe PAH with intimal remodeling in Bmpr2+/- rats but not in their wild-type littermates. Neointimal lesions in the diseased Bmpr2+/- rats gained endogenous 5-LO expression associated with elevated leukotriene B4 biosynthesis. Bmpr2-mutant hereditary PAH patients similarly expressed 5-LO in the neointimal cells. In vitro, BMPR2 deficiency, compounded by 5-LO-mediated inflammation, generated apoptosis-resistant and proliferative pulmonary artery endothelial cells with mesenchymal characteristics. These transformed cells expressed nuclear envelope-localized 5-LO consistent with induced leukotriene B4 production, as well as a transcriptomic signature similar to clinical disease, including upregulated nuclear factor Kappa B subunit (NF-κB), interleukin-6, and transforming growth factor beta (TGF-β) signaling pathways. The reversal of PAH and vasculopathy in Bmpr2 mutants by TGF-β antagonism suggests that TGF-β is critical for neointimal transformation. CONCLUSIONS In a new 2-hit model of disease, lung inflammation induced severe PAH pathology in Bmpr2+/- rats. Endothelial transformation required the activation of canonical and noncanonical TGF-β signaling pathways and was characterized by 5-LO nuclear envelope translocation with enhanced leukotriene B4 production. This study offers an explanation of how an environmental injury unleashes the destructive potential of an otherwise silent genetic mutation.
Collapse
Affiliation(s)
- Wen Tian
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Xinguo Jiang
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Yon K Sung
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Eric Shuffle
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Ting-Hsuan Wu
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Peter N Kao
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Allen B Tu
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Peter Dorfmüller
- Faculté de Médecine, Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France (P.D., M.H.).,Institut National de la Sante Et de la Recherche Medicale UMR_S 999, Le Plessis-Robinson, France (P.D., M.H.).,Pathology Department, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France (P.D.)
| | - Aiqin Cao
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Lingli Wang
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Gongyong Peng
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.).,State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, China (G.P.)
| | - Yesl Kim
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Patrick Zhang
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - James Chappell
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Shravani Pasupneti
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Petra Dahms
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Peter Maguire
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Hassan Chaib
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Roham Zamanian
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | | | - Michael P Snyder
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | | | - Marc Humbert
- Faculté de Médecine, Université Paris-Sud and Université Paris-Saclay, Le Kremlin-Bicêtre, France (P.D., M.H.).,Institut National de la Sante Et de la Recherche Medicale UMR_S 999, Le Plessis-Robinson, France (P.D., M.H.).,AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Department Hospitalo-Universitaire Thorax Innovation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France (M.H.)
| | - Marlene Rabinovitch
- Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| | - Mark R Nicolls
- Veterans Affairs Palo Alto Health Care System, CA (W.T, X.J., Y.K.S., E.S., A.B.T., G.P., Y.K., P.Z., S.P., P.D., M.R.N.).,Stanford University School of Medicine, CA (W.T., X.J., Y.K.S., E.S., T.H.W., P.N.K., A.B.T., A.C., L.W., G.P., Y.K., P.Z., J.C., S.P., P.D., P.M., H.C., R.Z., M.P.S., M.R., M.R.N.)
| |
Collapse
|
5
|
Tamosiuniene R, Manouvakhova O, Mesange P, Saito T, Qian J, Sanyal M, Lin YC, Nguyen LP, Luria A, Tu AB, Sante JM, Rabinovitch M, Fitzgerald DJ, Graham BB, Habtezion A, Voelkel NF, Aurelian L, Nicolls MR. Dominant Role for Regulatory T Cells in Protecting Females Against Pulmonary Hypertension. Circ Res 2018; 122:1689-1702. [PMID: 29545367 DOI: 10.1161/circresaha.117.312058] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 12/18/2022]
Abstract
RATIONALE Pulmonary arterial hypertension (PH) is a life-threatening condition associated with immune dysregulation and abnormal regulatory T cell (Treg) activity, but it is currently unknown whether and how abnormal Treg function differentially affects males and females. OBJECTIVE To evaluate whether and how Treg deficiency differentially affects male and female rats in experimental PH. METHODS AND RESULTS Male and female athymic rnu/rnu rats, lacking Tregs, were treated with the VEGFR2 (vascular endothelial growth factor receptor 2) inhibitor SU5416 or chronic hypoxia and evaluated for PH; some animals underwent Treg immune reconstitution before SU5416 administration. Plasma PGI2 (prostacyclin) levels were measured. Lung and right ventricles were assessed for the expression of the vasoprotective proteins COX-2 (cyclooxygenase 2), PTGIS (prostacyclin synthase), PDL-1 (programmed death ligand 1), and HO-1 (heme oxygenase 1). Inhibitors of these pathways were administered to athymic rats undergoing Treg immune reconstitution. Finally, human cardiac microvascular endothelial cells cocultured with Tregs were evaluated for COX-2, PDL-1, HO-1, and ER (estrogen receptor) expression, and culture supernatants were assayed for PGI2 and IL (interleukin)-10. SU5416-treatment and chronic hypoxia produced more severe PH in female than male athymic rats. Females were distinguished by greater pulmonary inflammation, augmented right ventricular fibrosis, lower plasma PGI2 levels, decreased lung COX-2, PTGIS, HO-1, and PDL-1 expression and reduced right ventricular PDL-1 levels. In both sexes, Treg immune reconstitution protected against PH development and raised levels of plasma PGI2 and cardiopulmonary COX-2, PTGIS, PDL-1, and HO-1. Inhibiting COX-2, HO-1, and PD-1 (programmed death 1)/PDL-1 pathways abrogated Treg protection. In vitro, human Tregs directly upregulated endothelial COX-2, PDL-1, HO-1, ERs and increased supernatant levels of PGI2 and IL-10. CONCLUSIONS In 2 animal models of PH based on Treg deficiency, females developed more severe PH than males. The data suggest that females are especially reliant on the normal Treg function to counteract the effects of pulmonary vascular injury leading to PH.
Collapse
Affiliation(s)
- Rasa Tamosiuniene
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Olga Manouvakhova
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Paul Mesange
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Toshie Saito
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Jin Qian
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Mrinmoy Sanyal
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Yu-Chun Lin
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Linh P Nguyen
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Amir Luria
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.).,VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Allen B Tu
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Joshua M Sante
- VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| | - Marlene Rabinovitch
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | | | - Brian B Graham
- University of Colorado Denver, School of Medicine, Department of Medicine, Aurora (B.B.G.)
| | - Aida Habtezion
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.)
| | - Norbert F Voelkel
- Virginia Commonwealth University School of Medicine, Department of Internal Medicine, Richmond (N.F.V.)
| | - Laure Aurelian
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.).,University of Maryland School of Medicine, Baltimore (L.A.)
| | - Mark R Nicolls
- From the Stanford University School of Medicine, Department of Medicine, CA (R.T., P.M., T.S., J.Q., M.S., L.P.N., A.L., M.R., A.H., L.A., M.R.N.) .,VA Palo Alto Health Care System, CA (O.M., Y.-C.L., A.L., A.B.T., J.M.S., M.R.N.)
| |
Collapse
|
6
|
Hsu JL, Manouvakhova OV, Clemons KV, Inayathullah M, Tu AB, Sobel RA, Tian A, Nazik H, Pothineni VR, Pasupneti S, Jiang X, Dhillon GS, Bedi H, Rajadas J, Haas H, Aurelian L, Stevens DA, Nicolls MR. Microhemorrhage-associated tissue iron enhances the risk for Aspergillus fumigatus invasion in a mouse model of airway transplantation. Sci Transl Med 2018; 10:10/429/eaag2616. [PMID: 29467298 PMCID: PMC5841257 DOI: 10.1126/scitranslmed.aag2616] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 02/23/2017] [Accepted: 09/26/2017] [Indexed: 01/25/2023]
Abstract
Invasive pulmonary disease due to the mold Aspergillus fumigatus can be life-threatening in lung transplant recipients, but the risk factors remain poorly understood. To study this process, we used a tracheal allograft mouse model that recapitulates large airway changes observed in patients undergoing lung transplantation. We report that microhemorrhage-related iron content may be a major determinant of A. fumigatus invasion and, consequently, its virulence. Invasive growth was increased during progressive alloimmune-mediated graft rejection associated with high concentrations of ferric iron in the graft. The role of iron in A. fumigatus invasive growth was further confirmed by showing that this invasive phenotype was increased in tracheal transplants from donor mice lacking the hemochromatosis gene (Hfe-/- ). The invasive phenotype was also increased in mouse syngrafts treated with topical iron solution and in allograft recipients receiving deferoxamine, a chelator that increases iron bioavailability to the mold. The invasive growth of the iron-intolerant A. fumigatus double-knockout mutant (ΔsreA/ΔcccA) was lower than that of the wild-type mold. Alloimmune-mediated microvascular damage and iron overload did not appear to impair the host's immune response. In human lung transplant recipients, positive staining for iron in lung transplant tissue was more commonly seen in endobronchial biopsy sections from transplanted airways than in biopsies from the patients' own airways. Collectively, these data identify iron as a major determinant of A. fumigatus invasive growth and a potential target to treat or prevent A. fumigatus infections in lung transplant patients.
Collapse
Affiliation(s)
- Joe L. Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Olga V. Manouvakhova
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Karl V. Clemons
- Infectious Diseases Research Laboratory, California Institute for Medical Research, San Jose, CA 95128, USA,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mohammed Inayathullah
- Biomaterials and Advanced Drug Delivery Laboratory, Cardiovascular Pharmacology Division, Cardio-vascular Institute, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Allen B. Tu
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Raymond A. Sobel
- Veterans Affairs Palo Alto Health Care System, Pathology and Laboratory Service, Palo Alto, CA 94304, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Amy Tian
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Hasan Nazik
- Infectious Diseases Research Laboratory, California Institute for Medical Research, San Jose, CA 95128, USA,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Medical Microbiology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Venkata R. Pothineni
- Biomaterials and Advanced Drug Delivery Laboratory, Cardiovascular Pharmacology Division, Cardio-vascular Institute, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Shravani Pasupneti
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Xinguo Jiang
- Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Harmeet Bedi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jayakumar Rajadas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Biomaterials and Advanced Drug Delivery Laboratory, Cardiovascular Pharmacology Division, Cardio-vascular Institute, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Hubertus Haas
- Division of Molecular Biology, Medical University Innsbruck, Innsbruck, Austria
| | - Laure Aurelian
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - David A. Stevens
- Infectious Diseases Research Laboratory, California Institute for Medical Research, San Jose, CA 95128, USA,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mark R. Nicolls
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Affairs Palo Alto Health Care System, Medical Service, Palo Alto, CA 94304, USA,Corresponding author.
| |
Collapse
|
7
|
Tian W, Rockson SG, Jiang X, Kim J, Begaye A, Shuffle EM, Tu AB, Cribb M, Nepiyushchikh Z, Feroze AH, Zamanian RT, Dhillon GS, Voelkel NF, Peters-Golden M, Kitajewski J, Dixon JB, Nicolls MR. Leukotriene B 4 antagonism ameliorates experimental lymphedema. Sci Transl Med 2018; 9:9/389/eaal3920. [PMID: 28490670 DOI: 10.1126/scitranslmed.aal3920] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/22/2016] [Accepted: 04/04/2017] [Indexed: 12/14/2022]
Abstract
Acquired lymphedema is a cancer sequela and a global health problem currently lacking pharmacologic therapy. We have previously demonstrated that ketoprofen, an anti-inflammatory agent with dual 5-lipoxygenase and cyclooxygenase inhibitory properties, effectively reverses histopathology in experimental lymphedema. We show that the therapeutic benefit of ketoprofen is specifically attributable to its inhibition of the 5-lipoxygenase metabolite leukotriene B4 (LTB4). LTB4 antagonism reversed edema, improved lymphatic function, and restored lymphatic architecture in the murine tail model of lymphedema. In vitro, LTB4 was functionally bimodal: Lower LTB4 concentrations promoted human lymphatic endothelial cell sprouting and growth, but higher concentrations inhibited lymphangiogenesis and induced apoptosis. During lymphedema progression, lymphatic fluid LTB4 concentrations rose from initial prolymphangiogenic concentrations into an antilymphangiogenic range. LTB4 biosynthesis was similarly elevated in lymphedema patients. Low concentrations of LTB4 stimulated, whereas high concentrations of LTB4 inhibited, vascular endothelial growth factor receptor 3 and Notch pathways in cultured human lymphatic endothelial cells. Lymphatic-specific Notch1-/- mice were refractory to the beneficial effects of LTB4 antagonism, suggesting that LTB4 suppression of Notch signaling is an important mechanism in disease maintenance. In summary, we found that LTB4 was harmful to lymphatic repair at the concentrations observed in established disease. Our findings suggest that LTB4 is a promising drug target for the treatment of acquired lymphedema.
Collapse
Affiliation(s)
- Wen Tian
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.,Stanford University School of Medicine, Stanford, CA 94305, USA
| | | | - Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.,Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jeanna Kim
- Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Adrian Begaye
- Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Eric M Shuffle
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.,Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Allen B Tu
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.,Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Matthew Cribb
- Georgia Institute of Technology, Atlanta, GA 30332, USA
| | | | | | | | | | | | | | - Jan Kitajewski
- University of Illinois at Chicago, Chicago, IL 60612, USA
| | | | - Mark R Nicolls
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA. .,Stanford University School of Medicine, Stanford, CA 94305, USA
| |
Collapse
|
8
|
Qian J, Tian W, Jiang X, Tamosiuniene R, Sung YK, Shuffle EM, Tu AB, Valenzuela A, Jiang S, Zamanian RT, Fiorentino DF, Voelkel NF, Peters-Golden M, Stenmark KR, Chung L, Rabinovitch M, Nicolls MR. Leukotriene B4 Activates Pulmonary Artery Adventitial Fibroblasts in Pulmonary Hypertension. Hypertension 2015; 66:1227-1239. [PMID: 26558820 DOI: 10.1161/hypertensionaha.115.06370] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 09/10/2015] [Indexed: 12/14/2022]
Abstract
A recent study demonstrated a significant role for leukotriene B4 (LTB4) causing pulmonary vascular remodeling in pulmonary arterial hypertension. LTB4 was found to directly injure luminal endothelial cells and promote growth of the smooth muscle cell layer of pulmonary arterioles. The purpose of this study was to determine the effects of LTB4 on the pulmonary adventitial layer, largely composed of fibroblasts. Here, we demonstrate that LTB4 enhanced human pulmonary artery adventitial fibroblast proliferation, migration, and differentiation in a dose-dependent manner through its cognate G-protein-coupled receptor, BLT1. LTB4 activated human pulmonary artery adventitial fibroblast by upregulating p38 mitogen-activated protein kinase as well as Nox4-signaling pathways. In an autoimmune model of pulmonary hypertension, inhibition of these pathways blocked perivascular inflammation, decreased Nox4 expression, reduced reactive oxygen species production, reversed arteriolar adventitial fibroblast activation, and attenuated pulmonary hypertension development. This study uncovers a novel mechanism by which LTB4 further promotes pulmonary arterial hypertension pathogenesis, beyond its established effects on endothelial and smooth muscle cells, by activating adventitial fibroblasts.
Collapse
Affiliation(s)
- Jin Qian
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | - Wen Tian
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | - Xinguo Jiang
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | - Rasa Tamosiuniene
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | - Yon K Sung
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | - Eric M Shuffle
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | - Allen B Tu
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| | | | - Shirley Jiang
- Stanford University, School of Medicine, Stanford, CA 94305
| | | | | | | | | | - Kurt R Stenmark
- University of Colorado Denver, School of Medicine, Aurora, CO 80045
| | - Lorinda Chung
- Stanford University, School of Medicine, Stanford, CA 94305
| | | | - Mark R Nicolls
- VA Palo Alto Health Care System, Palo Alto, CA 94304.,Stanford University, School of Medicine, Stanford, CA 94305
| |
Collapse
|