Clinical Translational Research Program in Pulmonary Arterial Hypertension (PAH): Disease Mechanisms, Biomarkers, and Novel Therapeutic Targets

肺动脉高压 (PAH) 临床转化研究项目：疾病机制、生物标志物和新治疗靶点

• 批准号: 10915306
• 负责人: Michael Solomon
• 金额: --
• 依托单位: CLINICAL CENTER
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10915306
• 关键词: Activities of Daily Living; Adult; Age; Algorithms; American; Angiography; Antiinflammatory Effect; Apoptotic; Autoimmune Diseases; Biological; Biological Markers; Blood; Blood Vessels; Blood specimen; Bone Marrow; Breast; Cardiac; Cardiac Catheterization Procedures; Cells; Cessation of life; Chest; Chronic; Circulation; Clinical; Clinical Data; Coagulation Process; Collaborations; Control Groups; Coronary Arteriosclerosis; Coronary artery; Creatinine; DNA Methylation; Data; Data Analyses; Diagnosis; Diagnostic; Disease; Disease Marker; Disease Progression; Double-Blind Method; Echocardiography; Endothelial Cells; Endothelium; Enrollment; Epigenetic Process; Evolution; Expression Profiling; Fibrinolysis; Fibrosis; Flow Cytometry; Functional disorder; Future; Gender; Gene Expression; General Hospitals; Generations; Genes; Genetic; Goals; Gynecomastia; HIV Infections; Heart failure; Hematology; Hematopoietic stem cells; Histopathology; Hospitalization; Hypoxemia; Imaging Techniques; Incidence; Individual; Inflammation; Inflammation Mediators; Injury; International; Intervention Trial; Kidney Failure; Kinetics; Laboratories; Left; Liver diseases; Lung; Lung diseases; Magnetic Resonance Imaging; Manuscripts; Measurement; Measures; Medical; Medical center; Meta-Analysis; Metabolic; Methodology; Mineralocorticoid Receptor; Mixed Connective Tissue Disease; National Heart, Lung, and Blood Institute; Natural History; New York Heart Association Class III/IV; Outcome; Oxygen Consumption; Pain; Pathogenesis; Patients; Peripheral Blood Mononuclear Cell; Pharmaceutical Preparations; Phase; Phenotype; Pilot Projects; Placebo Control; Placebos; Plasma; Plasma Cells; Population; Portal Hypertension; Potassium; Process; Protocols documentation; Publishing; Pulmonary Hypertension; Pulmonary artery structure; Pulmonary veins; RNA; Randomized; Reporting; Resolution; Right Ventricular Function; Right ventricular strain; Risk Factors; Safety; Sampling; Series; Serum; Severity of illness; Side; Societies; Source; Spironolactone; Surrogate Markers; Symptoms; Systemic Lupus Erythematosus; Systemic Scleroderma; T-Lymphocyte; Testing; Thrombelastography; Thrombosis; Time; Tissues; Transplantation; Treatment Efficacy; United States National Institutes of Health; VO2max; Validation; Vascular remodeling; Ventricular; Walking; X-Ray Computed Tomography; antagonist; biomarker identification; bisulfite sequencing; cell free DNA; circulating biomarkers; clinical center; clinical predictors; clinical translation; clinically relevant; cohort; comparison control; congenital heart disorder; differential expression; disease prognosis; endothelial dysfunction; exercise capacity; follow up assessment; functional disability; genetic signature; genome-wide; healthy volunteer; heart imaging; hemodynamics; hyperkalemia; improved; injury and repair; innovation; interest; lung pressure; lung vascular injury; material transfer agreement; mortality; new therapeutic target; novel; novel marker; novel therapeutics; open data; patient oriented; peripheral blood; primary endpoint; primary pulmonary hypertension; pro-brain natriuretic peptide (1-76); prognostic value; programs; pulmonary arterial hypertension; pulmonary vascular remodeling; research clinical testing; right ventricular failure; risk prediction; risk stratification; secondary endpoint; side effect; stem cells; study population; symposium; systemic inflammatory response; therapeutic target; tissue mapping; transcriptomics; translational research program; treatment group; treatment response; trend; vascular inflammation

Pulmonary hypertension (PH) due to direct pulmonary vascular injury is collectively referred to as pulmonary arterial hypertension (PAH), & is distinct from other causes of PH such as left sided heart failure, parenchymal lung disease with hypoxemia & chronic thromboembolic disease. Idiopathic PAH (IPAH) is an unexplained form of PAH where the triggering insult to the endothelium is unclear. Several diseases may manifest PAH that is identical in histopathology to IPAH. Diseases resulting in PAH (referred to as disease-associated PAH) include autoimmune disorders (i.e. limited systemic sclerosis, mixed connective tissue disease, & systemic lupus erythematosus), HIV infection, congenital heart disease, & liver disease with portal hypertension. Contemporary paradigms of PAH pathobiology include endothelial damage and disruption, genetic & epigenetic contributions, metabolic derangements with a hyper-proliferative, anti-apoptotic cellular phenotype, & both systemically & locally dysregulated inflammation. In the absence of PAH-specific surrogate markers for assessing disease severity & prognosis, risk prediction continues to rely on subjective functional assessments & invasive hemodynamic measurements. There is continued interest in the discovery of novel, biologically relevant, non-invasive biomarkers that may simplify PAH risk stratification & serve as markers of ongoing disease progression &, ideally, response to therapy. In PAH, inflammation appears to drive the dysfunctional endothelial phenotype, propagating cycles of injury & repair. However, detailed phenotypic studies are lacking on the temporal evolution of this process & its contribution to RV & pulmonary vascular remodeling. At the NIH Clinical Center patients with WHO group 1 PAH are being enrolled in a natural history study (13-CC-0012) assessing patients at baseline, biannually in the 1st year and then annually to: 1) Characterize the contribution of inflammation to disease progression & long-term outcomes in PAH & 2) Identify non-invasive markers of vascular inflammation that add prognostic value to traditional measures of disease severity & suggest novel therapeutic targets for future research. In addition, to standard clinical testing, patients undergo serial assessments using innovative imaging techniques, flow cytometric analyses of circulating endothelial cells & bone marrow progenitor cells, genome-wide blood transcriptomic profiles and novel biomarkers such as plasma cfDNA. The collective data will be used to investigate the ability of blood markers of vascular inflammation and/or high-resolution cardiac CT & MRI to stage disease severity & predict clinically relevant outcomes. The study has enrolled 89 individuals (66 patients / 23 healthy volunteers). Total study population will be 150 adult PAH subjects & 50 age & gender matched controls (i.e. healthy volunteer matched to 3 PAH patients). Inflammation is recognized as a feature of the abnormal pulmonary arteries in PAH patients, & it has been hypothesized, but remains unknown as to whether drugs that block inflammation could be beneficial in patients with PAH. Mineralocorticoid receptor (MR) antagonists, like spironolactone, have been widely used in patients with left sided heart failure or LV dysfunction post-MI. Evidence suggests spironolactone improves endothelial function & reduces inflammation. Patients with WHO group 1 PAH are being enrolled in the Spironolactone Interventional Trial (SPIRIT-PAH, 12-CC-0211); a phase 1-2 randomized, double blinded, placebo-controlled 6-month study of spironolactone treatment in PAH. The trial examines the safety & tolerability of spironolactone & its efficacy as assessed by effects on exercise capacity & clinical worsening. We seek to determine if spironolactone provides benefits in PAH through anti-inflammatory effects & improvements in endothelial function. The study has enrolled 40 individuals & per statistical assessment plan targets at least 50. Our original PAH protocol (05-CC-0041: n = 31) assessed whether CECs and/or PBMC may serve as PAH biomarkers. The project used flow cytometry to develop a methodology for isolating relevant numbers of viable CECs from healthy & PAH subjects. CECs & PBMCs were obtained from peripheral blood (PB) specimens. A subset of subjects had a right heart catheterization to assess pulmonary pressures and obtain pulmonary blood specimens. Available data suggested no trend towards CEC enrichment in pulmonary vein blood compared to PB for healthy (4.4 vs 4.8 CEC/ml) & PAH (2.4 vs 3.0 CEC/ml) subjects. There was a trend towards CEC enrichment in pulmonary artery blood compared to PB for healthy (13.8 vs 4.8 CEC/ml) & PAH (3.3 vs 3.0 CEC/ml) subjects. We published a manuscript (Am J Physiol Lung Cell Mol Physiol, 318(1): L98-L111, 2019) containing our PBMC data as part of a larger meta-analysis. The meta-analysis defined a robust & generalizable transcriptomic signature in the blood of PAH patients that can help inform the identification of biomarkers & therapeutic targets. This protocol (1 of 3) is closed to enrollment & open for data analysis. Remaining bio-specimens include RNA, plasma, serum, circulating endothelial cells & T-Cells. We are further evaluating systemic inflammation in PAH by using CT to assess Coronary Artery Plaque Burden in Patients with PAH. Preliminary data was presented at the American Thoracic Society (ATS) International Conference (AJRCCM, 199:A6795, 2019). Compared to controls (n = 7) matched for traditional risk factors of coronary artery disease, PAH subjects (n = 7) tended to have a higher burden of coronary artery plaque as determined by CT angiography. These findings & their relevance to symptoms & functional capacity, need to be further investigated in a larger PAH cohort which we are accumulating. We also investigated whether or not PAH Patients display normal kinetics of clot Formation. Preliminary data was presented at the AHA Scientific Sessions (Circulation, 140:A10714, 2019) & the complete analysis subsequently published (Pulm Circ, 11(3):1-9, 2021). PAH patients on stable medical therapy did not demonstrate abnormal clotting kinetics or fibrinolysis by thrombelastography (TEG). Additionally, these patients did not demonstrate abnormal levels of hematologic markers associated with thrombosis & fibrosis. In addition, we investigated whether or not HSCs, CPCs & CECs are altered in PAH patients compared to healthy controls. Preliminary data was presented at the ATS International Conf (AJRCCM, 207:A3790, 2023). Analysis revealed an increased number of CECs in PAH patients thereby supporting the pathobiological paradigm of endothelial injury. In collaboration with the NHLBI Laboratory of Applied Precision Omics (APO) we are investigating Plasma Cell-free DNA (cfDNA) as a novel marker of disease severity in PAH. Preliminary data was submitted to the ACC 68th Annual Scientific Session (J Am Coll Cardiol, 73(9, S1): S1897, 2019). Based on the encouraging preliminary results, we entered into an MTA with PAH programs at Allegheny General Hospital & Tufts Medical Center, receiving 48 plasma samples from Allegheny (exploratory cohort) & 161 samples from tufts (validation cohort) along with clinical data. We not only measured cfDNA levels in patients & healthy volunteers (n=48), but also subjected a subset of the samples to bisulfite sequencing and a deconvolution algorithm to map tissue-specific sources of cfDNA. The complete analysis published during this reporting period (Circulation, 146(14):1033-1045, 2022) revealed that in patients with PAH, circulating cfDNA is elevated, correlates with disease severity & predicts worse survival. cfDNA methylation analyses in patients with PAH are consistent with prevailing paradigms of disease pathogenesis, thus providing biologic plausibility for cfDNA as a PAH bio

由直接肺血管损伤引起的肺动脉高压（PH）统称为肺动脉高压（PAH），与其他引起肺动脉高压的原因不同，如左心衰竭、伴有低氧血症的肺实质疾病和慢性血栓栓塞性疾病。特发性多环芳烃 (IPAH) 是一种无法解释的多环芳烃，其触发内皮细胞的损伤尚不清楚。多种疾病可能表现为 PAH，其组织病理学与 IPAH 相同。导致PAH的疾病（称为疾病相关PAH）包括自身免疫性疾病（即局限性系统性硬化症、混合性结缔组织病和系统性红斑狼疮）、HIV感染、先天性心脏病和伴有门脉高压的肝病。 PAH 病理学的当代范式包括内皮损伤和破坏、遗传和表观遗传贡献、具有过度增殖、抗凋亡细胞表型的代谢紊乱，以及全身和局部炎症失调。 在缺乏用于评估疾病严重程度和预后的 PAH 特异性替代标志物的情况下，风险预测仍然依赖于主观功能评估和侵入性血流动力学测量。人们对发现新颖的、生物学相关的、非侵入性的生物标志物一直感兴趣，这些标志物可以简化 PAH 风险分层并作为正在进行的疾病进展的标志物以及理想情况下对治疗的反应。 在 PAH 中，炎症似乎会导致内皮表型功能失调，从而促进损伤和修复的循环。然而，关于这一过程的时间演变及其对 RV 和肺血管重塑的贡献，缺乏详细的表型研究。在 NIH 临床中心，患有 WHO 1 类 PAH 的患者正在参加一项自然史研究 (13-CC-0012)，该研究对患者进行基线评估，第一年每两年一次，然后每年一次，以：1) 描述炎症对疾病的影响PAH 的进展和长期结果；2) 识别血管炎症的非侵入性标志物，为疾病严重程度的传统测量增加预后价值，并为未来研究提出新的治疗目标。此外，除了标准临床测试外，患者还使用创新成像技术、循环内皮细胞和骨髓祖细胞的流式细胞术分析、全基因组血液转录组谱和血浆 cfDNA 等新型生物标志物进行系列评估。收集的数据将用于研究血管炎症血液标记物和/或高分辨率心脏 CT 和 MRI 来分期疾病严重程度并预测临床相关结果的能力。该研究招募了 89 名个体（66 名患者/23 名健康志愿者）。总研究人群为 150 名成年 PAH 受试者和 50 名年龄和性别匹配的对照组（即健康志愿者与 3 名 PAH 患者匹配）。 炎症被认为是 PAH 患者肺动脉异常的一个特征，并且已经有假设，但阻止炎症的药物是否对 PAH 患者有益仍不清楚。盐皮质激素受体 (MR) 拮抗剂（如螺内酯）已广泛用于治疗心肌梗死后左心衰竭或左心室功能障碍的患者。有证据表明螺内酯可改善内皮功能并减少炎症。 WHO 1 组 PAH 患者正在参加螺内酯介入试验（SPIRIT-PAH，12-CC-0211）；螺内酯治疗 PAH 的 1-2 期随机、双盲、安慰剂对照 6 个月研究。该试验检查了螺内酯的安全性和耐受性，以及通过对运动能力和临床恶化的影响来评估其疗效。我们试图确定螺内酯是否通过抗炎作用和改善内皮功能来治疗 PAH。该研究已招募 40 人，每个统计评估计划的目标至少为 50 人。 我们最初的 PAH 方案（05-CC-0041：n = 31）评估了 CEC 和/或 PBMC 是否可以作为 PAH 生物标志物。该项目使用流式细胞术开发了一种从健康受试者和 PAH 受试者中分离相关数量的活 CEC 的方法。 CEC 和 PBMC 是从外周血 (PB) 样本中获得的。一部分受试者进行了右心导管插入术，以评估肺压并获取肺血样本。现有数据表明，与健康受试者（4.4 vs 4.8 CEC/ml）和 PAH（2.4 vs 3.0 CEC/ml）受试者相比，肺静脉血中 CEC 没有富集趋势。健康受试者（13.8 vs 4.8 CEC/ml）和 PAH（3.3 vs 3.0 CEC/ml）受试者的肺动脉血液中存在 CEC 富集的趋势。我们发表了一份手稿（Am J Physiol Lung Cell Mol Physiol, 318(1): L98-L111, 2019），其中包含我们的 PBMC 数据，作为更大规模荟萃分析的一部分。该荟萃分析定义了 PAH 患者血液中强大且可概括的转录组特征，有助于识别生物标志物和治疗靶点。该协议（3 中的 1）已关闭注册并开放用于数据分析。剩余的生物样本包括 RNA、血浆、血清、循环内皮细胞和 T 细胞。 我们正在通过使用 CT 评估 PAH 患者的冠状动脉斑块负担来进一步评估 PAH 的全身炎症。初步数据已在美国胸科学会 (ATS) 国际会议 (AJRCCM, 199:A6795, 2019) 上公布。与传统冠状动脉疾病危险因素相匹配的对照组 (n = 7) 相比，根据 CT 血管造影确定，​​PAH 受试者 (n = 7) 往往具有更高的冠状动脉斑块负担。这些发现及其与症状和功能能力的相关性需要在我们正在积累的更大的 PAH 队列中进一步研究。 我们还研究了 PAH 患者是否表现出正常的血块形成动力学。初步数据在 AHA 科学会议上发布（Circulation，140：A10714，2019），完整分析随后发布（Pulm Circ，11（3）：1-9，2021）。接受稳定药物治疗的 PAH 患者并未通过血栓弹力图 (TEG) 表现出异常的凝血动力学或纤维蛋白溶解。此外，这些患者没有表现出与血栓形成和纤维化相关的血液学标志物水平异常。 此外，我们还研究了与健康对照相比，PAH 患者的 HSC、CPC 和 CEC 是否发生改变。初步数据已在 ATS 国际会议 (AJRCCM, 207:A3790, 2023) 上公布。分析显示 PAH 患者中 CEC 数量增加，从而支持内皮损伤的病理生物学范式。 我们与 NHLBI 应用精密组学实验室 (APO) 合作，正在研究血浆游离 DNA (cfDNA) 作为 PAH 疾病严重程度的新标志物。初步数据已提交给 ACC 第 68 届年度科学会议（J Am Coll Cardiol, 73(9, S1): S1897, 2019）。基于令人鼓舞的初步结果，我们与阿勒格尼总医院和塔夫茨医疗中心的 PAH 项目签订了 MTA，收到了来自阿勒格尼总医院和塔夫茨医疗中心的 48 个血浆样本（探索队列）和来自塔夫茨医疗中心的 161 个样本以及临床数据。我们不仅测量了患者和健康志愿者 (n=48) 的 cfDNA 水平，还对一部分样本进行了亚硫酸氢盐测序和反卷积算法，以绘制 cfDNA 的组织特异性来源。本报告期内发表的完整分析（Circulation, 146(14):1033-1045, 2022）显示，在 PAH 患者中，循环 cfDNA 升高，与疾病严重程度相关并预测生存率较差。 PAH 患者的 cfDNA 甲基化分析与疾病发病机制的流行范式一致，从而为 cfDNA 作为 PAH 生物提供了生物学合理性