Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
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effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
TODAY WE WELCOME OUR SPEAKERS,
THE CO-DIRECTORS OF THE
TRANSLATIONAL PULMONARY ARTERIAL
HYPERTENSION RESEARCH SECTION OF
THE NIH CRITICAL CARE MEDICINE
DEPARTMENT, DR. MICHAEL SOLOMON,
SENIOR RESEARCH PHYSICIAN AND
DR. JASON ELINOFF, TENURE TRACK
INVESTIGATOR.
OUR FIRST SPEAKER IS DR.
SOLOMON, SENIOR RESEARCH
PHYSICIAN, HEAD OF THE
CARDIOLOGY SECTION OF CRITICAL
CARE MEDICINE AND CO-DIRECTOR OF
THE TRANSLATIONAL PULMONARY
ARTERIAL HYPERTENSION RESEARCH
SECTION. DR. SOLOMON ALSO HOLD
AS JOINT APPOINTMENT IN THE
CARDIOVASCULAR BRANCH NATIONAL
HEART LUNG AND BLOOD INSTITUTE.
DR. SOLOMON RECEIVED HIS
UNDERGRADUATE DEGREE FROM BROWN
UNIVERSITY AND EARNED HIS
MEDICAL DEGREE FROM NEW YORK
UNIVERSITY SCHOOL OF MEDICINE.
HE COMPLETED INTERNAL MEDICINE
INTERNSHIP AND RESIDENCY
UNIVERSITY OF TEXAS SOUTH
WESTERN MEDICAL CENTER.
FOLLOWING RESIDENCY HE COMPLETED
CRITICAL CARE MEDICINE
FELLOWSHIP AT THE NIH.
AFTERWARDS DR. SOLOMON RETURNED
TO UT SOUTH WESTERN TO COMPLETE
A SECOND FELLOWSHIP IN
CARDIOVASCULAR DISEASES.
HE JOINED A CARDIOLOGY FACULTY
AT UT SOUTH WESTERN SPECIALIZING
IN PATIENTS WITH PULMONARY
HYPERTENSION, CARDIAC
TRANSPLANTATION.
HE RETURNED TO THE NIH AS HEAD
OF THE CARDIOLOGY SECTION OF
CRITICAL CARE MEDICINE IN 2000.
MOST RECENTLY DR. SOLOMON EARNED
HIS MBA IN 2000 WITH ADDITIONAL
CERTIFICATE IN BUSINESS
ANALYTICS FROM THE MASSACHUSETTS
INSTITUTE OF TECHNOLOGY SCHROENN
SCHOOL OF MANAGEMENT.
DR. SOLOMON SUPERVISES
ACTIVITIES RELATED TO THE FIELDS
OF CRITICAL CARE CARDIOLOGY AND
PULMONARY HYPERTENSION.
HIS RESEARCH INTERESTS INCLUDE
ENDOTHELIAL CELL DYSFUNCTION,
INFLAMMATION IN PULMONARY
ARTERIAL HYPERTENSION OR PAH.
AS WELL AS ORGANIZATIONAL
STRUCTURES AND OUTCOMES DELIVERY
OF CRITICAL CARE CARDIOLOGY.
DR. SOLOMON IS BOARD CERTIFIED
IN INTERNAL MEDICINE,
CARDIOVASCULAR DISEASE AND
CRITICAL CARE MEDICINE BY THE
AMERICAN BOARD OF INTERNAL
MEDICINE.
HE SERVES ON THE ADVISORY FOR
THE NIH MEDICAL RESEARCH
SCHOLARS PROGRAM, IS VICE CHAIR
OF THE NIH STAFF CLINICIAN
COUNCIL, AND IS CLAIRE OF THE
NIH INARM SHY AND THERAPEUTICS
COMMITTEE.
-- PHARMACY AND THERAPEUTICS
COMMITTEE.
HE IS CO-CHAIR OF AMERICAN CARE
CARDIOLOGY, LEADERSHIP COUNCIL.
A SECOND SPEAKER TODAY IS DR.
JASON ELINOFF.
TENURE TRACK INVESTIGATOR, HEAD
OF PULMONARY VASCULAR SECTION
AND CO-DIRECTOR TRANSLATIONAL
PULMONARY HYPERTENSION PROGRAM.
DR. ELINOFF EARNED UNDERGRADUATE
IN CHEMISTRY FROM PRINCETON
UNIVERSITY, MEDICAL DEGREE FROM
UNIVERSITY OF CHICAGO PRITCHARD
SCHOOL OF MEDICINE.
HE COMPLETED INTERNSHIP AND
RESIDENCY TRAINING AT
MASSACHUSETTS GENERAL HOSPITAL.
DR. ELINOFF COMPLETED HIS
FELLOWSHIP TRAINING CRITICAL
CARE MEDICINE AT THE NIH
CLINICAL CENTER AND PULMONARY
AND CRITICAL CARE MEDICINE AT
JOHNS HOPKINS UNIVERSITY.
HEATHEN JOINED NIH CLINICAL
CENTER AS STAFF CLINICIAN IN
YEAR 2011.
DR. ELINOFF RESEARCH FOCUS IS
CONTRIBUTIONS OF PULMONARY
VASCULAR ENDOTHELIUM AND IMMUNE
EFFECTOR CELLS TO DEVELOP
PROGRESSION OF PAH.
HIS CURRENT WORK INCLUDES THE IN
VITRO PROFILING OF HUMAN
PULMONARY ARTERIAL ENDOTHELIAL
CELLS WITH PH ASSOCIATED
MOLECULAR DEFECTS TO INVESTIGATE
MOLECULAR MECHANISM EXPLOITED
THERAPEUTICALLY.
THE OVERARCHING GOAL OF THE
PROGRAM IS TRANSLATE PRE-SCIENCE
AND PRE-CLINICAL STUDIES TO
EARLY PHASE THERAPEUTIC TRIALS
IN PAH PATIENTS.
DR. ELINOFF IS BOARD CERTIFIED
IN INTERNAL MEDICINE, PULMONARY
MEDICINE AND CRITICAL CARE
MEDICINE.
THE TITLE OF OUR SPEAKERS
PRESENTATION TODAY IS PULMONARY
ARTERIAL HYPERTENSION, WHAT LIES
BENEATH THE TIP OF THE ICEBERG.
WELCOME FIRST SPEAKER DR.
MICHAEL SOLOMON.
>> GOOD AFTERNOON, EVERYONE.
DR. ELINOFF AND I APPRECIATE THE
OPPORTUNITY TO PRESENT TO OUR
COLLEAGUES OUR EFFORTS TO
UNDERSTAND AND BETTER TREAT THE
RARE DISEASE PULMONARY ARTERIAL
HYPERTENSION.
TODAY WE WILL SHARE WITH YOU
WHAT LIES BENEATH THE TIP OF THE
ICEBERG.
NEITHER DR. ELINOFF NOR I HAVE
RELEVANT FINANCIAL DISCLOSURES
RELATED TO THIS PRESENTATION.
HOWEVER BOTH OF US WILL BE
DISCUSSING THE OFF LABEL USE OF
SPUR LACTONE IN PULL NO MARE
HYPERTENSION.
-- PULMONARY HYPERTENSION.
OUR LEARNING OBJECTIVES BY THE
CONCLUSION OF THE PRESENTATION
YOU SHOULD BE ABLE TO DESCRIBE
THE PATHOPHYSIOLOGY OF PULMONARY
ARTERIAL HYPERTENSION, DESCRIBE
HOW CELLULAR MODELS OF PAH
ASSOCIATED MOLECULAR DEFECTS,
CAN BE USED TO IDENTIFYING NEW
THERAPEUTIC TARGETS.
DISCUSS INFLAMMATION IN
PULMONARY ARTERIAL HYPERTENSION,
AND RECOGNIZE PROTEIN SPECIFIC
DEGRADATION AS A STRATEGY FOR
MODIFYING INFLAMMATION.
PULMONARY ARTERIAL HYPERTENSION
IS A RARE FEMALE PREDOMINANT
DISEASE.
PITTS WORLD HEALTH ORGANIZATION
CLASSIFICATION IS GROUP 1.
ITS PREVALENCE IS ESTIMATED AT
15 TO 50 CASES PER MILLION.
ITS INCIDENCE IS 2.4 CASES PER
MILLION PER YEAR.
PREDOMINANTLY EFFECTS WOMEN WHO
CONSTITUTE 70 TO 80% OF
PATIENTS, AGE AT DIAGNOSIS
RANGES FROM 30 TO 60 YEARS.
WITH THOSE HAVING THE IT OWE
PATHIC VARIETY BEING YOUNGER AT
DIAGNOSIS.
THE MAJORITY OF WHO GROUP 1
PULMONARY HYPERTENSION IS MADE
UP OF IDIOPATHIC UNEXPLAINED
VARIETY AND DISEASE ASSOCIATED.
TOGETHER THEY ACCOUNT FOR 90% OF
CASES.
DISEASE ASSOCIATED PAH CONSISTS
PREDOMINANTLY OF CONNECTIVE
TISSUE DISEASE AND CONGENITAL
HEART DISEASE, MAKING UP 80% OF
THIS CATEGORY.
THE MAJORITY OF WHO THERAPIES
ARE SHOWN HERE ON THIS TIME
LINE.
THE TIME LINE ILLUSTRATES THE
RELATIVELY REMARKABLE PACE OF
PAH DRUG DEVELOPMENT, WE HAVE
GONE FROM 0 TO 14 OPTIONS FOR
TREATMENT OVER A 20 YEAR PERIOD.
THEY TARGET THE ABNORMAL
VASOCONSTRICTION OF THE
DYSFUNCTIONAL ENDOTHELIUM;
CURRENT THERAPIES WORK THROUGH
THE ENDOTHREE LYNN, NITRIC OXIDE
AND FROST CYCLINE PATHWAYS.
ACTIVATION OF THE ENDOTHELIN
PATHWAY RESULTS IN
VASOCONSTRICTION THROUGH THE ET
1 RECEPTOR.
ENDOTHREE LYNN RECEPTOR
ANTAGONIST BLOCK THIS EFFECT.
THIS CLASS OF ORAL THERAPIES
CONSIST OF AMBERSENTIN, THE
SENTINEL STUDY WAS THE BOSENTIN
(PHONETIC) RANDOMIZED TRIAL OF
ENDOTHREE LYNN ANTAGONIST
THERAPY, ENDOTHELIN THERAPY.
THE PRIMARY END POINT WAS A
CHANGE IN SIX MINUTE WALK
DISTANCE WITH A SIGNIFICANT
INCREASE WITH BOSENTIN COMPARED
TO PLACEBO.
THE NITRIC OXIDE PATHWAY ACTS
THROUGH CYCLIC GMP TO CAUSE
VASODILATION.
PHOSPHODIE ESTERASE FIVE
METABOLIZES CYCLIC GMP
INHIBITING PATHWAY.
TO RESTORE VASODILATION WE TREAT
WITH PHOSPHODEESTERASE
INHIBITORS OR A CYCLASE
STIMULATOR.
PD 5 INHIBITORS AND REOSIGWA
(PHONETIC) IS A CYCLIC GMP
STIMULATOR.
THE SENTINEL STUDY WAS SEDINOFIL
USE IN PAH, THE SUPER ONE TRIAL,
THE PRIMARY END POINT WAS AGAIN
CHANGING SIX MINUTE WALK
DISTANCE WITH A SIGNIFICANT
INCREASE WITH SELDINOFIL
COMPARED TO PLACEBO.
NOTABLY 20, 40 AND 80 MILLIGRAMS
WERE NOT DIFFERENT FROM EACH
OTHER.
THE FROST CYCLINE PATHWAY ACTS
THROUGH OPPRESS CYCLIC PATHWAY
ENDS TO DERIVATIVES AND RECEPTOR
AGONIST STIMULATE CYCLIC AMP,
THE FROST CYCLINE DERIVATIVE
COMES IN ORAL, INHALED, SUB Q
AND INTRAVENOUS FORMS.
THE LATTER TWO BEING GIVEN
CONTINUOUSLY THROUGH A PUMP.
ILOPROST (PHONETIC) IS INHALED
AND IT IS GIVEN INTRAVENOUSLY AS
CONTINUES WAS INFUSION.
THE HALF LIFE OF IPOPROSNOL IS
ORDER OF MINUTES WHILE
TREPROSNOL IS FOUR AND A HALF
HOURS.
THE ORRILL AGENT IS THE ONLY FDA
APPROVED ORAL AGENT IS THE ONLY
FDA PROS STOW CYCLINE AGONIST.
EPO WAS STUDIED IN HIGHLY
SYMPTOMATIC PATIENTS NEW YORK
HEART ASSOCIATION CLASS 3, 4,
PATIENTS WITH MARK ACTIVITY
LIMITATIONS.
IT IS THE ONLY MEDICATION THAT
IS MET END POINT OF IMPROVED
SURVIVAL IN THE PAH POPULATION.
NOW LET'S BRIEFLY DISCUSS OUR
USAGE OF THESE MEDICATIONS.
FOR PATIENTS WHO ARE NEW YORK
HEART ASSOCIATION FUNCTIONAL
CLASS 2, THOSE WHO ORDINARY
PHYSICAL ACTIVITY CAUSES
FATIGUE, WE RECOMMEND DUAL
THERAPY WITH AN ERA AND A PD 5
INHIBITOR.
THIS IS IN PART BASED ON THE
AMBITION TRIAL WHICH COMPARED
DUAL THERAPY WITH AMBERSENTIN TO
MONOTHERAPY WITH EITHER DRUG.
AND FOUND COMBINATION THERAPY TO
LOWER THE RISK OF CLINICAL
WORSENING.
THERE'S ALSO RECENT DATA
SUGGESTING THAT INITIAL TRIPLE
ORAL THERAPY REDUCES DISEASE
PROGRESSION OVER INITIAL DOUBLE
ORAL THERAPY, THOUGH THE HAZARD
RATIO SLIGHTLY CROSSED OVER
IDENTITIES SPANNING 0.23 TO
1.079.
HOWEVER WITH THIS IN MIND,
PATIENTS WHO ARE INTERMEDIATE
RISK SHOULD RECEIVE TRIPLE ORAL
THERAPY WITH ORAL AGENTS ACTIVE
ON ALL THREE PATHWAYS.
ENDOTHELIN, NITRIC OXIDE AND
FROST CYCLINE PATHWAYS.
PATIENTS FAILING A PD 5
INHIBITOR SHOULD BE CONSIDERED
THE GAIN LACE CYCLASE STIMULATOR
AS AN ALTERNATIVE AGENT.
THOSE PATIENTS INTERMEDIATE TO
HIGH RISK WITH DISMIA FATIGUE
WITH LESS THAN ORDINARY ACTIVITY
SHOULD BE CHANGED FROM ORAL
FROST SIGH LYNN PATHWAY AGENTS
TO INHALED OR CONTINUOUS IV OR
SUB Q FROST CYCLINE DERIVATIVES.
IF APPROPRIATE REFERRED TO
TRANSPLANT CENTER FOR WORK UP.
PATIENTS WHO NEW YORK HEART
ASSOCIATION CLASS 4 HIGH RISK.
THESE CANDIDATES SHOULD BE FOR
CONTINUOUS EPOPROTNOL,HE ONLY
MEDICATION SHOWN TO HAVE
SURVIVAL BENEFIT IN NEW YORK
HEART ASSOCIATION CLASS 4 PAH
PATIENTS.
THEY ALSO SHOULD BE REFERRED TO
A TRANSPLANT CENTER FOR TIMELY
WORK UP.
THE MOST COMMON CAUSE OF DEATH
IN PULMONARY ARTERIAL
HYPERTENSION PATIENTS IS RIGHT
HEART FAILURE.
DEPICTED HERE ARE TWO ECHO
CARDIOGRAPHIC VIEWS OF NORMAL
LEFT AND RIGHT VENTRICLE.
NOTE THE LEFT VENTRICLE THE
LARGER THAN THE RIGHT AND IN
CROSS SECTION BELOW THE LEFT
VENTRICLE IS CIRCULAR IN SHAPE.
IN PATIENTS WITH PULMONARY
ARTERIAL HYPERTENSION,
PROGRESSIVE NARROWING AND
OBLITERATION OF THE DISTAL SMALL
PULMONPULMONARY ARTERIES LEADS O
INCREASES IN PULMONARY VASCULAR
RESISTANCE, WORSENING OF RV
FUNCTION, AND A DROP IN CARDIAC
OUTPUT AND EVENTUALLY DEATH DUE
TO RIGHT HEART FAILURE.
SHOWN ON THE RIGHT ARE TWO ECHO
CARDIOGRAPHIC VIEWS OF A PATIENT
WITH ADVANCED PULMONARY ARTERIAL
HYPERTENSION.
IN STARK CONTRAST TO OUR HEALTHY
PATIENT ECHOCARDIOGRAMS THESE
REVEAL A HYPERTROPHIED AND
MASSIVELY DILATED RIGHT
VENTRICLE, THAT IS MUCH LARGER
THAN THE LEFT VENTRICLE.
THE RIGHT VENTRICLE COMPRESSES
THE LEFT VENTRICLE INTO A D
SHAPE WITH THE SEPTUM NOW
BULGING TO THE LV AS SHOWN IN
CROSS SECTION IN THE LOWER RIGHT
IMAGE.
THE RIGHT ATRIUM SIMILARLY
COMPROMISES LEFT ATRIAL FILLING.
THE I PAS DYSFUNCTION ALVING
RIGHT ATRIUM AND RIGHT VENTRICLE
HAVE COMPROMISED LV PRE-LOAD AND
FUNCTION.
THE PATIENT REQUIRED LIFE SAVING
LUNG TRANSPLANT A FEW WEEKS
AFTER THIS HE CAN COWAS
PERFORMED AS -- ECHO WAS
PERFORMED AS PARTS OF OUR
NATURAL HISTORY STUDY.
SURVIVOR DATA FROM THE 1980s
PRIOR TO THE AVAILABILITY OF
MOST CURRENT THERAPIES REVEALED
50% MORTALITY AT THREE YEARS
AFTER DIAGNOSTIC RIGHT HEART
CATHETERIZATION.
THE REVEAL REGISTERED SPANNING
2001 TO 2009 CAPTURES THE IMPACT
OF CURRENT THERAPIES ON
SURVIVAL.
UNFORTUNATELY MEDIAN SURVIVAL
HAS BEEN EXTENDED BY ONLY A FEW
YEARS WITH A 50% MORTALITY
BETWEEN 5 TO 7 YEARS AFTER
DIAGNOSTIC RIGHT HEART
CATHETERIZATION.
THUS, DESPITE 14 FDA APPROVED
PULMONARY VASODILATED THERAPIES,
MORTALITY REMAINS VERY HIGH.
THERE MUST BE PATHOLOGIC
PATHWAYS WE ARE NOT TREATING.
IDENTIFYING THESE PATHWAYS WILL
REQUIRE A DEEP DIVE BELOW THE
TIM OF THE PULMONARY
HYPERTENSION ICEBERG.
IN ORDER TO FURTHER EXPLORE AND
EXPLOIT OTHER TREATABLE
PATHWAYS, WE MUST ACKNOWLEDGE
SOME FOUNDATIONAL PRINCIPLES SO
WE STUDY THE CORRECT PATIENT
POPULATION.
FIRST AMONG THEM, IS NOT ALL
PULMONARY HYPERTENSION IS
PULMONARY ARTERIAL HYPERTENSION.
THE WORLD HEALTH ORGANIZATION
CLINICAL CLASSIFICATION
DISTINGUISHES FIVE SEPARATE
GROUPS OF PULMONARY HYPERTENSION
BASED ON CLINICAL
CHARACTERISTICS, UNDERLYING
PATHOBIOLOGY, AND DISTINCT
TREATMENT APPROACHES.
THESE ARE GROUP 1, OUR GROUP OF
INTEREST, WHICH IS PULMONARY
HYPERTENSION DUE TO PULMONARY
VASCULAR DISEASE, GROUP 2 A MUCH
LARGER GROUP WHICH IS PULMONARY
HYPERTENSION DUE TO LEFT HEART
DISEASE, GROUP 3 ALSO FAIRLY
LARGE GROUP WHICH IS PULMONARY
HYPERTENSION DUE TO PULMONARY
PARYNCHEMAL DISEASE, AND
HYPOXIA, GROUP 4 WHICH IS PH DUE
TO CHRONIC THROMBO EMBOLIC
PULMONARY DISEASE, AND GROUP 5,
PH DUE TO UNCLEAR OR
MULTI-FACTORIAL MECHANISMS.
ABOVE THE SURFACE, ALL OF THESE
GROUPS LOOK SIMILAR, WITH
DYSPNEA AND FATIGUE, DUE TO
ELEVATED PULMONARY ARTERY
PRESSURE AND RV DYSFUNCTION.
EVEN JUST BELOW THE SURFACE,
HEMODYNAMICS CAN BE SIMILAR AS
GROUPS 1, 3, 4 AND 5 ALL PRESENT
AS PRE-CAPILLARY PH.
THE 2006, SORRY THE 2018 SIX
WORLD SYMPOSIUM DEFINE
PRE-CAPILLARY PH AS A MEAN
PULMONARY ARTERY PRESSURE
GREATER THAN 20-MILLIMETERS OF
MERCURY PLUS PULMONARY ARTERY
OCCLUSION PRESSURE OF LESS THAN
OR EQUAL TO 15-MILLIMETERS OF
MERCURY AWE LONG WITH PULMONARY
VASCULAR RESISTANCE OF THREE
UNITS.
ISOLATED POST CAPILLARY PH
REPRESENTATIVE OF GROUP 2 HAS A
SIMILAR MEAN PULMONARY ARTERY
PRESSURE BUT THEIR PULMONARY
ARTERY OCCLUSION PRESSURE IS
GREATER THAN 15-MILLIMETER OF
MERCURY AND THEIR PULMONARY
VASCULAR RESISTANCE IS LESS THAN
3 WOOD UNITS.
HOWEVER IT GETS MORE
COMPLICATED.
GROUP 2 PH CAN PRESENT AS
COMBINED PRE AND POST CAPILLARY
PH.
IN WHICH CASE THEIR PBR WOULD BE
GREATER THAN OR EQUAL TO 3 WOOD
UNITS AND SIMILAR TO
PRE-CAPILLARY PH.
SO RATHER THAN ONLY TREATING THE
ELEVATED PULMONARY ARTERIAL
PRESSURE IN THE RIGHT
VENTRICULAR DISFUNCTION AT THE
TIP OF THE ICEBERG AND
PRE-CAPILLARY HEMODYNAMIC
DERANGEMENTS IN SHALLOW WATERS
WE LEAD TO LOOK DEEPER IN ORDER
TO APPRECIATE THE COMPLEX
INTERRELATED MOLECULAR PROCESSES
SOME OF WHICH ARE ESSENTIALLY
IGNORED, BY CURRENT TREATMENTS.
ENDOTHELIUM DYSFUNCTION, THE
FOCUS OF CURRENT PH THERAPIES,
IS CHARACTERIZED BY ENDOTHELIAL
TO MESENCHYMAL TRANSITION AND
IMPAIRED VASOREACTIVITY.
MESENCHYMAL TRANSITION IS A
PROCESS WHEREBY AN ENDOTHELIAL
CELL UNDERGOES A SERIES OF
MOLECULAR EVENTS THAT LEADS TO
CHANGE IN PHENOTYPE TOWARDS
MESENCHYMAL TYPE CELL,
FIBROBLASTS OR SMOOTH MUSCLE
CELL.
ABNORMAL CELLULAR PROLIFERATION
IS CHARACTERIZED BY MYOGENESIS,
ANGIOGENESIS AND VASCULAR SMOOTH
MUSCLE CELLS THAT ARE
HYPERPROLIFERATIVE AND RESISTANT
TO APOPTOSIS.
EMERGING PARADIGMS INCLUDE
METABOLIC REPROGRAMMING, IN
SIMILAR FASHION TO CANCER,
PROLIFERATING CELLS AND
PULMONARY ARTERIAL HYPERTENSION
SWITCH THEIR METABOLISM TOWARDS
AEROBIC GLYCOLYSIS, ASSOCIATED
WITH VASCULAR EXPANSION.
IN ADDITION THERE IS ALSO
EVIDENCE OF MYO-- MITOCHONDRIAL
DYSFUNCTION, RELATED TO
BIOGENESIS AND BIOENERGETICS.
INFLAMMATION IN PULMONARY
ARTERIAL HYPERTENSION IS
CHARACTERIZED BY PULMONARY
PERIVASCULAR PRO INFLAMMATORY
INFILTRATES AND CIRCULATING
INFLAMMATORY CYTOKINES.
THERE IS EVIDENCE OF BOTH LOCAL
AND SYSTEMIC IMMUNE ACTIVATION
IN PULMONARY ARTERIAL
HYPERTENSION.
IT IS ALSO NOTABLE THAT
AUTOIMMUNE DISEASES INFECTION
AND PRIOR INTERFERON TREATMENT
ARE RISK FACTORS FOR PULMONARY
ARTERIAL HYPERTENSION.
NONE, I REPEAT, NONE OF THE
CURRENT THERAPIES FOCUS ON
INFLAMMATORY MEDIATORS OF
VASCULAR REMODELING.
SHOWN HERE IS A CROSS SECTION OF
A NORMAL PULMONARY ARTERY.
THIS IS AN ILLUSTRATION OF
LUMINAL NARROWING DUE TO
CELLULAR PROLIFERATION IN THE
LIGHT RED CIRCLE, ALSO PRESENT
IS PERIVASCULAR INFLAMMATION
INSIDE THE PINK OUTLINE.
IN ADDITION, THE EXTENT OF
VESSEL REMODELING CORRELATES
WITH THE SEVERITY OF THESE
PERIVASCULAR INFLAMMATORY
INFILTRATES.
WE NOW REALIZE THAT IN PULMONARY
ARTERIAL HYPERTENSION P THE
PULMONARY VASCULAR LESIONS
SUBSIST IN AN INFLAMMATORY
MICROENVIRONMENT.
SYSTEMIC EVIDENCE OF
INFLAMMATION CAN BE FOUND FROM
STUDIES COMPARING SERUM CYTOKINE
LEVELS IN IDIOPATHIC PULMONARY
ARTERIAL HYPERTENSION PATIENTS
TO HEALTHY CONTROLS.
IL 2, IL 6, IL 8 ARE
INFLAMMATION RELATED CYTOKINES.
IL 2, IL 6 AND IL 8 ARE ALL
SIGNIFICANTLY ELEVATED IN
IDIOPATHIC PULMONARY ARTERIAL
HYPERTENSION PATIENTS COMPARED
TO CONTROLS.
KEY POINTS SO FAR.
PAH IS CURRENTLY AN INCURABLE
HIGH MORTALITY DISEASE DUE TO
PULMONARY VASCULAR REMODELING
LEADING TO VESSEL NARROWING AND
RIGHT VENTRICULAR FAILURE.
MAJOR DRIVERS OF UNDERLYING
PATHOBIOLOGY ARE ENDOTHELIAL
DYSFUNCTION, ABNORMAL CELLULAR
PROLIFERATION, INFLAMMATION, AND
METABOLIC REPROGRAMMING.
CURRENT THERAPIES DO NOT TARGET
INFLAMMATION.
DR. ELINOFF WILL NOW REGALE YOU
WITH HIS BENCH WORK DELINEATING
INFLAMMATORY PATHWAYS IN PH.
I WILL PASS THE BATON FOR
SPEAKING TO DR. ELINOFF.
>>THANK YOU, MICHAEL.
AS HIGHLIGHTED BY DR. SOLOMON
DESPITE THERAPEUTIC ADVANCES PAH
REMAINS INCURABLE DISEASE.
IMPORTANTLY, CURRENT THERAPIES
DON'T TARGET INFLAMMATION
UNDERLYING PAH PATHOBIOLOGY.
THEREFORE OUR PROGRAMS GOAL IS
TO IDENTIFY AND DEVELOP
THERAPIES THAT TARGET VASCULAR
INFLAMMATION AND VESSEL
REMODELING.
TODAY I'M GOING TO SHARE TWO
STORIES OF HOW OUR WORK IN THE
LAB IS LAYING THE FOUNDATION FOR
TRANSLATION OF NEW TREATMENT
APPROACHES INTO CLINICAL
STUDIES.
IN THE FIRST STORY I WILL
DESCRIBE THE ANTI-INFLAMMATORY
EFFECTS OF SCONOLACTONE DURING
SCLERODERMA PI PIGMENTOSA,
LEVERAGING CELLULAR MODELS OF
PAH ASSOCIATED MOLECULAR DEFECTS
TO IDENTIFY NEW THERAPEUTIC
TARGETS.
SPIRIT LACTONE IS A CORTICOID
RECEPTOR ANTAGONIST THAT
IMPROVES ENDSTHELIAL DISFUNCTION
REDUCES I INFLAMMATION AND
INCREASES SURVIVAL WITH LEFT
HEART FAILURE.
IT IS KNOWN TO HAVE BOTH MR
DEPENDENT AND INDEPENDENT
ANTI-INFLAMMATORY EFFECTS.
HOWEVER, DESPITE DECADES OF
RESEARCH, THE MOLECULAR
MECHANISMS RESPONSIBLE FOR MR
INDEPENDENT EFFECTS WERE POORLY
UNDERSTAND.
-- UNDERSTOOD.
WE ESTABLISHED A MODEL SYSTEM IN
HUMAN EMBRYONIC KIDNEY CELLS
THAT DIDN'T EXPRESS STEROID HER
HONE RECEPTORS THEREFORE ABLE TO
SELECTIVELY EXPRESS THOSE
RECEPTORS KNOWN TO INTERACT WITH
SPURNO LACTONE.
USING THE MODEL SYSTEM TWO
CENTRAL INFLAMMATORY SIGNALING
PATHWAYS NF KAPPA B AN AP 1 WERE
INVESTIGATED USING APPROXIMATE
LUCIFERASE REPORTER SYSTEM.
HERE N NF KAPPA B IS ON Y AXIS
RELATIVE TO IMIS THE RATION WITH
TNF ALPHA, VALUES ALONG THE LINE
SIGNIFY NO EFFECT.
BELOW THE LINE SIGNIFIES
SUPPRESSION OF TNF INDUCED
ACTIVITY.
INCREASING CONCENTRATIONS OF
SPURNO LACTONE SHOWN ON THE
RIGHT AXIS.
ON THE RIGHT THEY ARE CONTROL
VECTOR IN RED OR MR SPECIFIC
RECEPTOR IN BLUE.
DEMONSTRATING THE DIFFERENCES IN
MR EXPRESSION.
HERE YOU SEE THAT IN THE ABSENCE
OF MR EXPRESSION, DOSE
DEPENDENTLY SUPPRESSED NF KAPPA
B ACTIVITY AN EFFECT NOT
SIGNIFICANTLY ALTERED WHEN MR IS
HIGHLY EXPRESSED.
TO SUMMARIZE OUR FINDINGS AT
THIS POINT INCLUDING DATA I DID
NOT HAVE TIME TO SHOW, WE FOUND
THAT SPURNO LACTONE SUPPRESSED
NF KAPPA B AND AP 1 PROMOTER
ACTIVITY INDEPENDENT OF THE
MINERALOCORTICOID RECEPTOR.
THESE EFFECTS WERE INDEPENDENT
OF ANDROGEN, PROGESTERONE AND
GLUCOCORTICOID RECEPTOR
EXPRESSION.
AND A MORE SELECTIVE ANTAGONIST
DID NOT SUPPRESS INFLAMMATION IN
THIS SYSTEM.
A PREVIOUS STUDY IDENTIFIED
SPURNO LACTONE OF INHIBITOR OF
NUCLEOTIDE EXCISION REPAIR, A
SPECIFIC DNA REPAIR MECHANISM,
IN SETTING OF RADIATION, CELLS
RECRUIT REPAIR MECHANISMS
INCLUDING THE GENERAL
TRANSCRIPTION FACTOR TH 2H.
IN CELLS TREAT TREATED, DNA
REPAIR WAS INHIBITED.
TF 2H IS A PROTEIN COMPLEX
COMPOSED OF 11 SUBUNITS
INCLUDING IS SCLERODERMA PIG MEN
TO IS A OR XPB.
THEY HAVE A CENTRAL ROLE IN RNA
TRANSCRIPTION AND DNA REPAIR.
THEY DEMONSTRATED IT INHIBITED
DNA REPAIR AS A RESULT OF
PROTEOSOME DEPENDENT
DEGRADATION.
HOWEVER, THE LINK BETWEEN THIS
EFFECT AND ITS ANTI-INFLAMMATORY
PROPERTIES HAD NOT BEEN
PREVIOUSLY EXPLORE.
WE RETURNED TO OUR REPORTER
SYSTEM TO INVESTIGATE WHETHER
DEGRADATION CONTRIBUTES TO THE
ANTI-INFLABTORY EFFECTS.
IT SUPPRESSES AP 1 ACTIVITY
INDUCED BY PMA, HOWEVER THIS
EFFECT WAS REVERSED IN THE
PRESENCE OF A PROTEOSOME
INHIBITOR.
UNDER THE SAME EXPERIMENTAL
CONDITIONS AS OUR REPORTER
ASSAY, WE FOUND SPIRN LACTONE
TRIGGERS XPV DEGRADATION,
REVERSED AS INHIBITOR BY WESTERN
BLOT BELOW.
WE OVEREXPRESSED IN OUR MODEL
SYSTEM TO IN ORDER TO STRENGTHEN
THE EVIDENCE THAT SPIRNO LACTONE
SUPPRESSES INFLAMMATION AS A
RESULT OF XPB LOSS.
IT SUPPRESSED ACTIVITY AND
REDUCED XPV LEVELS SHOWN BELOW.
IN THE PRESENCE OF
OVEREXPRESSION THE EFFECT IS
COMPLETELY REVERSED.
SIMILARLY ON THE RIGHT IT
SUPPRESSED NF KAPPA B ACTIVITY
AND REDUCED XPB LEVELS BUT AGAIN
WITH OVEREXPRESSION OF XPV BOTH
EFFECTS ARE REVERSED SO TO
SUMMARIZE THE RESULTS OF THESE
EXPERIMENTS, SPIRNO LACTONE
TRIGGERS PROTEOSOME DEGRADATION
OF XPV AND BLOCKING DEGRADATION
WITH EITHER PROTEOSOME INHIBITOR
OR OVEREXPRESSING XPB REVERSES
SPURNO LACTONE MEDIATED
SUPPRESSION AND NF KAPPA B
PROMOTER ACTIVITY.
WE TRANSLATED FINDINGS TO HUMAN
PULMONARY ARTERY ENDOTHELIAL
CELLS AND INVESTIGATED THE
EFFECT OF SPIRNO LACTONE TNF
INDUCED INFLAMMATORY MEDIATORS
WITH PH PATHOGENESIS.
IL 8 EXPRESSION IS SHOWN HERE
PLOTTED ON THE Y AXIS, IN RED
TNF INDUCES IL 8 TRANSCRIPTION
SUPPRESS BY SPIRNO LACTONE.
ON THE RIGHT CELL SUPERNATANT
COLLECTED AT 4, 8 AND 24 HOURS
ON THE X AXIS AND LOG
TRANSFOREIGN PROTEIN
CONCENTRATION ON THE Y AXIS.
AS EXPECT WED SEE INCREASE IN IL
8 SECRETION IN PRESENCE OF TNF
ALPHA STIMULATION AND IT
SUPPRESSES SECRETION AT EACH
TIME POINT.
IT ALSO SUPPRESSED A VARIETY OF
OTHER TNF INDUCED INFLAMMATORY
MEDIATORS INCLUDING CYTOKINES,
CHEMOKINES, AND ADHESION
MOLECULES.
NEXT WE UTILIZE
IMMUNOCYTOCHEMISTRY TO DETERMINE
XPV PROTEIN EXPRESSION IN
ENDOTHELIUM.
CELLS ARE STIMULATE WITH TNF
ALPHA ALONE ON THE LEFT, XPV
STAINED IN GREEN AND ACTIN IN
RED.
ON THE RIGHT YOU CAN SEE IN
CELLS TREATED WITH SPIRNO
LACTONE THERE IS DECREASE IN XPV
EXPRESSION.
AS SHOWN EARLIER, IT
SIGNIFICANTLY SUPPRESSED IL 8
mRNA EXPRESSION IN PULMONARY
ARTERY ENDOTHELIAL CELLS.
WE IDENTIFIED I P KAPPA RNA
EXPRESSION RESISTANT TO IT.
THEREFORE, IN ORDER TO FURTHER
EXPLORE THESE DIFFERENCES WE
USED DNA BINDING EXPERIMENTS TO
EXAMINE BOTH VASOOCCUPANCY AND
TNF INDUCED RECRUITMENT OF RNA
POLYMERASE 2 AND XPV.
ON THE LEFT TOTAL RNA POL 2
BINDING IS SHOWN RELATIVE TO
UNSTIMULATED CONTROL CELLS,
BINDING TO THE IL 8 PROMOTER
SHOWN IN WHITE AND BINDING TO
THE I KAPPA B ALPHA PROMOTER IN
BLACK.
YOU CAN SEE TNF STIMULATION HAS
A MUCH LARGER EFFECT ON RNA POL
2 RECRUITMENT TO IL 8 COMPARED
TO THE I KAPPA BE ALPHA
PROMOTER.
CONSISTENT WITH IL 8
TRANSCRIPTION IT INDUCES POLL 2
RECRUITMENT BY MORE THAN 50%.
THE EFFECT AT THE I KAPPA B
ALPHA PROMOTER WAS MORE MODEST.
NOTABLY RNA POL 2 APPEARS
PRE-POSITIONED AT THE iKAPPA B
ALPHA PROTOMOTORRER HAVE
VASOSOCK PANSY IS HIGHER THAN
THE IL 8 PROET NOER.
THESE RESULTS WERE SIMILAR WHEN
PROBING ACTIVATED RNA POLYMERASE
2 DNA BINDING.
CONSISTENT WITH DIFFERENCES
BETWEEN THE PROMOTER STRUCTURE
OF THESE TWO GENES, TNF ALPHA
STIMULATION LED TO SIGNIFICANTLY
MORE XPB RECRUITMENT TO THE IL 8
COMPARED TO I KAPPA B ALPHA
PROMOTER.
SIMILAR TO RNA POL 2 IT
SUPPRESSED TNF INDUCE
RECRUITMENT OF XPB TO IL 8
PROMOTE EVERY BY MORE THAN 50 --
PROMOTER BY 50% EFFECTS
RECRUITMENT OF I KAPPA BE ALPHA
WAS MUCH LESS.
IN CONTRAST, VASOXPB OCCUPANCY
WAS NOT SIGNIFICANTLY DIFFERENT
BETWEEN TWO PROMOTER REGIONS.
IN SUMMARY, S PURNO LACTONE
BLOCKS RECRUITMENT OF ACTIVATED
RNA POL 2 BUT NOT THE --
VASOOCCUPANCY OF TOTAL ACTIVATED
PLO 2 WAS SIGNIFICANTLY HIGHER
AT THE IL 8 PROMOTER REGION.
THEREFORE DIFFERENCES IN VASORNA
POL 2 OCCUPANCY APPEAR TO
DISTINGUISH BETWEEN GENES MORE
OR LESS PRONE TO SPURNO LACTONE
MEDIATED DEGRADATION.
THUS IMPLYING IT DOES NOT
INDISCRIMINATELY IMPAIR GLOBAL
GENE TRANSCRIPTION.
BELOW IS A SIMPLIFIED SCHEMATIC
OF EVENTS AT PROMOTER REGION OF
TARGET GENE, FOLLOWING
ACTIVATION OF CELL THE
INFLAMMATORY TRANSCRIPTION
FACTORS ARE RECRUITED TO THE
RESPECTSTIVE BINDING SITES.
THIS IS ACCOMPANIED BY
RECRUITMENT OF THE TRANSCRIPTION
GNASHIATION COMPLEX AND
ACTIVATION OF GENE
TRANSCRIPTION.
HOWEVER, IN THE PRESENCE OF
SPURNO LACTONE XPB AN ENTRYCAL
SUB UNIT OF TRANSCRIPTION FACTOR
TF 2H IS DEGRADED BY THE
PROTEOSOME.
THIS DOESN'T ALTER TRANSCRIPTION
FACTOR BINDING, IT DOES RESULT
IN DECREASE RECRUITMENT OF RNA
POL 2 AND XPB TO THE PROMOTER
REGION LEADING TO SUPPRESSION OF
INFLAMMATORY GENE TRANSCRIPTION.
NOTABLY THIS IS THE FIRST
DETAILED CHARACTERIZATION OF MR
INDEPENDENT MECHANISM FOR SPURNO
LACTONE.
IT INDUCE XPV DEGRADATION,
EXPRESSES GENE TRANSCRIPTION AND
IT IS A APPROPRIATE TO IT FOR
NEW CLASS OF DRUGS THAT DEGRADES
SPECIFIC PROTEIN TARGETS WHICH
MAYBE USEFUL STRATEGY FOR
MODULATING INFLAMMATION.
WHETHER CLINICALLY RELEVANT
CONCENTRATION OF IT LEAD TO XPV
DEGRADATION AND CONTRIBUTE TO
CLINICAL BENEFITS REMAINS
UNKNOWN.
NEXT I WILL DISCUSS HOW OUR LAB
IS LEVERAGING CELLULAR MODELS OF
PAH AS A TOOL FOR DISSECTING THE
PATHOBIOLOGY UNDERLYING LUNG
VESSEL INFLAMMATION.
INVESTIGATING MECHANISMS THAT
CONTRIBUTE TO VASCULAR MODEL
ROCK HAMPERD BY INABILITY TO
SAFELY OBTAIN LUNG TISSUE DURING
COURSE OF PATIENT DISEASE.
FOR INSTANCE THE HISTOPATHOLOGIC
SAMPLE HERE CAN BE OBTAINED FROM
EITHER EXPLANTED LUNGS AT TIME
OF LUNG TRANSPLANT OR AUTOPSY.
NOTABLY THE PREDICTED
CONSEQUENCEs OF ALL KNOWN
MUTATIONS IN PAH ASSOCIATED
GENES IS LOSS OF FUNCTION.
THEREFORE WE HAVE TAKEN A
MOLECULAR APPROACH UTILIZING
SMALL INTERFERING RNA
TRANSFECTION TO MIMIC PAH
ASSOCIATED MOLECULAR DEFECTS.
CURRENTLY WE ARE INVESTIGATING A
NUMBER OF DIFFERENT CELL MODELS
IN OUR LAB, AND TODAY I WILL
HIGHLIGHT ONE MODEL IN
PARTICULAR BASED ON SILENCING
CAV 1 IN PRIMARY HUMAN ARTERY
ENDOTHELIAL CELLS.
LOSS OF FUNCTION MUTATIONS ARE A
RARE HEREDITARY CAUSE OF PAH.
HOWEVER, SUGGESTING AN EVEN
BROADER ROLE IN DISEASE
PATHOGENESIS, WILD TYPE CAV 1
PROTEIN EXPRESSION IS REDUCED IN
LUNG VASCULAR LESION OF PATIENTS
WITH IDIOPATHIC AND DISEASE
ASSOCIATED PAH.
AS YOU CAN SEE GENE SILENCING
SIGNIFICANTLY REDUCED CAV 1
EXPRESSION IN HUMAN PULMONARY
ARTERY ENDOTHELIAL CELLS.
RELATIVE mRNA SHOWN ON THE
LEFT AND PROTEIN EXPRESSION IS
SHOWN ON THE RIGHT.
IN OUR MODEL CAV 1 DEFICIENCY
PRODUCED A DYSFUNCTIONAL PAH
LIKE ENDSTHELIAL PHENOTYPE,
SHOWN HERE ON THE LEFT YOU CAN
SEE THAT COMPARED TO CONTROL S
RNA TRANSFECTED CELLS IN RED CAV
1 SILENCE CELLS WERE HIGHLY
PROLIFERATIVE.
LIKEWISE WHEN COMPARED TO NORMAL
CELL MIGRATION OVER 72 HOURS IN
CULTURE, CAV 1 LOSS PRODUCED
HYPERMIGRATORY PHENOTYPE.
NEXT GENOME WIDE EXPRESSION
PROFILING WAS PERFORMED TO
UNBIASLY ASSESS IMPACT OF CAV 1
DEFICIENCY ON GENE TRANSCRIPTION
IN PULMONARY ARTERY ENDOTHELIAL
CELLS.
CAV 1 SILENCE CELLS SHOWED
STRONG ENRICHMENT FOR THE
ANTIVIRAL RESPONSE AND SYSTEMIC
AUTO-IMMUNITY.
IN ADDITION, INTERFERON
SIGNALING PREDICTED TO BE
ACTIVATING CAV 1 SILENCE CELLS
WAS IDENTIFIED AS THE TOP
CANONICAL PATHWAY.
EXPRESSION OF A STRONG
INTERFERON GENE SIGNATURE IN OUR
TRANSCRIPTOMIC ANALYSIS
INDICATED ENDOTHELIAL
DYSFUNCTION FROM CAV 1 LOSS
MIGHT BE A DIRECT CONSEQUENCE OF
CONSTITUTIVE INTERFERON
INFLAMMATORY RESPONSE.
CONSISTENT WITH THIS HYPOTHESIS
YOU SEE THAT TOTAL AND
PHOSPHORYLATED STAT 1 LEVELS ARE
INCREASED IN CAV 1 CELLS,
THERE'S INCREASE DNA BINDING OF
BOTH INTERFERON REGULATORY
FACTORS 3 AND 7, AS WELL AS
INDUCTION OF CANONICAL
INTERFERON TARGET GENES
INCLUDING CXCL 10.
COLLECTIVELY THESE RESULTS
DEMONSTRATE CAV 1 LOSS
CONSTITUTIVELY ACTIVATES
ENDOGENOUS JAK STAT INTERFERON
SIGNALING.
IMPORTANTLY, IN PAH PATIENTS
WITH PATHOGENIC CAV 1 MUTATIONS,
ELEVATED CXCL 10 LEVELS AND
THEIR CELLS MIRRORED THE
PHENOTYPIC MOLECULAR FEATURES
AND SILENCE CELLS FROM OUR
MODEL.
IN SUPPORT OF A BROADER ROLE FOR
CAV 1 DEFICIENCY, ASSOCIATED
INTERFERON ACTIVATION, WE
PERFORMED IMMUNOFLUORESCENCE
STAINING OF EXPLANTED LUNG
TISSUE FROM PATIENTS WITH
IDIOPATHIC PAH.
ON THE TOP THE ARROWS INDICATE
GREEN STAINING FOR CAV 1
EXPRESSION IN ENDSTHELIAL LINING
OF A NORMAL VESSEL.
BELOW IN IPAH TISSUE I'M
OUTLINING THE ENDOTHELIAL LINING
OF ABNORMAL VESSEL IN YELLOW AND
IN CONTRAST TO HEALTHY YOU SEE
SIGNIFICANT REDUCTION OF CAV 1
STAINENING THE LINING OF THIS
IPAH VESSEL.
LIKEWISE, THERE IS ABSENCE OF
RED STAINING FOR PHOSPHORYLATED
STAT 1 IN HEALTHY ENDOTHELIUM,
STAT 1 PHOSPHORYLATION IS
SIGNIFICANTLY HIGHER IN IPH
ENDOTHELIAL CELLS AS INDICATED
BY THE RED STAINING BELOW.
NEXT THE JAK STAT INTERFERON
PATHWAY EXPLORED POTENTIAL
THERAPEUTIC TARGET IN PAH
ASSOCIATED WITH CAV 1 LOSS.
USING CLINICALLY ACHIEVABLE
CONCENTRATIONS THREE CURRENTLY
AVAILABLE JACK INHIBITORS NOT
ONLY BLOCK STAT 1 ACTIVATION AND
CXCL 10 EXPRESSION BUT ALSO
BLOCK CELL PROLIFERATION AND
MIGRATION IN CAV 1 SILENCE
CELLS.
SO TO SUMMARIZE, CAV 1
SUFFICIENCY ELICITS INFLAMMATORY
RESPONSE THAT RESULTS IN A PAH
LIKE CELLULAR PHENOTYPE.
INHIBITING JAK STAT REVERSED
DYSFUNCTIONAL ENDSTHELIAL
PHENOTYPE ASSOCIATED WITH CAV 1
LOSS IN VITRO.
IN EXPERIMENTS I DIDN'T HAVE
TIME TO SHARE, INTERESTINGLY
EXOGENOUS INTERFERON STIMULATION
ALONE REDUCES CAV 1 PROTEIN
LEVELS IN OTHERWISE NORMAL
PULMONARY ARTERY ENDOTHELIAL
CELLS.
SUGGESTING THAT CAV 1
INSUFFICIENCY MAY CONTRIBUTE TO
DEVELOPMENT OF AUTOIMMUNE AND
AUTOINFLAMMATORY DISEASE
ASSOCIATE CANNED PH.
THEREFORE CELLULAR MODELS OF PAH
ASSOCIATED MOLECULAR DEFECTS CAN
BE LEVERAGED TO FURTHER OUR
UNDERSTANDING OF DISEASE
PATHOBIOLOGY, AS WELL AS A TOOL
TO IDENTIFY THERAPEUTIC TARGETS.
I WILL NOW PASS THE BATON BACK
TO YOU MIKE SO YOU CAN EXPLAIN
HOW WE TRANSLATED OUR INTEREST
AND INFLAMMATION INTO OUR
CLINICAL STUDIES IN IN PAH
PATIENTS.
>> THANK YOU.
THE TRANSLATIONAL ARM OF THE NIH
CLINICAL CENTER PAH SECTION HAS
SYNERGIZED WITH AND BUILT UPON
DR. ELINOFF'S BENCH
INVESTIGATIONS TO FURTHER
ELUCIDATE INFLAMMATORY PROCESSES
IN PAH WITH THE ULTIMATE GOAL OF
INTERVENING THERAPEUTICALLY.
IN COLLABORATION WITH THE NIH
CENTER FOR HUMAN IMMUNOLOGY, WE
ALSO LOOKED FOR EVIDENCE OF
ELEVATED SITE -- INFLAMMATORY
CYTOKINES IN OUR PAH POPULATION.
SHOWN ON THIS SLIDE ARE SERUM
CONCENTRATIONS, OF IL 6, IL 8,
TNF ALPHA AND INTERFERON GAMMA.
HEALTHY CONTROLS ARE SHOWN IN
BLACK AND PH PATIENTS IN RED.
AS YOU CAN SEE THERE IS
SIGNIFICANT ELEVATION OF ALL
SERUM CYTOKINE LEVELS IN PH
PATIENTS COMPARED TO HEALTHY
CONTROLS PROVIDING EVIDENCE OF
SYSTEMIC INFLAMMATION IN IF
PULMONARY ARTERIAL HYPERTENSION.
NEXT IN COLLABORATION WITH THE
BIOMEDICAL AND METABOLIC IMAGING
BRANCH, WE ASSESSED CORONARY
PLAQUE BURDEN AS ANOTHER MARKER
OF SYSTEMIC INFLAMMATION.
THIS CARDIAC CT IMAGE IS FROM A
3-D GLOBAL RECONSTRUCTED
PROJECTION OF THE HEART SHOWN IN
THE CENTER IS AORTIC VALVE WITH
PROJECTING CORONARY ARTERIES
COLOR CODED.
TO ASSESS CORONARY PLAQUE
BURDEN, WE DIVIDE THE CORONARY
SYSTEM INTO 16 SEGMENTS AND
DETERMINE THE PERCENT OF THE 16
SEGMENTS WITH EVIDENCE OF
ATHEROSCLEROSIS.
PH PATIENTS ARE MATCHED TO
CONTROLS BY RISK FOR CORONARY
ARTERY DISEASE USING AGE,
GENDER, AND FRAMINGHAM SCORE.
THE BOX AND WHISKER PLOTS SHOW
PH PATIENTS IN RED BOX HAVE
SIGNIFICANTLY GREATER BURDEN OF
CORONARY PLAQUE COMPARED TO
HEALTHY INDIVIDUALS SHOWN IN THE
BLUE BOX.
AGAIN, EVIDENCE OF SYSTEMIC
INFLAMMATION.
IN OUR COHORT WE ALSO COMPARED
AND LOOK AT BLOOD MONONUCLEAR
CELL GENE EXPRESSION PROFILING
AMONG HEALTHY AND PULMONARY
ARTERIAL HYPERTENSION PATIENTS.
THIS HEAT MAP DEPICTS A
SUBSTANCETIVE GENES FROM PH LIST
THAT ANNOTATED TO INFLAMMATORY
RESPONSE.
EACH COLUMN REPRESENTS A
SUBJECT.
TEN HEALTHY SUBJECTS, AND TEN
PAH PATIENTS.
EACH ROW REPRESENTS AN
INFLAMMATORY RESPONSE GENE.
RED INDICATES OVEREXPRESSION AND
GREEN INDICATES UNDEREXPRESSION
OF THE TRANSCRIPT.
LISTED ALONG THE Y AXIS ARE
EXAMPLES OF INFLAMMATORY
RESPONSE GENES FROM OUR DATA
SET, SUCH AS INTEGRINS,
INTERLEUKINS AND P SELECTED.
THE PH PATIENTS COMPARED TO THE
HEALTHY CONTROLS SHOW CLEAR
OVEREXPRESSION OF INFLAMMATORY
RESPONSE GENES AS INDICATED BY
THE CONSIDERABLE BRIGHT RED
COLOR OF THEIR PANEL.
THERE EXISTS ABNORMAL
INFLAMMATORY RESPONSE IN BLOOD
MONONUCLEAR CELLS OF PAH
PATIENTS.
SUBSEQUENTLY WE COMPARED BLOOD
MONONUCLEAR CELL GENE EXPRESSION
PROFILING AMONG THE DIFFERENT
GROUPS OF PAH PATIENTS AND
HEALTHY CONTROLS.
SHOWN HERE ARE FOUR GROUPS,
IDIOPATHIC PULMONARY
HYPERTENSION, CONNECTIVE TISSUE
DISEASE ASSOCIATED PULMONARY
ARTERIAL HYPERTENSION, AND OTHER
ETIOLOGIES OF PULMONARY ARTERIAL
HYPERTENSION AND HEALTHY
VOLUNTEER GROUP.
ONCE AGAIN IN THE HEAT MAP, RED
INDICATES INCREASE EXPRESSION
AND THIS TIME BLUE INDICATES
DECREASED EXPRESSION.
EACH COLUMN REPRESENTS A
DIFFERENT PERSON AS ILLUSTRATED
BY THE BLACK VERTICAL BOX.
EACH ROW REPRESENTS A DIFFERENT
BLOOD INFLAMMATORY PROTEIN AS
SHOWN BY THE BLACK HORIZONTAL
BOX.
PLEASE APPRECIATE HOW MUCH
REDDER IT IS FOR THOSE WITH PAH
COMPARED TO ALL THE BLUE YOU SEE
ON THE RIGHT SIDE WHERE THE
HEALTHY VOLUNTEERS ARE LOCATED.
THUS THE STUDY DETECTED AN
ABNORMAL INFLAMMATORY RESPONSE
IN THE BLOOD OF PH PATIENTS EVEN
WHEN DIVIDED BY SPECIFIC
DIFFERING ETIOLOGIES.
WE ALSO PERFORM AD META ANALYSIS
OF BLOOD GENOME WIDE EXPRESSION
PROFILING STUDIES IN PULMONARY
ARTERIAL HYPERTENSION.
WE FOUND INFLAMMATORY PATHWAYS
TO BE OVERREPRESENTED AMONG
BIOFUNCTIONS, AS SHOWN ON THE
LEFT AND CANONICAL PATHWAYS
SHOWN ON THE RIGHT.
RECENTLY IN COLLABORATION WITH
THE LABORATORY OF APPLIED
PRECISION OMICS, WE INVESTIGATED
THE CONCENTRATIONS OF CELL FREE
DNA IN PATIENTS WITH IDIOPATHIC
CONNECTIVE TISSUE DISEASE AND
HYPERTENSION ASSOCIATED PAH.
COMPARED TO HEALTHY VOLUNTEER
PLASMA, CELL FREE DNA WAS
ELEVATED IN IDIOPATHIC PULMONARY
HYPERTENSION, CONNECTIVE TISSUE
DISEASE ASSOCIATED PULMONARY
ARTERIAL HYPERTENSION.
PORTAL HYPERTENSION ASSOCIATED
PAH AND ALL HE WILL VAGUES WERE
SIGNIFICANT.
WE USE BISULFIDE SEQUENCES AND
QUESTION CONVOLUTION ALGORITHM
TO MAP TISSUE SPECIFIC SOURCES
OF CELL FREE DNA.
THE INDIVIDUALS ARE CODE AID
CROSS THE DOP ROW, WITH HELL --
TOP ROW WITH HEALTHY BEING
PURPLE COLOR AND PH REPRESENTED
BY GREEN YELLOW AND RED.
WITH RED HAVING MOST SEVERE
PULMONARY ARTERIAL HYPERTENSION.
ALONG THE RIGHT IN A VERTICAL
COLUMN ARE VARIOUS TISSUES THAT
TURN OVER AND RELEASE CELL FREE
DNA.
HERE IS THE HEAT MAP, RED
IMPLIES RELATIVELY INCREASED
CELL FREE DNA COPY, AND BLUE
IMPLIES RELATIVELY DECREASED
CELL FREE DNA COPIES.
ONCE AGAIN, EACH COLUMN IS AN
INDIVIDUAL PERSON.
EACH ROW REPRESENTS A TISSUE
TYPE.
INSIDE THESE HORIZONTAL BLACK
BOXES I HIGHLIGHTED ROWS FROM
CELL FREE DNA NEUTROPHILS, AND
NATURAL KILLER CELLS.
ON THE RIGHT IN THE VET PALCAL
BLACK BOX IS HEALTHY CONTROLS
NOTE PURPLE ON THE TOP.
ON THE LEFT INSIDE THE VERTICAL
BLACK BOX IS MOSTLY PATIENT,
NOTE RED YELLOW AND GREEN AT THE
TOP.
NOTICE THE PA PATIENTS
PARTICULARLY THE HIGH RISK
GROUP, TEND TO BE REDDER
INDICATING THAT PART OF THE
INCREASED CELL FREE DNA COPIES
IN PULMONARY ARTERIAL
HYPERTENSION PATIENTS IS COMING
FROM INFLAMMATORY CELLS.
NEXT PAIR WISE COMPARISONS WERE
DONE BETWEEN PH PATIENTS AND
HEALTHY CONTROLS WHERE CELL
SPECIFIC DNA CONCENTRATIONS
RELATED TO NEUTROPHILS,
MONOCYTES AND NATURAL KILLER
CELLS.
DATA ARE DISPLAYED AS A MEAN
PLUS OR MINUS STANDARD DEVIATION
OF THE LOG 10 TRANSFORM VALUES.
PATIENTS ARE DIVIDED TO THREE
RISK GROUPS, BASED ON REVEAL 2.0
SCORE, LOW, MEDIUM AND HIGH.
PAIR WISE COMPARISONS BETWEEN
LOW RISK PH PATIENTS AND HEALTHY
CONTROLS WERE SIGNIFICANT FOR
ALL THREE CELL TYPES.
PAIR WISE COMPARISONS BETWEEN
MODERATE RISK PA PATIENTS AND
HEALTHY CONTROLS WERE
SIGNIFICANT FOR THE NEUTROPHILS
AND THE MONOCYTES AND FINALLY
PAIR WISE COMPARISONS BETWEEN
HIGH RISK PA PATIENTS AND
HEALTHY CONTROLS WERE
SIGNIFICANT FOR ALL THREE CELL
TYPES.
IN ALL INSTANCES CELL FREE DNA
FROM INFLAMMATORY CELLS WERE
HIGHER IN PH PATIENTS.
I WOULD NOW LIKE TO BRIEFLY
DISCUSS THE BASIS FOR OUR
SPURONO LACTONE INTERVENTIONAL
PULMONARY HYPERTENSION TRIAL.
CURRENTLY NONE OF THE IMPROVE
TREATMENT FOR PAH DIRECTLY
LIMITS INFLAMMATION.
DR. ELINOFF HAS ALREADY REVIEWED
THE MOLECULAR DATA SUGGESTING
SPIRONO LACTONE HAS
ANTI-INFLAMMATORY EFFECTS IN
PULMONARY ARTERIAL HYPERTENSION.
WE ALSO PERFORM A RETROSPECTIVE
COHORT ANALYSIS TO INVESTIGATE
THE EFFECTS OF SPIRONO LACTONE
THERAPY ON CIRCULATING MEDIATORS
OF INFLAMMATION.
ON THE LEFT THE INDICATOR SHOWS
DECREASES IN SERUM MEDIATED
CONCENTRATIONS SHOWN IN BLUE,
AND INCREASES IN ORANGE.
AS YOU CAN SEE, TREATMENT WITH
SPIRONO LACTONE WAS CONSISTENTLY
ASSOCIATED WITH DECREASED
CONCENTRATIONS OF INFLAMMATORY
MEDIATORS WHEN COMPARED TO
PATIENTS WHO WERE NOT TREATED
WITH SPIRONO LACTONE.
IN STARK CONTRAST, TREATMENT BE
ENDOTHELIN 1 RECEPTOR
ANTAGONIST, A PH SPECIFIC
THERAPY WAS INCREASED WITH
ANTI-INFLAMMATORY CONCENTRATIONS
AND OTHER DRUGS WERE ASSOCIATED
WITH MIXED EFFECTS.
TO DATE, WE HAVE ENROLLED 37 OF
A PLANNED 50 PATIENTS IN OUR
SPIRONO LACTONE RANDOMIZED
INTERVENTIONAL TRIAL.
THE STUDY IS RANDOMIZE DOUBLE
BLINDED PLACEBO CONTROL PHASE 1,
2 TRIAL, PRIMARY END POINTS
INCLUDES CHANGE IN PLACEBO
CORRECTED SIX MINUTE WALK
DISTANCE AND INCIDENCE OF
CLINICAL WORSENING.
THIS SLIDE ILLUSTRATES THE TIME
LINE OF OUR SPIR PH TRIAL,
PATIENTS UNDERGO BASELINE
TESTING CONSISTING OF CLINICAL
ASSESS.
, SIX MINUTE WALK TESTING, ECHO
CARD YES GRAM AND CARDIAC MRI
AND BLOOD RESEARCH TESTING.
PATIENTS WERE RANDOMIZED TO
STUDY LAB OR PLACEBO, LAB CHECKS
ARE DONE AND IF ALL WELL
PATIENTS DUCK YOU KNOW DOUBLED.
THEY RETURN FOR REPEAT TESTING
AT 12 AND 24 WEEKS.
PATIENTS CONTINUE RESEARCH
PARTICIPATION AT THE NIH
CLINICAL CENTER THROUGH NATURAL
HISTORY PROTOCOL TO DATE WE HAVE
ENROLLED 86 PATIENTS IN OUR
NATURAL HISTORY PULMONARY
ARTERIAL HYPERTENSION PROTOCOL.
KEY POINTS NORMAL RESPONSE
DETECTED IN BLOOD OF PH PATIENTS
ELEVATED CELL FREE DNA LEVELS
DETECTED IN PAH AND ASSOCIATED
WITH TISSUE INJURY PATTERN
INVOLVING INFLAMMATORY CELLS.
IN I A DIVISION TO CURRENT
PULMONARY VASODILATED THERAPY
TARGETED INFLAMMATION MAY REVEAL
A NEW TREATMENT PARADIGM.
DR. ELINOFF WILL NOW DESCRIBE
HOW WE HAVE TAKEN THE RESEARCH
BACK TO BENCH WITH PLANS TO
COLLABORATE WITH NCATS TO
LEVERAGE THEIR DRUG DISCOVERY
TOOLBOX TO PRODUCE SIMILAR
COMPOUNDS WITH ENHANCED BENEFIT
TO ADVERSE DRUG REACTION RATIOS.
I WILL TAKE THE BATON AND PASS
IT BACK TO HIM.
>> THANK YOU, MICHAEL.
SO IN THE LAST PART, OF OUR
PRESENTATION TODAY MOVING FROM
THE BEDSIDE BACK TO BENCH.
LY DISCUSS NEXT STEPS IN OUR
INVESTIGATION OF XPV DEGRADATION
AS NOVEL MECHANISM FOR TREATING
ENOPLIA FLAYMATION.
EARLY YE I PRODUCED SPIRONO
LACTONE.
THIS IS A DRUG DISCOVERY
PARADIGM AILING ATTORNEYTIVE TO
INHIBITING PROTEIN FUNCTION
THROUGH ACTIVE SITE BINDING.
THIS STRATEGY TARGETS WHAT IS
GENERALLY CONSIDERED THE
UNDRUGGABLE PROTEOME.
INCLUDING TRANSCRIPTION FACTORS,
SCAFFOLDING PROTEINS AND UNOTHER
NON-ENZYMATIC PROTEINS.
HERE ON THE LEFT IS SCHEMATIC OF
THE TF 2H TRANSCRIPTION FACTOR
COMPLEX.
FOLLOWING IN VITRO TREATMENT OF
CELLS WITH SPIRONO LACTONE THE
PROXIMATE KNOWN STEP IN XPV
DEGRADATION IS CDK 7 DEPENDENT
PHOSPHORYLATION OF XPV.
NEXT LEADS TO FORMATION OFCF
XPB UBIQUITINATION.
ONCE UBIQUITINATED VCP
SEGREGATES APPEARS REQUIRED FOR
SUBSEQUENT DEGRADATION OF THE
26S PROTEOSOME.
HOWEVER THERE ARE POTENTIAL
LIMITATIONS TO TRANSLATING THE
MECHANISM OF SPIRONO LACTONE
INDUCED DEGRADATION INTO
CLINICALLY RELEVANT OUTCOMES.
ON THE LEFT YOU CAN SEE
SIGNIFICANT REDUCTION OF XPV
BEGINS SPIRONO LACTONE
CONCENTRATIONS OF 3 MICROMOLAR
IN VITRO WHICH MAY NOT BE
ACHIEVABLE.
DATA FROM A RECENT TRIAL IN
PATIENTS WITH HEART FAILURE AND
PRESERVE EJECTION FRACTION, AT
DOSES UP TO 45 MILLIGRAMS THE
MEDIAN CONCENTRATION MAJOR
METABOLITE WAS WELL BELOW 1
MICROMOLAR.
THIS IS PARTICULARLY RELEVANT
GIVEN THAT SPIRONO LACTONE
ADVERSE EVENTS ARE DOSE
DEPENDENT AN LIMIT AMOUNT OF
DRUG SAFELY TOLERATED.
ADDITIONALLY, IN VIVO SPIRONO
LACTONE IS CONVERTED TO TWO
MAJOR METABOLITES.
7 ALPHA SPIRONO LACTONE AND --
NOTED THE THE LAST SLIDE.
UNLIKE SHOWN IN GREEN, BENEATH
EVERY OF THESE METABOLITES
INDUCE XPV DEGRADATION.
LIKEWISE SHOWN EARLIER WHILE
SPIRONO LACTONE IN GREEN REDUCES
NF KAPPA B AN AP 1 REPORTER
ACTIVITY, THIS ANTI-INFLAMMATORY
I WASOR EFFECT IS NOT OBSERVED
WITH EITHER TWO MAJOR
METABOLITES.
THEREFORE, IN PARTNERSHIP WITH
THE EARLY TRANSLATION BRANCH AT
THE NATIONAL CENTER FOR
ADVANCING TRANSLATIONAL
SCIENCES, OR NCATS, OUR GOAL IS
TO IDENTIFY NEW THERAPEUTICALLY
RELEVANT COMPOUNDS THAT INDUCE
XPV DEGRADATION AND SUPPRESS
INFLAMMATION.
WE ALSO PROPOSE TO USE GENOME
WIDE RNAi SCREENING AS WELL AS
MOLECULAR MODELING AND STRUCTURE
BASED PREDICTION TOOLS IN ORDER
TO DETERMINE SPECIFIC BINDING
TARGETS.
THERE BY ADVANCING THE CURRENT
WORKING MODEL OF DRUG INDUCED
XPV DEGRADATION.
THE FIRST STEP IN THIS PROJECT
WAS TO DESIGN AND VALIDATE ASSAY
SYSTEM THAT WAS AMENABLE TO HIGH
THROUGH PUT SCREENING.
IN COLLABORATION WITH KEN CHANG
IN THE FUNCTIONAL GENOMICS LAB
AT NCATS, CRISPR C SARKS 9 WAS
USED TO TAG PROTEIN WITH 1 # 1
AMINO ACID LUMINESCENT REPORTER
PEPTIDE IN HUMAN EMBRYONIC
KIDNEY CELLS.
DUE TO ITS SMALL SIZE, IT CAN BE
EFFECTIVELY INSERTED TO THE
GENOME WITHOUT DELETERIOUS
EFFECTS TO THE FUNCTION OR
LOCALIZATION OF THE TAG
ENDOGENOUS PROTEIN.
IN OUR CASE, FOUR GUIDE RNAs
WERE TESTED FOR GENE EDITING.
THIS RESULTED IN FOUR DIFFERENT
CELL LINES EXPRESSING XPV HIGH
BIT FUSION PROTEIN.
WHEN CELLS CONTAINING HIGH BIT
TAG XPV ARE LYSED AND COMPLEX
WITH L G BIT THEY RECONSTITUTE A
SENSITIVE LYM LESS SENT REPORTER
AND LIGHT IS REDUCED IN
PROPORTION TO PROTEIN LEVELS.
T SHOWN ON THE LEFT THE Y AXIS
REPRESENTS FULL CHANGE IN
LUMINESCENCE OF THE TRANSFECTED
CELLS.
OF THE FOUR RNAs, 3 AND 4 HAD
HIGHEST INCREASE IN
LUMINESCENCE.
WE EXAMINED SPIRONO LACTONE
INDUCED DEGRADATION.
ON THE RIGHT WESTERN BLOTTING
WITH AN ANTI-XPV ANTIBODY SHOWS
REDUCTION OF XPV IN THE PRESENCE
OF SPIRON LACTONE BUT MORE
IMPORTANTLY USING ANTI-HIGH BIT
ANTIBODY WE SEE THAT THE X PV
HIGH BIT FUSION PROTEIN IS
SIMILARLY REDUCED IN THE
PRESENCE OF SPIRONO LACTONE
DEMONSTRATING IT REMAINS
SUSCEPTIBLE TO INDUCED
DEGRADATION.
CONSISTENT WITH SPIRONO LACTONE
INDUCED DEGRADATION OF HIGH BIT
FUSION PROTEIN WE SEE REDUCTION
IN LUMINESCENCE FOLLOWING
TREATMENT FOR ONE, TWO AND 4
FORCE.
THUS THIS ASSAY SYSTEM CAN BE
USED FOR HIGH THROUGH PUT SMALL
MOLECULE SCREENING TO IDENTIFY
OTHER COMPOUNDS THAT INDUCE XPV
DEGRADATION AS A WELL AS A
PLATFORM FOR GENOME WIDE RNAi
SCREENING.
IN ADDITION TO CONFIRMING THAT
THE FUSION PROTEIN IS
SUSCEPTIBLE TO SPIRONO LACTONE
INDUCED DEGRADATION IT WAS USED
TO VERIFY LOCALIZATION AND
FUNCTION OF THE HIGH BIT TAG
XPB: AS SHOWN HERE STAINED IN
RED, HIGH BIT TAG XPB APPEARS
PREDOMINANTLY LOCALIZED TO THE
NUCLEUS.
SIMILAR TO THE BLUE NUCLEAR
STAIN.
THIS IS HIGHLIGHTED IN THE
MERGED IMAGE TO THE RIGHT WHERE
OVERLAPPING OF RED AND BLUE
RESULT IN A PURPLE COLOR.
FURTHERMORE WHEN CELLS TREAT
WITH SPIRONO LACTONE SIGNIFICANT
REDUCTION IN RED STAINING HIGH
BIT TAG XPB LEADS BLUE NUCLEAR
STAINENING THE MERGED IMAGE --
STAINENING THE MERGED IMAGE TO
THE RIGHT.
IN TERMS OF FUNCTION IN PRESENCE
OF INFLAMMATORY STIMULUS, THE NF
KAPPA B AN AP 1 REPORTER GENES
ARE ACTIVATED IN HEP 293 CELLS
EXPRESSING THE HIGH BIT FUSION
PROTEIN.
AND AS EXPECTED, GENE ACTIVATION
IS SUPPRESSED BY SPIRONO
LACTONE.
NOW WITH A VALIDATED WORKING
HIGH THROUGH PUT ASSAY IN HAND
WE PLAN TO PROCEED WITH
SCREENING NCATS SMALL MOLECULE
LIBRARIES INCLUDING PHARMACO
LOGICALLY ANNOTATED CHEMICAL
TOOLBOX, COMPLIMENTARY
APPROACHES WOULD INCLUDE A
GENOME WIDE RNAi SCREEN
MOLECULAR MODELING AND STRUCTURE
BASED PREDICTION TOOLS.
COMPOUNDS IDENTIFIED IN THIS
INITIAL SCREEN WOULD BE TESTED
FOR ANTI-INFLAMMATORY ACTIVITY
AS WELL AS UNDERGO ADDITIONAL
MECHANISTIC STUDIES.
LEAD COMPOUNDS WOULD BE TESTED
IN OUR HUMAN ENDOTHELIAL CELL
MODELS OF PAH AND UNDERGO
PHARMACOKINETIC AND
PHARMACODYNAMIC OPTIMIZATION.
FOLLOWED BY PRE-CLINICAL TESTING
IN PAH SMALL ANIMAL MODELS AND
ULTIMATELY EARLY PHASE CLINICAL
TRIALS CONDUCTED HERE AT THE NIH
CLINICAL CENTER.
CRITICAL TO THIS ENDEAVOR WE
ESTABLISHED A RELEVANT RAT MODEL
PAH IN ORDER TO INVESTIGATE
PROMISING THERAPEUTIC TARGETS
IDENTIFIED IN OUR LAB.
RATS ARE INJECTED SUBCUTANEOUSLY
WITH A SINGLE DOSE OF SU 5416
TYROSINE KINASE INHIBITOR.
THEN EXPOSED TO HYPOXIA FOR
THREE WEEKS.
AFTER THEY RETURN TO NORM OXIA
FOR THE REMAINDER OF THE STUDY.
IN THIS THE RATS DEVELOPED
SEVERE DYSFUNCTION AS SHOWN BY
CARDIAC MRI WHERE THE RATIO OF
THE THE RV AND DIASTOLIC VOLUME
TO LV DIASTOLIC VOLUME INCREASE.
IN CARDIAC INDEX IS REDUCED THE
PA CLASS.
INVASIVE HEMODYNAMIC
MEASUREMENTS AT TEN WEEKS
DEMONSTRATE SIGNIFICANTLY
ELEVATED PULMONARY ARTERY
PRESSURE, AND LUNG HISTOLOGY
DEMONSTRATES SEVERE VASCULAR
REMODELING THAT CLOSELY
RESEMBLES THE CHANGES FOUND IN
LUNGS FOR PAH PATIENTS.
IN SUMMARY, INDUCING XPV
DEGRADATION IS A NOVEL STRATEGY
TORR TREATING VASCULAR
INFLAMMATION IN PAH THAT MAY BE
APPLICABLE TO A WIDE RANGE OF
CARDIOVASCULAR CONDITIONS.
ANTI-INFLAMMATORY COMPOUNDS WITH
UNIQUE MECHANISM OF ACTION IDE
ANIED MAY OFFER NEW OPTIONS FOR
PATIENTS SUFFERING FROM
AUTOIMMUNE OR AUTOI BELIEVE AUTY
DISEASE.
THE SELECTION OF PROTEIN
DEGRADATION HAS BROAD
IMPLICATIONS FOR DRUG DISCOVERY
AND DEVELOPMENT AND MAY ENABLE
TARGETING MOLECULES HEAVE
EVIDENCE PREVIOUSLY THOUGHT
UNDRUGGABLE.
IN CONCLUSION WE HOPE WE
EMPHASIZED THE CURRENT NEED FOR
THERAPIES IN PAH GIVEN THAT OUR
CURRENT ARMAMENTARIUM DOESN'T
OFFER A CURE AND RATHER THAN
ONLY TREATING ELEVATED PULMONARY
ARTERIAL PRESSURE, IN RIGHT
VENTRICULAR DYSFUNCTION AT TIP
OF THE ICEBERG WE NEED TO LOOK
DEEPER TO APPRECIATE THE COMPLEX
INTERRELATED MOLECULAR
PROCESSES.
IN PAH PULMONARY VASCULAR
LESIONS SUBSIST IN A
MICROENVIRONMENT UNTARGETTED BY
CURRENT THERAPIST.
-- THERAPIES.
OUR PROGRAM IS LEVERAGING A
BENCH TO BEDSIDE AND BACK
APPROACH TO IDENTIFY NOVEL
THERAPIES THAT CAN BE TESTED
HERE AT THE NIH CLINICAL CENTER
WITH THE HOPE ONE DAY WE WILL BE
ABLE TO OFFER OUR PATIENTS A
CURE.
ON BEHALF OF MIKE AND I WE WOULD
LIKE TO THANK THE ENTIRE PAH
GROUP HERE IN THE CRITICAL CARE
MEDICINE DEPARTMENT, WE COULDN'T
HAVE DONE IT WITH SUCH A
WONDERFUL GROUP OF HARDWORKING
ENERGETIC BRILLIANT PEOPLE, ALSO
VERY THANKFUL FOR THE INTRAMURAL
COMMUNITY AND THE COLLABORATIONS
THAT WE HAVE HAD THAT HELPED
THESE PROJECTS AS WELL AS
EXTRAMURAL CLAY B COLLABORATOR.
WITH THAT WE ARE HAPPY TO TAKE
QUESTIONS WITH THE REMAINING
TIME.
>> THANK YOU, DR. SOLOMON AND
DR. ELINOFF FOR THE REALLY
WONDERFUL PRESENTATION ON THE
PATHOPHYSIOLOGY OF PAH AND ITS
GROUP THERAPIES AND YOUR WORK ON
SUSTAINING INFORMATION IN PAH
ESPECIALLY WITH YOUR SPIR TRIAL,
INSIGHTS IN YOUR COLLABORATION
ONE ANOTHER AND APPROACH OF
NCATS OFFERS SOME VERY EXCITING
THERAPEUTIC STRATEGIES FOR
DISEASE THAT IS HISTORICALLY
FRUSTRATINGLY DIFFICULT TO
TREAT.
BEFORE I GO ON TO QUESTIONS, I
WANT TO JUST FOR THE VIEWING
AUDIENCE, THE CORRECT CME CODE
TODAY WE GAVE YOU THE WRONG ONE
IS 36726.
PLEASE TEXT THE CODES TO THE
JOHNS HOPKINS CME PHONE NUMBER.
WE APOLOGIZE FOR THAT.
WE HAVE TIME FOR COUPLE OF
QUESTIONS.
ONE GIVEN THE EFFECT OF
(INDISCERNIBLE) IN JAK STAT
MEDIATED INFLAMMATION, IS THERE
A ROLE FOR NK 6 G2 CELLS IN PAH?
>>
>> THAT IS INTERESTING QUESTION.
SO SOME OF THE JAK STAT
INHIBITORS HAVE BEEN TESTED IN
ANIMAL MODELS OF PAH, CHRONIC
HYPOXIA MODEL MONOCLONALLY MODEL
THAT IS CHARACTERIZED BY QUITE
BIT OF INFLAMMATORY RESPONSE.
THEY HAVE BEEN SUCCESSFUL THERE.
AS FAR AS THAT EFFICACY BEING
ATTRIBUTED SPECIFICALLY TO NK
CELLS ACTUALLY THEIR WORK ON NK
CELLS WHICH IS A LITTLE OUTSIDE
MY EXPERTISE, HAS SHOWN IN THE
FIELD THERE BEING IMBALANCE NK
CELL SUB SETS IN PAH PATIENTS
AND THEN IN MODELS OF NK CELL
DEFICIENCY AND KNOCK OUT MOUSE
MORE SEVERE HYPOXIA RESPONSES IN
PH IN THAT ANIMAL MODEL.
SO THERE DOES APPEAR TO BE AN
IMPORTANT ROLE FOR NK CELLS IN
PH PATHOGENESIS.
OUR CELL FREE DNA ALSO DETECTED
THE CELL FREE DNA FROM THAT
LYMPHOCYTE SUBSET, WHETHER THE
EFFICACY OF JAK STAT INHIBITORS
ARE DUE TO SPECIFIC NK CELL,
SUBTYPE I'M NOT SURE YET.
>> OKAY.
THANK YOU.
FROM UNFORTUNATELY, THAT BRINGS
US UP TO -- I HAD A QUESTION
MYSELF I MAY EMAIL SEPARATELY.
THANK YOU, THAT BRINGS US UP TO
THE HOUR.
I WANT TO THANK BOTH OF YOU FOR
CAPTIVATING PRESENTATIONS AND WE
WISH ALL OF YOU MUCH SUCCESS IN
YOUR INVESTIGATIONS.
TO EVERYONE, HAVE A GREAT
AFTERNOON.
THANK YOU FOR JOINING US TODAY.
>>THANK YOU, EVERYONE.