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Hemodynamic and Clinical Onset in Patients with Hereditary Pulmonary

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Hemodynamic and Clinical Onset in Patients with Hereditary Pulmonary Pfarr et al. Respiratory Research 2011, 12:99 http://respiratory-research.com/content/12/1/99 RESEARCH Open Access Hemodynamic and clinical onset in patients with hereditary pulmonary arterial hypertension and BMPR2 mutations Nicole Pfarr1,2†, Justyna Szamalek-Hoegel2†, Christine Fischer2†, Katrin Hinderhofer2, Christian Nagel1, Nicola Ehlken1, Henning Tiede3, Horst Olschewski4, Frank Reichenberger3, Ardeschir HA Ghofrani3, Werner Seeger3 and Ekkehard Grünig1* Abstract Background: Mutations in the bone morphogenetic protein receptor 2 (BMPR2) gene can lead to idiopathic pulmonary arterial hypertension (IPAH). This study prospectively screened for BMPR2 mutations in a large cohort of PAH-patients and compared clinical features between BMPR2 mutation carriers and non-carriers. Methods: Patients have been assessed by right heart catheterization and genetic testing. In all patients a detailed family history and pedigree analysis have been obtained. We compared age at diagnosis and hemodynamic parameters between carriers and non-carriers of BMPR2 mutations. In non-carriers with familial aggregation of PAH further genes/gene regions as the BMPR2 promoter region, the ACVRL1, Endoglin, and SMAD8 genes have been analysed. Results: Of the 231 index patients 22 revealed a confirmed familial aggregation of the disease (HPAH), 209 patients had sporadic IPAH. In 49 patients (86.3% of patients with familial aggregation and 14.3% of sporadic IPAH) mutations of the BMPR2 gene have been identified. Twelve BMPR2 mutations and 3 unclassified sequence variants have not yet been described before. Mutation carriers were significantly younger at diagnosis than non-carriers (38.53 ± 12.38 vs. 45.78 ± 11.32 years, p < 0.001) and had a more severe hemodynamic compromise. No gene defects have been detected in 3 patients with HPAH. Conclusion: This study identified in a large prospectively assessed cohort of PAH- patients new BMPR2 mutations, which have not been described before and confirmed previous findings that mutation carriers are younger at diagnosis with a more severe hemodynamic compromise. Thus, screening for BMPR2 mutations may be clinically useful. Introduction been identified as a gene underlying HPAH in approxi- Pulmonary arterial hypertension (PAH) is a rare vascular mately 10 to 40% of patients with apparently sporadic disorder characterised by increased pulmonary vascular disease [1,3-6] and in 58% to 74% of patients with famil- resistance and right heart failure. PAH can be idiopathic ial PAH [1,4,6,7]. In total 298 different mutations in (IPAH), heritable (HPAH) or associated with other con- BMPR2 have been identified so far in independent ditions (APAH) as connective tissue diseases, congenital patients including those with a known PAH family his- heart diseases, portal hypertension, drug or toxin expo- tory, sporadic disease and PAH associated with other sure [1,2]. Heterozygous germline mutations in the bone diseases [1]. In a few PAH patients mutations in other morphogenetic protein type 2 receptor (BMPR2)have genes participating in the BMPR2 signalling pathway have been identified, as Activin A receptor type II-like 1 * Correspondence: [email protected] (ACVRL1, also called ALK1)[8],Endoglin [9], and † Contributed equally 1Centre for Pulmonary Hypertension Thoraxclinic, University of Heidelberg, SMAD8 [10]. Nevertheless, there is still a small Heidelberg, Germany Full list of author information is available at the end of the article © 2011 Pfarr et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pfarr et al. Respiratory Research 2011, 12:99 Page 2 of 10 http://respiratory-research.com/content/12/1/99 proportion of patients with familial aggregation of PAH mortem examination. Familial disease has been postu- in which no gene defects can be detected so far [7,11]. lated when PAH was diagnosed in at least two family HPAH patients carrying a BMPR2 mutation develop members. Sporadic IPAH was stated when family history the disease approximately 10 years earlier than non-car- and medical records of family members were negative. riers, with more severe hemodynamic changes [6,12-15] The Ethics Committees of the Medical Faculties of the and a reduced response to acute vasodilator testing Universities of Heidelberg and Giessen approved the [6,12,14-16]. Patients carrying ACVRL1 or Endoglin protocol of this study, and the family members gave mutations have been characterised to be of younger age their written informed consent. All participating patients at diagnosis and death as patients without mutations and family members underwent genetic counselling. The [14]. A recent study of Austin et al [17] showed that study was part of the European Projects “Pulmotension” HPAH female patients with missense mutations in the which belongs to the 6th European Framework. BMPR2 gene had a more severe disease than patients with truncating mutations. These publications indicate Mutation analysis of the BMPR2 gene that the clinical phenotype of PAH can be affected by EDTA-blood samples were collected for genetic analysis the type of mutation. However, most data comparing in all patients and from all family members, if available. clinical features between BMPR2 mutation carriers and Human genomic DNA was prepared from peripheral non-carriers have been obtained from registries as from blood lymphocytes. The complete coding sequence and the French Network of Pulmonary Hypertension exon/intron boundaries of the BMPR2 gene from each [6,13-15], and from centres in the United States as the individual were amplified and analysed by DHPLC and/ New York Presbyterian Pulmonary Hypertension Center or direct sequencing as previously described [4]. HPAH [12], the Utah Pulmonary Hypertension Genetics Project patients without an obvious BMPR2 mutation were also [16] or the Vanderbilt University School of Medicine, analysed for mutations in the BMPR2 promoter, the Nashville, Tennessee [7,17,18] and are retrospective in ACVRL1 gene, Endoglin gene, and SMAD8 gene. In design. The genetic mechanism of PAH remains unclear HPAH cases all first degree relatives were investigated in those families in which no BMPR2 mutation can be for the mutation identified in the index patient. Primer detected. sequences and PCR conditions are available upon Therefore, the aim of this study was to evaluate hemo- request. Standard DNA sequencing reactions were per- dynamic parameters and genetic status in a large Ger- formed using version 1.1 of Big Dye terminator cycle man cohort of patients using a prospective design. The sequencing kit (Applied Biosystems Inc., Darmstadt) and frequency of known BMPR2 mutations has been ana- were analysed on a Genetic Analyzer 3100 (Applied Bio- lysed and a detailed search for new BMPR2 mutations systems Inc., Darmstadt). Pathogenicity of identified has been performed. In this study, we present 12 new sequence alterations were assessed by use of the pro- BMPR2 mutations and 3 unclassified variants which gram MutationTaster http://www.mutationtaster.org/ have not been described before. Furthermore, we and by ESEfinder 3.0 software http://rulai.cshl.edu/cgi- describe the clinical features of families with confirmed bin/tools/ESE3/esefinder.cgi. familial aggregation of PAH but no detectable mutations Screening for larger rearrangements was performed of the BMPR2 gene and tested these families for muta- with the SALSA Multiplex Ligation-dependent Probe tions of the genes ACVRL1, Endoglin, and SMAD8. Amplification (MLPA) P093-B1 HHT/PPH1 probe mix kit (MRC-Holland BV, Amsterdam, The Netherlands). Materials and methods The mutation nomenclature refers to the NCBI Study Population human BMPR2 nucleotide sequence (NCBI: This prospective study investigated adult patients (≥ 18 NM_001204) and is expressed following the standard years) with confirmed sporadic IPAH or familial HPAH recommendations of the Association for Molecular between January 2006 and December 2009, who agreed Pathology Training and Education Committee [19] with to a genetic testing and from whom EDTA-blood was the A of the ATG start codon denoted as +1 and the obtained. Patients have been seen in the centres of pul- initiator methionine as codon 1. monary hypertension (PH) of Heidelberg and Giessen and underwent complete clinical and genetic work-up. Results In all patients a right heart catheterization and a Study Population detailed family history was obtained and a three to four Between January 2006 and December 2009 in total 262 generation pedigree was constructed. For deceased rela- patients agreed to participate in the study and EDTA- tives, medical records were reviewed when available and blood has been stored for genetic analysis. Thirty-one the diagnosis of PAH was based on the criteria used for patients had to be excluded due to several reasons. In indexpatientsaswellasontheresultsofthepost 23 patients the further diagnostic work-up revealed a Pfarr et al. Respiratory Research 2011, 12:99 Page 3 of 10 http://respiratory-research.com/content/12/1/99 non-idiopathic form of pulmonary hypertension. In 3 Clinical and hemodynamic characteristics patients the clinical data have been incomplete and in The mean age at diagnosis of all 231 patients was 43.49 another 5 patients not enough blood for genetic analysis ±
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