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Correcting Smad1/5/8, mTOR, and VEGFR2 treats pathology in hereditary hemorrhagic telangiectasia models
Santiago Ruiz, … , Fabien Campagne, Philippe Marambaud
Santiago Ruiz, … , Fabien Campagne, Philippe Marambaud
Published November 5, 2019
Citation Information: J Clin Invest. 2020;130(2):942-957. https://doi.org/10.1172/JCI127425.
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Research Article Cell biology Vascular biology

Correcting Smad1/5/8, mTOR, and VEGFR2 treats pathology in hereditary hemorrhagic telangiectasia models

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Abstract

Hereditary hemorrhagic telangiectasia (HHT), a genetic bleeding disorder leading to systemic arteriovenous malformations (AVMs), is caused by loss-of-function mutations in the ALK1/ENG/Smad1/5/8 pathway. Evidence suggests that HHT pathogenesis strongly relies on overactivated PI3K/Akt/mTOR and VEGFR2 pathways in endothelial cells (ECs). In the BMP9/10-immunoblocked (BMP9/10ib) neonatal mouse model of HHT, we report here that the mTOR inhibitor, sirolimus, and the receptor tyrosine kinase inhibitor, nintedanib, could synergistically fully block, but also reversed, retinal AVMs to avert retinal bleeding and anemia. Sirolimus plus nintedanib prevented vascular pathology in the oral mucosa, lungs, and liver of the BMP9/10ib mice, as well as significantly reduced gastrointestinal bleeding and anemia in inducible ALK1-deficient adult mice. Mechanistically, in vivo in BMP9/10ib mouse ECs, sirolimus and nintedanib blocked the overactivation of mTOR and VEGFR2, respectively. Furthermore, we found that sirolimus activated ALK2-mediated Smad1/5/8 signaling in primary ECs — including in HHT patient blood outgrowth ECs — and partially rescued Smad1/5/8 activity in vivo in BMP9/10ib mouse ECs. These data demonstrate that the combined correction of endothelial Smad1/5/8, mTOR, and VEGFR2 pathways opposes HHT pathogenesis. Repurposing of sirolimus plus nintedanib might provide therapeutic benefit in patients with HHT.

Authors

Santiago Ruiz, Haitian Zhao, Pallavi Chandakkar, Julien Papoin, Hyunwoo Choi, Aya Nomura-Kitabayashi, Radhika Patel, Matthew Gillen, Li Diao, Prodyot K. Chatterjee, Mingzhu He, Yousef Al-Abed, Ping Wang, Christine N. Metz, S. Paul Oh, Lionel Blanc, Fabien Campagne, Philippe Marambaud

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Figure 8

Siro + Nin effectively reduces GI bleeding and ameliorates anemia in adult Alk1-iKO mice.

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Siro + Nin effectively reduces GI bleeding and ameliorates anemia in adu...
(A–C) GI tract from stomach to rectum of 2- to 4-month-old CreER-negative control (CTRL; A) and Alk1-iKO mice treated with vehicle (DMSO; B) or Siro + Nin (C). Higher magnifications show the cecum. Scale bars: 10 mm (A–C). (D–G) Scatter plots measuring cecum bleeding index (D), hematocrit (HCT) level (E), red blood cell (RBC) number (F), and hemoglobin (Hb) level (G). Data represent mean ± SEM (n = 2–4, 7–8, and 10 mice for the CTRL, DMSO, and Siro + Nin groups, respectively); 1-way ANOVA (D–F) and 2-way ANOVA (G), Tukey’s multiple-comparisons test. **P < 0.01; ***P < 0.001; ****P < 0.0001. CBC parameters of the controls were within the expected ranges for adult mice.
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