Pregnancy-associated plasma protein A – a new indicator of pulmonary vascular remodeling in chronic thromboembolic pulmonary hypertension?
verfasst von:
Steffen D. Kriechbaum, Felix Rudolph, Christoph B. Wiedenroth, Lisa Mielzarek, Moritz Haas, Stefan Guth, Christian W. Hamm, Eckhard Mayer, Christoph Liebetrau, Till Keller
In chronic thromboembolic pulmonary hypertension (CTEPH) impaired pulmonary hemodynamics lead to right heart failure. Natriuretic peptides reflect hemodynamic disease severity. Pregnancy-associated plasma protein-A (PAPP-A) might address another aspect of CTEPH - chronic tissue injury and inflammation. This study assessed dynamics of PAPP-A in CTEPH patients who undergo therapy with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA).
Methods
The study included a total of 125 CTEPH patients scheduled for treatment (55 PEA/ 70 BPA) and a control group of 58 patients with pulmonary hypertension other than CTEPH. Biomarker measurement was performed at baseline and follow-up in the CTEPH cohort, prior to each BPA in the BPA cohort and once in the control group.
Results
The median PAPP-A level was slightly higher (p = 0.05) in CTEPH patients [13.8 (11.0–18.6) mU/L], than in the control group [12.6 (8.6–16.5) mU/L], without a difference between the BPA and PEA group (p = 0.437) and without a correlation to mean pulmonary artery pressure (p = 0.188), pulmonary vascular resistance (p = 0.893), cardiac index (p = 0.821) and right atrial pressure (p = 0.596). PEA and BPA therapy decreased the mean pulmonary artery pressure (p < 0.001) and pulmonary vascular resistance (p < 0.001) and improved the WHO-functional-class (baseline: I:0/II:25/III:80/IV:20 vs. follow-up: I:55/II:58/III:10/IV:2). PAPP-A levels decreased after PEA [13.5 (9.5–17.5) vs. 11.3 (9.8–13.6) mU/L; p = 0.003) and BPA treatment [14.3 (11.2–18.9) vs. 11.1 (9.7–13.3) mU/L; p < 0.001). The decrease of PAPP-A levels is delayed in comparison to N-terminal pro-B-type natriuretic peptide.
Conclusion
PAPP-A is overexpressed in CTEPH and decrease significantly after surgical or interventional therapy, however without association to hemodynamics. Further investigation is needed to define the underlying mechanism of PAPP-A expression and changes after therapy in CTEPH.
Hinweise
Christoph Liebetrau and Till Keller contributed equally as last authors.
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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abkürzungen
12-MFU
Follow-Up twelve month after PEA
6-MFU
Follow-Up six month after last BPA
BPA
Balloon pulmonary angioplasty
CTEPH
Chronic thromboembolic pulmonary hypertension
eGFR
estimated glomerular filtration rate
IGF(−I)
Insulin-like growth factor (− 1)
IQR
Interquartile range
meanPAP
Mean pulmonary artery pressure
NT-proBNP
N-terminal pro brain natriuretic peptide
PAPP-A
Pregnancy-associated plasma protein A or Pappalysin-1
PCWP
Pulmonary capillary wedge pressure
PEA
Pulmonary endarterectomy
PH
Pulmonary hypertension
PVR
Pulmonary vascular resistance
SD
Standard deviation
WU
Wood units
Introduction
In chronic thromboembolic pulmonary hypertension (CTEPH) insufficient thrombus resolution and vascular remodeling lead to chronic obstructions of the pulmonary arteries [1]. The corresponding impaired pulmonary hemodynamics burden the right heart, cause right heart remodeling and ultimately failure [1]. Pulmonary endarterectomy (PEA), medical treatment targeting pulmonary hypertension (PH) and balloon pulmonary angioplasty (BPA) are specific treatment modalities [1]. Impaired pulmonary hemodynamics in CTEPH correlate with non-invasively measured blood biomarkers such as natriuretic peptides and render such markers as indicators for disease severity and therapy response [2]. Considering the multifaceted pathophysiology of CTEPH, biomarkers not primarily reflecting hemodynamics might further provide information about individual disease mechanisms facilitating treatment decisions. Pregnancy-associated plasma protein-A (PAPP-A), clinically established in the pregnancy first-trimester-screening, was identified as key regulator of insulin-like growth factor (IGF)/IGF-binding-protein pathways via cleaving of IGF-binding-protein [3]. This pathway has been reported in the context of atherosclerosis, coronary artery disease, heart failure and non-cardiac conditions [4]. Its role in PH, especially CTEPH, has not been investigated so far.
The current study aimed to evaluate PAPP-A levels in CTEPH and to explore the potential modification of PAPP-A levels by PEA or BPA treatment.
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Methods
We analyzed 125 consecutive patients with CTEPH and 58 controls (Patients with PH and suspected CTEPH that was excluded after diagnostic workup). Standardized diagnostic and therapeutic work-up of CTEPH patients has been published earlier [2]. The CTEPH group of the study included 55 patients that underwent PEA and 70 in whom BPA was performed. In PEA patients, biospecimen were obtained at baseline and 12 months after surgery (12-MFU), in BPA at baseline, before each staged procedure and 6 months after the final procedure (6-MFU). In control patients, biomaterial was obtained at enrollment. The biomaterial included venous blood samples that were aliquoted and frozen at − 80 °C. The study was approved by the respective local ethics committee and each patient gave written informed consent. PAPP-A was measured in frozen serum samples using an automated immunofluorescence assay on the Kryptor compact plus instrument (PAPP-A Thermo Scientific, BRAHMS GmbH, Henningsdorf, Germany).
Variables are expressed as median (IQR), mean ± SD or number (%) as appropriate. Comparative analyses used the Student t-test, Mann-Whitney-U-test, Wilcoxon signed-rank test, X2-test and Fisher-Yates test. Bivariate Pearson correlation assessed associations of PAPP-A with pulmonary hemodynamics and other biomarkers. All p-values are seen as descriptive. Statistical analyses were performed with R3.5.1 software package (R Foundation for Statistical Computing, Vienna, Austria).
Results
The comparative analysis of hemodynamic findings revealed a higher pulmonary artery pressure (meanPAP; 43.1 ± 9.7 vs. 39.9 ± 10.9 mmHg; p = 0.041) and pulmonary vascular resistance (PVR; 6.76(5.27–9.61) vs. 4.63(3.15–10.3) WU; p = 0.006) in CTEPH patients compared to the PH control group at baseline. A comprehensive illustration of baseline characteristics of the CTEPH cohort and the control group is provided in Table 1.
Table 1
Baseline characteristics of the CTEPH cohort and the control group
CTEPH (total)
CTEPH (BPA)
CTEPH (PEA)
Pulmonary Hypertension other than CTEPH (Controls)
PEA vs. BPA
CTEPH vs. Controls
n = 125
n = 70
n = 55
n = 58
(p-value)
(p-value)
Data availability
Demographics
Age, y; mean ± SD
183/183
59.3 ± 14.3
60.83 ± 13.5
57.35 ± 15.2
62.28 ± 14.6
0.277
0.14
Female sex; n (%)
183/183
52 (41.6%)
30 (42.86%)
22 (40%)
35 (60.34%)
0.89
0.028
Body mass index, kg/m2; mean ± SD
183/183
25.94 ± 4.5
25.09 ± 3.7
27.02 ± 5.1
30.89 ± 7.9
0.046
< 0.001
History and risk factors
Smoker; n (%)
181/183
55 (44.72%)
31 (45.59%)
24 (43.64%)
31 (53.45%)
0.973
0.348
Diabetes mellitus; n (%)
183/183
6 (4.8%)
4 (5.71%)
2 (3.64%)
16 (27.59%)
0.694
< 0.001
Dyslipidemia; n (%)
182/183
23 (18.55%)
17 (24.29%)
6 (11.11%)
14 (24.14%)
0.101
0.499
Arterial hypertension; n (%)
182/183
59 (47.58%)
36 (51.43%)
23 (42.59%)
36 (62.07%)
0.426
0.096
Chronic renal failure; n (%)
183/183
26 (20.8%)
13 (18.57%)
13 (23.64%)
15 (25.86%)
0.638
0.566
Coronary artery disease; n (%)
182/183
20 (16.13%)
14 (20.29%)
6 (10.91%)
12 (20.69%)
0.244
0.586
History of cancer; n (%)
183/183
18 (14.4%)
13 (18.57%)
5 (9.09%)
16 (27.59%)
0.214
0.054
History of acute pulmonary embolism; n (%)
182/183
110 (88.71%)
56 (81.16%)
54 (98.18%)
45 (77.59%)
0.003
0.081
Chronic obstructive pulmonary disease; n (%)
175/183
8 (6.84%)
4 (6.35%)
4 (7.41%)
12 (20.69%)
1
0.014
History of splenectomy; n (%)
183/183
9 (7.2%)
6 (8.57%)
3 (5.45%)
3 (5.17%)
0.73
0.755
Chronic inflammatory disease; n (%)
183/183
3 (2.4%)
1 (1.43%)
2 (3.64%)
6 (10.34%)
0.582
0.030
Laboratory parameters
Ceatinine, μmol/l; mean ± SD
183/183
0.97 ± 0.3
0.95 ± 0.3
1 ± 0.3
0.93 ± 0.4
0.298
0.058
eGFR, ml/min; mean ± SD
183/183
82.5 ± 25.7
83.62 ± 26.6
81.08 ± 24.7
86.63 ± 34.5
0.603
0.558
NT-proBNP, ng/l; median (IQR)
176/183
845 (184.2–1860)
743.7 (197.2–1470)
1094 (149.775–2078.25)
412 (181.8–1454.5)
0.296
0.282
PAPP-A, mU/L
183/183
13.8 (11.0–18.6)
14.5 (11.2–18.9)
13.7 (10.4–17.6)
12.6 (8.6–16.5)
0.437
0.051
Symptoms and medication
Guanylate cyclase stimulator; n (%)
183/183
65 (52%)
49 (70%)
16 (29.09%)
8 (13.79%)
< 0.001
< 0.001
WHO-functional class (I-IV)
183/183
I:0;II:25;III:80;IV:20
I:0;II:11;III:49;IV:10
I:0;II:14;III:31;IV:10
I:0;II:7;III:40;IV:11
Examination results
LVEF, %; median (IQR)
158/183
55 (55–60)
55 (55–59.25)
55 (55–60)
55 (55–55)
0.416
< 0.001
TAPSE, mm; mean ± SD
153/183
19.08 ± 5.3
18.68 ± 4.8
19.54 ± 5.8
19.5 ± 5.3
0.449
0.788
6-min-walk distance, m; mean ± SD
85/183
405.18 ± 99.1
404.52 ± 91.8
409.44 ± 144.7
329.56 ± 122.3
0.312
0.01
Hemodynamics
RAP, mmHg; median (IQR)
108/183
7 (5–9)
7 (5–9)
7 (5–8)
7.5 (4.5–11.75)
0.977
0.764
MeanPAP, mmHg; mean ± SD
181/183
43.09 ± 9.7
42.44 ± 9.1
43.93 ± 10.6
39.86 ± 10.9
0.384
0.041
PVR, WU (IQR)
172/183
6.76 (5.27–9.61)
6.76 (5.27–8.56)
7.065 (5.3075–11.8075)
4.63 (3.15–10.265)
0.184
0.006
CI, L/min/m2; mean ± SD
169/183
2.5 ± 0.6
2.61 ± 0.7
2.33 ± 0.6
2.58 ± 0.8
0.015
0.705
PCWP, mmHg; median (IQR)
179/183
9 (8–12)
9 (8–11)
9 (8–13)
11 (9–13)
0.332
0.004
Values represent N (%) or mean ± SD or median (IQR)
Abbreviations: BPA Balloon pulmonary angioplasty, CI cardiac index, GFR glomerular filtration rate, hs-cTnT high-sensitivity cardiac troponin T, LVEF left ventricular ejection fraction, NT-proBNP N-terminal pro-B-type natriuretic peptide, PAP pulmonary artery pressure, PCWP Pulmonary capillary wedge pressure, PVR pulmonary vascular resistance, RAP right atrial pressure, TAPSE Tricuspid Annular Plane Systolic Excursion
PAPP-A levels at baseline were comparable in CTEPH patients [13.8(IQR 11.0–18.6) mU/L] and PH controls [12.6(IQR 8.6–16.5) mU/L] (p = 0.051). No relevant correlation between PAPP-A and hemodynamic parameters such as meanPAP (r = 0.120; p = 0.188), pulmonary vascular resistance (PVR) (r = 0.013; p = 0.893) or NT-proBNP (r = 0.128; p = 0.169) was observed in CTEPH patients. Nevertheless, PAPP-A correlated with C-reactive protein (r = 0.259; p = 0.004).
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Surgical and interventional treatment led to an improvement of pulmonary hemodynamics and a decrease of natriuretic peptides, which is illustrated in Table 2.
Table 2
Comparison of hemodynamic findings and NT-proBNP levels between baseline and follow-up in CTEPH patients
The PAPP-A levels did not differ between the PEA and BPA treatment group (13.7 (10.4–17.6) vs. 14.5 (11.2–18.9) mU/L; p = 0.437) at baseline (Fig. 1, left panel). PAPP-A levels decreased significantly after treatment from 13.7 (10.4–17.6) to 11.4 (9.9–14.6) mU/L (p = 0.003) after PEA and 14.5 (11.2–18.9) to 11.1 (9.8–12.9) mU/L (p < 0.001) after BPA therapy (Fig. 1, left panel).
×
BPA is a staged procedure (median 6 procedures/patient) with only a limited number of pulmonary segments treated per session. PAPP-A levels decreased continuously reaching a significant change after 4 procedures in contrast to the hemodynamic marker NT-proBNP as a comparator that was significantly lowered already after the first procedure (Fig. 1, right panel).
Discussion
Key findings of this study are: (1) PAPP-A levels might be associated with CTEPH and decrease after interventional or surgical treatment. (2) The PAPP-A treatment response shows a slow and continuous lowering in marker levels in contrast to the rapid improvement in hemodynamics reflected by biomarkers such as NT-proBNP.
The PAPP-A levels in CTEPH patients, which are modifiable by treatment. Seem not to be mediated by hemodynamics and their improvement after treatment raising the question about the origin and role of PAPP-A in CTEPH.
Acute pulmonary embolism impairs pulmonary vascular homeostasis. The mechanisms leading to development of CTEPH in a subset of PE patients are not fully understood. Endothelial damage, dysfunction and inflammation are known to be involved in vascular remodeling. The IGF-I/IGF-receptor signaling promotes inflammation, anti-apoptosis and proliferation in various cell types such as endothelial and smooth muscle cells [5, 6]. Yang et al. reported a key role of the IGF-I/IGF-receptor signaling in neonatal PH, revealing an upregulation of IGF-I expression in pulmonary endothelial and smooth muscle cells under experimental hypoxia [7, 8]. Further, Harrington et al. identified PAPP-A as a promotor of atherosclerotic plaque progression and plaque vulnerability. This processes seemed to be driven by PAPP-A-mediated proinflammatory effects of macrophage cytokines and a consecutive upregulation of the IGF-I/IGF-receptor axis [9].
One might hypothesize, that an overexpression of PAPP-A might thus reflect chronic vascular remodeling in CTEPH. The potential use as a biomarker indicating disease mechanisms other than hemodynamics is further supported by the availability of robust automated measurement technology due to the routine use in the context of pregnancy. Further, as the IGF pathway plays a relevant role in certain cancer entities, PAPP-A has already been discussed as treatment target that led to e.g. development of monoclonal PAPP-A antibodies [10].
The present clinical study is based on relatively small cohort and therefore the results only allow to hypothesize about the potential role of PAPP-A. However, it is the first analysis showing an association of PAPP-A with CTEPH. Especially the modification of PAPP-A levels by treatment not primary mediated via hemodynamic improvement should stimulate further investigations to confirm the present results from a small cohort and further analyze the specific role of PAPP-A in the pathophysiology of CTEPH and a potential clinical use as biomarker or even treatment target.
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Acknowledgements
We thank Dimitri Grün for statistical support and Claudia Brüderle for help with data management of the study cohort. The present analyses include data from the doctoral thesis of FR.
Ethics approval and consent to participate
The study was approved by the local ethics committee of the Facility of Medicine of the Justus-Liebig-University in Giessen, Germany in July of 2014 (referral numbers 43/14 and 44/14). All participating patients were comprehensively informed by a physician and gave written informed consent.
Consent for publication
All participants gave written informed consent to be included in the study. This manuscript does not include any individual person’s data in any form, including individual details, images or videos. Therefore, no dedicated consent for publication is needed.
Competing interests
CBW received consultant honoraria and/or speaker fees from Actelion, Bayer AG, MSD, Pfizer and BTG; CWH received lecture or consulting honoraria from BRAHMS/ Thermo Fisher; EM received lecture or consulting honoraria from Actelion, Bayer, MSD, GSK, Pfizer and MSD; CL received lecture or consulting honoraria from Abbott, Astra Zeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Daiichi-Sankyo and Pfizer-Bristol-Myers Squibb. TK received speaker fees from Abbott and Brahms; SDK, FR and LM have nothing to declare.
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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Pregnancy-associated plasma protein A – a new indicator of pulmonary vascular remodeling in chronic thromboembolic pulmonary hypertension?
verfasst von
Steffen D. Kriechbaum Felix Rudolph Christoph B. Wiedenroth Lisa Mielzarek Moritz Haas Stefan Guth Christian W. Hamm Eckhard Mayer Christoph Liebetrau Till Keller
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