Angiogenic factors and prediction for ischemic placental disease in future pregnancies.

OBJECTIVES: Ischemic placental disease (IPD), including preeclampsia, abruption, and fetal growth restriction, often recurs in subsequent pregnancies. Angiogenic factors of placental origin have been implicated in the pathogenesis of preeclampsia, but have not been studied as predictors of IPD in subsequent pregnancies. We hypothesized that elevated angiogenic factors in an index pregnancy would be associated with recurrence of IPD. STUDY DESIGN: We conducted a retrospective cohort study of patients undergoing evaluation for preeclampsia who had angiogenic factors measured in an index pregnancy and experienced a subsequent pregnancy at the same institution. Patients with IPD in the index pregnancy were included. A high ratio of soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) was defined as greater than or equal to 85. MAIN OUTCOME MEASURES: The primary outcome was IPD in a subsequent pregnancy. RESULTS: We included 109 patients in the analysis. The sFlt1/PlGF ratio was elevated in 30% of participants. Those with an elevated ratio were more likely to be nulliparous in the index pregnancy, and less likely to have chronic hypertension. The recurrence of IPD in the study was 27%, with a non-significant difference in risk based on a high sFlt-1/P1GF ratio RR 0.58 (95% CI 0.21 - 1.6) compared to a low ratio. CONCLUSIONS: A high sFlt1/P1GF ratio in an index pregnancy is not associated with a higher risk of IPD in a subsequent pregnancy. These data suggest placental angiogenic biomarkers are specific to the pregnancy and not a reflection of maternal predisposition to IPD.

Risk of pre-eclampsia in patients with a maternal genetic predisposition to common medical conditions: a case-control study.

OBJECTIVE: To assess whether women with a genetic predisposition to medical conditions known to increase pre-eclampsia risk have an increased risk of pre-eclampsia in pregnancy. DESIGN: Case-control study. SETTING AND POPULATION: Pre-eclampsia cases (n = 498) and controls (n = 1864) in women of European ancestry from five US sites genotyped on a cardiovascular gene-centric array. METHODS: Significant single-nucleotide polymorphisms (SNPs) from 21 traits in seven disease categories (cardiovascular, inflammatory/autoimmune, insulin resistance, liver, obesity, renal and thrombophilia) with published genome-wide association studies (GWAS) were used to create a genetic instrument for each trait. Multivariable logistic regression was used to test the association of each continuous scaled genetic instrument with pre-eclampsia. Odds of pre-eclampsia were compared across quartiles of the genetic instrument and evaluated for significance. MAIN OUTCOME MEASURES: Genetic predisposition to medical conditions and relationship with pre-eclampsia. RESULTS: An increasing burden of risk alleles for elevated diastolic blood pressure (DBP) and increased body mass index (BMI) were associated with an increased risk of pre-eclampsia (DBP, overall OR 1.11, 95% CI 1.01-1.21, P = 0.025; BMI, OR 1.10, 95% CI 1.00-1.20, P = 0.042), whereas alleles associated with elevated alkaline phosphatase (ALP) were protective (OR 0.89, 95% CI 0.82-0.97, P = 0.008), driven primarily by pleiotropic effects of variants in the FADS gene region. The effect of DBP genetic loci was even greater in early-onset pre-eclampsia cases (at <34 weeks of gestation, OR 1.30, 95% CI 1.08-1.56, P = 0.005). For other traits, there was no evidence of an association. CONCLUSIONS: These results suggest that the underlying genetic architecture of pre-eclampsia may be shared with other disorders, specifically hypertension and obesity. TWEETABLE ABSTRACT: A genetic predisposition to increased diastolic blood pressure and obesity increases the risk of pre-eclampsia.

A core outcome set for pre-eclampsia research: an international consensus development study.

OBJECTIVE: To develop a core outcome set for pre-eclampsia. DESIGN: Consensus development study. SETTING: International. POPULATION: Two hundred and eight-one healthcare professionals, 41 researchers and 110 patients, representing 56 countries, participated. METHODS: Modified Delphi method and Modified Nominal Group Technique. RESULTS: A long-list of 116 potential core outcomes was developed by combining the outcomes reported in 79 pre-eclampsia trials with those derived from thematic analysis of 30 in-depth interviews of women with lived experience of pre-eclampsia. Forty-seven consensus outcomes were identified from the Delphi process following which 14 maternal and eight offspring core outcomes were agreed at the consensus development meeting. Maternal core outcomes: death, eclampsia, stroke, cortical blindness, retinal detachment, pulmonary oedema, acute kidney injury, liver haematoma or rupture, abruption, postpartum haemorrhage, raised liver enzymes, low platelets, admission to intensive care required, and intubation and ventilation. Offspring core outcomes: stillbirth, gestational age at delivery, birthweight, small-for-gestational-age, neonatal mortality, seizures, admission to neonatal unit required and respiratory support. CONCLUSIONS: The core outcome set for pre-eclampsia should underpin future randomised trials and systematic reviews. Such implementation should ensure that future research holds the necessary reach and relevance to inform clinical practice, enhance women's care and improve the outcomes of pregnant women and their babies. TWEETABLE ABSTRACT: 281 healthcare professionals, 41 researchers and 110 women have developed #preeclampsia core outcomes @HOPEoutcomes @jamesmnduffy. [Correction added on 29 June 2020, after first online publication: the order has been corrected.].

PP059. Angiogenic factors and risk of preeclampsia related adverse outcomes in twin pregnancies.

INTRODUCTION: Preeclampsia (PE) is a pregnancy specific hypertensive disorder with an overall incidence of 5-8% among all pregnancies.Incidence of PE in twins is about 2-4 fold higher compared to singletons.Angiogenic factors are implicated in pathogenesis of PE and related adverse outcomes.No studies exist evaluating angiogenic factor assessment in twin pregnancies complicated by PE or use of these proteins for prediction of PE-related adverse outcomes in twins. OBJECTIVES: Our objective was to evaluate whether angiogenic factor levels correlate with the diagnosis of PE and predict adverse maternal and perinatal outcomes in women with twin pregnancy. METHODS: This was a prospective cohort study of women with suspected PE and twin pregnancy from July 2009-August 2011.Antiangiogenic soluble fms-like tyrosine kinase 1 (sFlt1) and proangiogenic placental growth factor (PlGF) were measured at presentation on an automated platform.Diagnosis of hypertension PE during pregnancy was based on ACOG criteria.All diagnoses and outcomes were recorded 2 weeks later.An adverse outcome was defined as hemolysis elevated liver enzymes and low platelets (HELLP) syndrome; disseminated intravascular coagulation (DIC); abruption; pulmonary edema; cerebral hemorrhage; maternal, fetal and neonatal death; eclampsia; acute renal failure; small for gestational age; and indicated delivery.Data are presented as median (interquartile range).We computed the area under the curve (AUC) from the receiver operating characteristic curves to evaluate the ability of clinical values to discriminate between women who would and would not develop an adverse outcome within 2 weeks. RESULTS: There were 79 women with twin gestation who presented to triage for evaluation of PE. The median gestational age at enrollment was 33.9 (31.9-36.0) weeks.The incidence of PE was 58.2%, of which 60.9% was mild and 39.1% was severe.The median sFlt1/PlGF ratio was 72.2 (42.5-111.9) in women with PE compared to 47.4 (5.5-82.2) in women with no hypertensive disorder (P=0.052).Among the 52 (65.8%) women who experienced an adverse outcome within 2 weeks, the median sFlt1/PlGF ratio at presentation was elevated [74.2 (43.5-110.5)] compared to the 27 (34.2%) women without an adverse outcome [36.2 (7.1-71.3); P=0.0003].Among those presenting at <34 weeks (n=40), the difference in sFlt1/PlGF ratio was more striking [97.7 (76.6-178.1) versus 31.7 (6.5-48.7); P=0.001].When using only the highest systolic blood pressure at presentation and proteinuria the AUC was 0.61.Adding the sFlt1/PlGF ratio significantly improved the AUC to 0.77 (P=0.01).When restricting to women who presented at <34 weeks, a similar, although not statistically significant, improvement was seen when adding the sFlt1/PlGF ratio (AUC=0.85) compared with blood pressure and proteinuria alone(AUC=0.69;P=0.08). CONCLUSION: In women with twin pregnancy and suspected PE, the sFlt1/PlGF ratio at the time of initial evaluation is associated with subsequent diagnosis of PE and, more importantly, PE-related adverse maternal and perinatal outcomes. These findings are similar to singleton pregnancies and may implicate similar pathogenic pathways.

Placental ischemia and soluble fms-like tyrosine kinase 1: cause or consequence of preeclampsia?

Elevated circulating soluble fms-like tyrosine kinase 1 (sFLT-1) is associated with the development of the clinical signs and symptoms of preeclampsia. Placental ischemia has been suggested as one of the etiological factors that mediate increased sFLT-1 production in patients with preeclampsia, but definitive evidence for this hypothesis was lacking. Makris et al. demonstrate that inducing placental ischemia in primates is sufficient to induce sFLT-1 upregulation and the clinical signs and symptoms of preeclampsia.

[Cause-effect relatioships between circulating placental angiogenic proteins and serum IL-2, IL-6 and IL-10 levels in pregnant women with preeclampsia].

AIM: The object of the present study was to cause-effect relationships between serum placental angiogenic proteins and IL-2, IL-6, IL-10 levels in pregnant women with preeclampsia. MATERIAL AND METHODS: We studied a total of 70 women, aget 18-36/25+/-4.1/40 women had preeclampsia, 30 had normal pregnancies and 30 women were healthy controls. We measured the serm levels of fms-like tyrosine kinase-1, placental growth factor (PLGF), IL-2, IL-6, IL-10 using ELISA. RESULTS: sFlt-1 serum levels were significantly higher and PLGF levels were significantly lower in women with preeclampsia as compare to those of healthy Pregnant women Likewise, IL-2, IL-6 levels were significantly higher in women with preeclampsia as compared to those of healthy pregnant women. IL-10 levels were not different between the two groups, sFlt-1, IL-2 and IL-6 were strongly correlated, PLGF and IL-2 were moderately correlated and there was no correlation with IL-10. There was a significant negative correlation between the two growth factors. CONCLUSIONS: The abnormal balance of circulating angiogenic factors is a major pathgenetic mechanism underlying the endothelial dysfunction and clinical manifestations of preeclampsia. Endothelial dysfunction activated the expression and production of IL-2, and IL-6. The correlation of sFlt-1 and PLGF on one hand, and IL-2 and IL-6, on the other, is probably an factor which supports the participation of angiogenic proteins and cytokines in the pathogenesis of preeclampsia.

Low urinary placental growth factor is a marker of pre-eclampsia.

Recent reports of increased serum levels of soluble fms-like tyrosine kinase 1 (sFlt-1) and decreased levels of placental growth factor (PlGF) suggest the key role of angiogenic factors in development of pre-eclampsia. PlGF is excreted in urine, and reduced urinary level has been suggested as a marker of this condition as well as help in its prediction. We measured urinary PlGF and creatinine values in 69 pregnant women (35 with pre-eclampsia and 34 normotensive controls). Over 70% patients had severe pre-eclampsia. Compared to controls, the urinary PlGF and PlGF/creatinine levels were significantly reduced in women with pre-eclampsia. The hospital stay was longer and fetal outcomes poorer in this group. Three normotensive women who showed very low levels developed pre-eclampsia 2-6 weeks later. Reduced urinary PlGF level in a pregnant woman is a marker of pre-eclampsia. The value of reduced urinary PlGF levels in predicting pre-eclampsia in currently normotensive pregnant women needs to be evaluated. A simple predictive test is likely to be of value in the developing countries.

Placental soluble fms-like tyrosine-kinase-1 (sFlt-1) in pregnant women with preeclampsia.

UNLABELLED: The pathophysiology of preeclampsia remains largely unknown. A number of circulating placenta-produced factors have been implicated in causing the endothelial dysfunction and the clinical phenotype characteristic of preeclampsia. AIM: Determination of serum levels of placental soluble fms-like tyrosine-kinase-1 (sFlt-1) in pregnant women with preeclampsia. Eleven pregnant women with preeclampsia and 11 healthy women (controls) were included in the study. Determination of sFlt-1 was done with ELISA. The mean serum sFlt-1 levels of pregnant women with preeclampsia were twice as high as that of women with normal pregnancy. The highest level of sFlt-1 was found in women with severe preeclampsia. In women with mild form of preeclampsia the sFlt-1 level was close to that of the controls. sFlt-1 appears to be involved in the pathogenesis of preeclampsia and its serum levels can be used as a diagnostic marker of preeclampsia.

Endostatin regulates branching morphogenesis of renal epithelial cells and ureteric bud.

Endostatin (ES) inhibits endothelial cell migration and has been found to bind to glypicans (Gpcs) on both endothelial cells and renal epithelial cells. We examined the possibility that ES might regulate epithelial cell morphogenesis. The addition of ES to cultured epithelial cells causes an inhibition of both hepatocyte growth factor- and epidermal growth factor-dependent process formation and migration. In contrast, ES does not inhibit epidermal growth factor-dependent morphogenesis in renal epithelial cells derived from Gpc-3 -/mice, whereas expression of Gpc-1 in these cells reconstitutes ES responsiveness. Gpc-3 -/mice have been shown to display enhanced ureteric bud (UB) branching early in development, and cultured UB cells release ES into the media, suggesting that ES binding to Gpcs may regulate UB branching. The addition of ES inhibits branching of the explanted UB, whereas a neutralizing Ab to ES enhances UB outgrowth and branching. Thus, local expression of ES at the tips of the UB may play a role in the regulation of UB arborization.

Cell surface glypicans are low-affinity endostatin receptors.

Endostatin, a collagen XVIII fragment, is a potent anti-angiogenic protein. We sought to identify its endothelial cell surface receptor(s). Alkaline phosphatase- tagged endostatin bound endothelial cells revealing two binding affinities. Expression cloning identified glypican, a cell surface proteoglycan as the lower-affinity receptor. Biochemical and genetic studies indicated that glypicans' heparan sulfate glycosaminoglycans were critical for endostatin binding. Furthermore, endostatin selected a specific octasulfated hexasaccharide from a sequence in heparin. We have also demonstrated a role for endostatin in renal tubular cell branching morphogenesis and show that glypicans serve as low-affinity receptors for endostatin in these cells, as in endothelial cells. Finally, antisense experiments suggest the critical importance of glypicans in mediating endostatin activities.

VHL tumor suppressor regulates Cl-/HCO3- exchange and Na+/H+ exchange activities in renal carcinoma cells.

Mutations in the von Hippel-Lindau (VHL) tumor suppressor gene are thought to play a critical role in the pathogenesis of both sporadic and VHL disease-associated clear-cell renal carcinomas (RCC). Differential display-PCR identified the AE2 anion exchanger as a candidate VHL target gene. AE2 mRNA and polypeptide levels were approximately threefold higher in 786-O VHL cells than in 786-O Neo cells. In contrast, Cl(-)/HCO(3)(-) exchange activity in 786-O VHL cells was 50% lower than in 786-O Neo cells. Since resting intracellular pH (pH(i)) values were indistinguishable, we postulated that Na(+)/H(+) exchange activity (NHE) might be similarly reduced in 786-O VHL cells. NHE-mediated pH(i) recovery from acid load was less than 50% that in 786-O Neo cells, whereas hypertonicity-stimulated, amiloride-sensitive NHE was indistinguishable in the two cell lines. The NHE3 mRNA level was higher in 786-O VHL than 786-O Neo cells, but NHE1 mRNA levels did not differ. AE2 and NHE3 are the first transcripts reported to be upregulated by pVHL. Elucidation of mechanisms responsible for downregulation of both ion exchange activities will require further investigation.

The 104-123 amino acid sequence of the beta-domain of von Hippel-Lindau gene product is sufficient to inhibit renal tumor growth and invasion.

The von Hippel-Lindau (VHL) tumor suppressor gene is mutated in patients with VHL disease and in the majority of patients with sporadic renal cell carcinomas (RCCs). RCCs are dependent on insulin-like growth factor-1 receptor-mediated signaling for tumor growth and invasion in vivo. Reintroduction of the VHL gene product (pVHL) can inhibit on insulin-like growth factor-I receptor-mediated signaling in RCC cells in vitro through interaction with protein kinase C delta and is mediated by a specific amino acid sequence (104-123) in the beta-domain of the pVHL. In the present study, the amino acid sequence (104-123) of the pVHL was conjugated to the protein transduction domain of HIV-TAT protein (TATFLAGVHL-peptide) to facilitate entry into cells, and we demonstrate that this amino acid region of VHL is sufficient to block proliferation and invasion of 786-O renal cancer cells in vitro. Furthermore, daily i.p. injections with the TATFLAGVHL peptide retarded and, in some cases, caused partial regression of renal tumors that were implanted in the dorsal flank of nude mice. Treatment with this peptide also inhibits the invasiveness of renal tumors. A 56% decrease in the proliferative index in tumors treated with the TATFLAGVHL-peptide versus control-peptide-treated mice was observed. Taken together, these results show the novel importance of a 20-amino acid sequence of the beta-domain of the VHL gene product capable of inhibiting tumor growth and invasion. These results lay the foundation for a unique approach toward treating RCCs using this small-molecular-weight peptide fused to the TAT-sequence, which may, in the future, be used alone or in conjunction with other therapies.