Tissue-Resident TSP1-CD47 Signaling Promotes Sickle Cell-Associated Arterial Vasculopathy and Pulmonary Hypertension
Authors: Novelli Enrico M , Ihrig Lynda L , Knupp Heather E , Rogers Natasha M , Yao Mingyi , Huang Xiaojun , Baust Jeffrey , Meijles Daniel , St Croix Claudette M , Ross Mark A , Pagano Patrick J , Champion Hunter C , Miles George , Potoka Karin P , Gladwin Mark T , Isenberg Jeffrey S 
Published: April 2021

Abstract
Pulmonary hypertension (PH) is a chronic pulmonary complication of sickle cell disease (SCD) and a leading cause of death in adults. The exact molecular causes of SCD-associated PH are unknown although pathologic hemolysis related to chronic nitric oxide depletion and oxidative stress are recognized as contributing factors. We have reported that the protein thrombospondin-1 (TSP1) is elevated in the plasma of patients with SCD and by interacting with its receptor CD47 limits vasodilation of distal pulmonary arteries ex vivo . We hypothesized that the TSP1-CD47 interaction may promote PH in the BERK sickle mouse model. To test this hypothesis, we inquired whether TSP1 and CD47 are upregulated in the lungs of BERK mice and patients with SCD-associated PH. We found that lungs of age matched male 13-14 months old BERK sickle mice overexpressed TSP1 and CD47 as compared to both C57BL/6J and Hemi BERK mice and also confirmed our prior findings that sickle mice develop PH as they age. Immunohistochemistry of lung sections from 6 patients with SCD-associated PH revealed increased levels of CD47 as compared to sections from patients without PH or overt lung disease. We interrogated the TSP1-CD47 axis in vivo by generating chimeric animals with a sickle erythropoiesis on a CD47KO background by transplanting BERK sickle bone marrow into C57BL/6J (n=24) and CD47 knockout (CD47KO, n=27) mice. Fully engrafted chimeric mice underwent pulmonary hemodynamic assessment after 6 months. Right ventricular (RV) pressures were lower in Sickle-to-CD47KO chimeras as compared to Sickle-to-C57BL/6J chimeras as shown by the reduced maximum pressure of the RV (22.1 ± 3.6 vs. 28.1 ± 8.8 mmHg, p=0.013) and mean pulmonary artery pressure (15.3 ± 2.6 vs. 18.8 ± 5.7 mmHg, p=0.020). The afterload of the Sickle-to-CD47KO chimeras was lower compared to Sickle-to-C57BL/6J chimeras as shown by the diminished pulmonary vascular resistance (1.2 ± 0.7 vs. 2.4 ± 2.2 Wood units, p=0.024) and RV effective arterial elastance (1.5 ± 0.9 vs. 2.7 ± 2.6 mmHg/µL, p=0.052). The RV diastolic function as measured by the RV dP/dtmin also showed a trend towards improvement as compared to Sickle-to-C57BL/6J chimeras (-1297.0 ± 318.2 vs. -1604.0 ± 668.2 mmHg/s, p=0.059). Finally, the Sickle-to-CD47KO chimeras had a tendency for less RV hypertrophy as evidenced by lower RV free wall weight as compared to Sickle-to-C57BL/6J chimeras (21.45 ± 5.0 vs. 24.63 ± 6.0 mg, p=0.056). Interestingly, plasma levels of soluble TSP1 were reduced in Sickle-to-CD47KO chimeras (61.45 ± 10.11 vs. 76.89 ± 10.84 pg/mL, p=0.012). On myography, aortic segments from Sickle-to-CD47KO chimeras had improved relaxation to the endothelial activator acetylcholine. We hypothesized that in SCD TSP1-CD47 signaling promotes PH, in part, by increasing ROS generation. Treatment with exogenous TSP1 (2.2x10-9 M, a concentration found in the plasma of SCD patients) stimulated increased levels of superoxide and hydrogen peroxide in human pulmonary artery endothelial cells by cytochrome C and Amplex Red assays, respectively. Furthermore, lungs of CD47KO chimeras had decreased oxidative damage as measured by reduced 4-hydroxynonenal and 3-nitrotyrosine staining vs. Sickle-to-C57BL/6J chimeras. Finally, suppression of CD47 with a morpholino (10 mg/kg body weight i.p. weekly) for 8 weeks (n=8 animals) also reduced pulmonary pressures in BERK mice. Our results show that genetic deletion or suppression of CD47 ameliorates SCD-associated PH, which may be due, in part, to decreased ROS levels. Targeting TSP1-CD47 may provide a new molecular approach to the treatment of SCD-associated PH.

Disclosures
Isenberg: Tioma Therapeutics: Equity Ownership; Radiation Control Technologies, Inc.: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.