Login| Sign Up| Help| Contact|

Patent Searching and Data


Title:
GENE PANEL SPECIFIC FOR PULMONARY HYPERTENSION AND ITS USES
Document Type and Number:
WIPO Patent Application WO/2018/041959
Kind Code:
A1
Abstract:
The present invention relates to a gene panel of at least 14 genes or the combination of said at least 14 genes for use in a method of diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH). The present invention relates to using said gene panel or combination of genes in the in vitro or ex vivo diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH). The present invention relates to a method and a kit for the diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH). The present invention further relates to said gene panel, method and kit with respect to a genetic disposition to pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

Inventors:
GRÜNIG EKKEHARD (DE)
HINDERHOFER KATRIN (DE)
EICHSTAEDT CHRISTINA A (DE)
Application Number:
EP2017/071886
Publication Date:
March 08, 2018
Filing Date:
August 31, 2017
Export Citation:
Click for automatic bibliography generation   Help
Assignee:
UNIV HEIDELBERG RUPRECHT KARLS (DE)
THORAXKLINIK HEIDELBERG GGMBH (DE)
International Classes:
C12Q1/68
Other References:
ANONYMOUS: "Pulmonary Arterial Hypertension - PAH", 1 August 2016 (2016-08-01), XP055323855, Retrieved from the Internet [retrieved on 20161129]
AUSTIN ED; MA L; LEDUC C; BERMAN ROSENZWEIG E; BORCZUK A; PHILLIPS JA, 3RD ET AL.: "Whole exome sequencing to identify a novel gene (caveolin-1) associated with human pulmonary arterial hypertension", CIRC CARDIOVASC GENET, vol. 5, no. 3, 2012, pages 336 - 43, XP055323389
DE JESUS PEREZ VA; YUAN K; LYUKSYUTOVA MA; DEWEY F; ORCHOLSKI ME; SHUFFLE EM ET AL.: "Whole-Exome Sequencing Reveals TopBPl as a Novel Gene in Idiopathic Pulmonary Arterial Hypertension", AM J RESPIR CRIT CARE MED., vol. 189, no. 10, 2014, pages 1260 - 72, XP055323405
CHIDA A; SHINTANI M; NALCAYAMA T; FURUTANI Y; HAYAMA E; INAI K ET AL.: "Missense mutations of the BMPR1B (ALK6) gene in childhood idiopathic pulmonary arterial hypertension", CIRC J., vol. 76, no. 6, 2012, pages 1501 - 8, XP055323399
NASIM MT; GHOURI A; PATEL B; JAMES V; RUDARAKANCHANA N; MORRELL NW ET AL.: "Stoichiometric imbalance in the receptor complex contributes to dysfunctional BMPR-II mediated signalling in pulmonary arterial hypertension", HUM MOL GENET, vol. 17, no. 11, 2008, pages 1683 - 94, XP055323960
KWAPISZEWSKA G; RODRIGUEZ VIALES R; EHLKEN N; EICHSTAEDT C; RIEMKASTEN G; GRUNIG G ET AL.: "Epigenetik und Genetik der pulmonal arteriellen Hypertonie - neue Erkenntnisse der letzten Jahre", DTSCH MED WOCHENSCHR., vol. 139, no. 04, 2014, pages 111 - 5, XP055323963
C. V. REMILLARD ET AL: "Function of Kv1.5 channels and genetic variations of KCNA5 in patients with idiopathic pulmonary arterial hypertension", AMERICAN JOURNAL OF PHYSIOLOGY. CELL PHYSIOLOGY., vol. 292, no. 5, 13 December 2006 (2006-12-13), US, pages C1837 - C1853, XP055323968, ISSN: 0363-6143, DOI: 10.1152/ajpcell.00405.2006
PIAO C; ZHU Y; ZHANG C; XI X; LIU X; ZHENG S; LI X; GUO J; JIA L; NAKANISHI T: "Identification of multiple ACVRL1 mutations in patients with pulmonary arterial hypertension by targeted exome capture", CLIN SCI (LOND, vol. 130, no. 17, 28 June 2016 (2016-06-28), pages 1559 - 69, XP009192626
ANDERSON KP; KERN CB; CRABLE SC; LINGREL JB: "Isolation of a gene encoding a functional zinc finger protein homologous to erythroid Kruppel-like factor: identification of a new multigene family", MOL CELL BIOL, vol. 15, no. 11, 1995, pages 5957 - 5965
AUSTIN ED; MA L; LEDUC C; BERMAN ROSENZWEIG E; BORCZUK A; PHILLIPS JA ET AL.: "Whole exome sequencing to identify a novel gene (caveolin-1) associated with human pulmonary arterial hypertension", CIRC CARDIOVASC GENET., vol. 5, no. 3, 2012, pages 336 - 43, XP055323389, DOI: doi:10.1161/CIRCGENETICS.111.961888
BARRIOS-RODILES M; BROWN KR; OZDAMAR B; BOSE R; LIU Z; DONOVAN RS; SHINJO F; LIU Y; DEMBOWY J; TAYLOR IW ET AL.: "High-throughput mapping of a dynamic signaling network in mammalian cells", SCIENCE, vol. 307, no. 5715, 2005, pages 1621 - 1625, XP055062889, DOI: doi:10.1126/science.1105776
BERLANGA JJ; SANTOYO J; DE HARO C: "Characterization of a mammalian homolog of the GCN2 eukaryotic initiation factor 2alpha kinase", EUR J BIOCHEM, vol. 265, no. 2, 1999, pages 754 - 762, XP002167888, DOI: doi:10.1046/j.1432-1327.1999.00780.x
BEST DH; SUMNER KL; AUSTIN ED; CHUNG WK; BROWN LM; BORCZUK AC ET AL.: "EIF2AK4 mutations in pulmonary capillary hemangiomatosis", CHEST, vol. 145, no. 2, 2014, pages 231 - 6, XP055323395, DOI: doi:10.1378/chest.13-2366
BHATTACHARYA R; SENBANERJEE S; LIN Z; MIR S; HAMIK A; WANG P; MUKHERJEE P; MUKHOPADHYAY D; JAIN MK: "Inhibition of vascular permeability factor/vascular endothelial growth factor-mediated angiogenesis by the Kruppel-like factor KLF2", J BIOL CHEM, vol. 280, no. 32, 2005, pages 28848 - 28851
CHANDRA SM; RAZAVI H; KIM J; AGRAWAL R; KUNDU RK; DE JESUS PEREZ V; ZAMANIAN RT; QUERTERMOUS T; CHUN HJ: "Disruption of the apelin-APJ system worsens hypoxia-induced pulmonary hypertension", ARTERIOSCLER THROMB VASE BIOL, vol. 31, no. 4, 2011, pages 814 - 820
CHAOUAT A; COULET F; FAVRE C; SIMONNEAU G; WEITZENBLUM E; SOUBRIER F ET AL.: "Endoglin germline mutation in a patient with hereditary haemorrhagic telangiectasia and dexfenfluramine associated pulmonary arterial hypertension", THORAX, vol. 59, no. 5, 2004, pages 446 - 8, XP055323398, DOI: doi:10.1136/thx.2003.11890
CHIDA A; SHINTANI M; NAKAYAMA T; FURUTANI Y; HAYAMA E; INAI K ET AL.: "Missense mutations of the BMPR1B (ALK6) gene in childhood idiopathic pulmonary arterial hypertension", CIRC J., vol. 76, no. 6, 2012, pages 1501 - 8, XP055323399, DOI: doi:10.1253/circj.CJ-11-1281
CLIPSON A; WANG M; DE LEVAL L; ASHTON-KEY M; WOTHERSPOON A; VASSILIOU G; BOLLI N; GROVE C; MOODY S; ESCUDERO-IBARZ L ET AL.: "KLF2 mutation is the most frequent somatic change in splenic marginal zone lymphoma and identifies a subset with distinct genotype", LEUKEMIA, vol. 29, no. 5, 2015, pages 1177 - 1185
DEKKER RJ; VAN THIENEN JV; ROHLENA J; DE JAGER SC; ELDERKAMP YW; SEPPEN J; DE VRIES CJ; BIESSEN EA; VAN BERKEL TJ; PANNEKOEK H ET: "Endothelial KLF2 links local arterial shear stress levels to the expression of vascular tone-regulating genes", AM J PATHOL, vol. 167, no. 2, 2005, pages 609 - 618, XP002629118, DOI: doi:10.1016/S0002-9440(10)63002-7
DENG Z; MORSE JH; SLAGER SL; CUERVO N; MOORE KJ; VENETOS G ET AL.: "Familial primary pulmonary hypertension (gene PPH1) is caused by mutations in the bone morphogenetic protein receptor-II gene", AM J HUM GENET, vol. 67, no. 3, 2000, pages 737 - 44
DE JESUS PEREZ VA; YUAN K; LYUKSYUTOVA MA; DEWEY F; ORCHOLSKI ME; SHUFFLE EM ET AL.: "Whole-Exome Sequencing Reveals TopBPl as a Novel Gene in Idiopathic Pulmonary Arterial Hypertension", AM J RESPIR CRIT CARE MED., vol. 189, no. 10, 2014, pages 1260 - 72, XP002764710
DEN DUNNEN JT; DALGLEISH R; MAGLOTT DR; HART RK; GREENBLATT MS; MCGOWAN-JORDAN J; ROUX AF; SMITH T; ANTONARAKIS SE; TASCHNER PE ET: "HGVS Recommendations for the Description of Sequence Variants", UPDATE. HUM MUTAT, vol. 37, no. 6, 2016, pages 564 - 569
DUNGEY A; DENG Y; YIN J; ROZOWSKY S; STEWART DJ: "Kriippel-Like Transcription Factor-2 Preserves Endothelial Function and Protects Against Pulmonary Hypertension", CIRCULATION, vol. 124, no. 21, 2011, pages A17982
EHLKEN N; LICHTBLAU M; KLOSE H; WEIDENHAMMER J; FISCHER C; NECHWATAL R; UIKER S; HALANK M; OLSSON K; SEEGER W ET AL.: "Exercise training improves peak oxygen consumption and haemodynamics in patients with severe pulmonary arterial hypertension and inoperable chronic thrombo-embolic pulmonary hypertension: a prospective, randomized, controlled trial", EUR HEART J, vol. 37, no. 1, 2016, pages 35 - 44
EICHSTAEDT CA; SONG J; BENJAMIN N; HARUTYUNOVA S; FISCHER C; GRANIG E; HINDERHOFER K: "EIF2AK4 mutation as ''second hit'' in hereditary pulmonary arterial hypertension", RESPIR RES., vol. 17, no. 1, 2016, pages 141
EICHSTAEDT CA; SONG J; RODRIGUEZ VIALES R; PAN Z; BENJAMIN N; FISCHER C; HOEPER M; ULRICH S; HINDERHOFER K; GRUNIG E: "First identification of Kruppel-like factor 2 mutation in heritable pulmonary arterial hypertension", CLIN SCI., vol. 131, no. 8, 2017, pages 689 - 698
EVANS JD; GIRERD B; MONTANI D; WANG XJ; GALIE N; AUSTIN ED ET AL.: "BMPR2 mutations and survival in pulmonary arterial hypertension: an individual participant data meta-analysis", LANCET RESPIR MED., vol. 4, no. 2, 2016, pages 129 - 37, XP055323407, DOI: doi:10.1016/S2213-2600(15)00544-5
EYRIES M; MONTANI D; GIRERD B; PERRET C; LEROY A; LONJOU C ET AL.: "EIF2AK4 mutations cause pulmonary veno-occlusive disease, a recessive form of pulmonary hypertension", NAT GENET., vol. 46, no. 1, 2014, pages 65 - 9
FORBES SA; BEARE D; GUNASEKARAN P; LEUNG K; BINDAL N; BOUTSELAKIS H; DING M; BAMFORD S; COLE C; WARD S ET AL.: "COSMIC: exploring the world's knowledge of somatic mutations in human cancer", NUCLEIC ACIDS RES, vol. 43, 2015, pages D805 - 811, XP055386484, DOI: doi:10.1093/nar/gku1075
FRYDMAN N; STEFFANN J; GIRERD B; FRYDMAN R; MUNNICH A; SIMONNEAU G ET AL.: "Pre-implantation genetic diagnosis in pulmonary arterial hypertension due to BMPR2 mutation", EUR RESPIR J., vol. 39, no. 6, 2012, pages 1534 - 5, XP055323409, DOI: doi:10.1183/09031936.00185011
GALIE N; HUMBERT M; VACHIERY JL; GIBBS S; LANG I; TORBICKI A ET AL.: "ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS", EUR HEART J. 2016, vol. 37, no. 1, 2015, pages 67 - 119
GIRERD B; MONTANI D; COULET F; SZTRYMF B; YAICI A; JAIS X; TREGOUET D; REIS A; DROUIN-GARRAUD V; FRAISSE A ET AL.: "Clinical outcomes of pulmonary arterial hypertension in patients carrying an ACVRL1 (ALK1) mutation", AM J RESPIR CRIT CARE MED, vol. 181, 2010, pages 851 - 861
GIRERD B; COULET F; JAIS X; EYRIES M; VAN DER BRUGGEN C; DE MAN F ET AL.: "Characteristics of pulmonary arterial hypertension in affected carriers of a mutation located in the cytoplasmic tail of bone morphogenetic protein receptor type 2", CHEST, vol. 147, no. 5, 2015, pages 1385 - 94
GIRERD B; MONTANI D; JAIS X; EYRIES M; YAICI A; SZTRYMF B ET AL.: "Genetic counselling in a national referral centre for pulmonary hypertension", EUR RESPIR J., vol. 47, no. 2, 2016, pages 541 - 52
GOMEZ J; REGUERO JR; ALVAREZ C; JUNQUERA MR; ARANGO A; MORIS C; COTO E: "A Semiconductor Chip-Based Next Generation Sequencing Procedure for the Main Pulmonary Hypertension Genes", LUNG., vol. 193, no. 4, 2015, pages 571 - 4, XP035511720, DOI: doi:10.1007/s00408-015-9736-4
GRANZOW M; PARAMASIVAM N; HINDERHOFER K; FISCHER C; CHOTEWUTMONTRI S; KAUFMANN L ET AL.: "Loss of function of PGAP1 as a cause of severe encephalopathy identified by Whole Exome Sequencing: Lessons of the bioinformatics pipeline", MOL CELL PROBES, vol. 29, no. 5, 2015, pages 323 - 9
GRIINIG E; JANSSEN B; MERELES D; BARTH U; BORST MM; VOGT IR ET AL.: "Abnormal pulmonary artery pressure response in asymptomatic carriers of primary pulmonary hypertension gene", CIRCULATION, vol. 102, no. 10, 2000, pages 1145 - 50
GRÜNIG E; WEISSMANN S; EHLKEN N; FIJALKOWSKA A; FISCHER C; FOURME T ET AL.: "Stress Doppler echocardiography in relatives of patients with idiopathic and familial pulmonary arterial hypertension: results of a multicenter European analysis of pulmonary artery pressure response to exercise and hypoxia", CIRCULATION, vol. 119, no. 13, 2009, pages 1747 - 57
GRIINIG E; BARNER A; BELL M; CLAUSSEN M; DANDEL M; DUMITRESCU D ET AL.: "Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011", INT J CARDIOL., vol. 154, no. 1, 2011, pages 3 - 12
HARRISON RE; FLANAGAN JA; SANKELO M; ABDALLA SA; ROWELL J; MACHADO RD ET AL.: "Molecular and functional analysis identifies ALK-1 as the predominant cause of pulmonary hypertension related to hereditary haemorrhagic telangiectasia", J MED GENET, vol. 40, no. 12, 2003, pages 865 - 71
HE H; SINGH I; WEK SA; DEY S; BAIRD TD; WEK RC; GEORGIADIS MM: "Crystal structures of GCN2 protein kinase C-terminal domains suggest regulatory differences in yeast and mammals", J BIOL CHEM, vol. 289, no. 21, 2014, pages 15023 - 15034
HINDERHOFER K; FISCHER C; PFARR N; SZAMALEK-HOEGEL J; LICHTBLAU M; NAGEL C; EGENLAUF B; EHLKEN N; GRÜNIG E: "Identification of a new intronic BMPR2-mutation and early diagnosis of heritable pulmonary arterial hypertension in a large family with mean clinical follow-up of 12 years", PLOS ONE, vol. 9, no. 3, 2014, pages e91374
KABATA H; SATOH T; KATAOKA M; TAMURA Y; ONO T; YAMAMOTO M ET AL., RESPIROLOGY, vol. 18, no. 7, 2013, pages 1076 - 82
KABITZ HJ; SCHWOERER A; BREMER HC; SONNTAG F; WALTERSPACHER S; WALKER D ET AL.: "Impairment of respiratory muscle function in pulmonary hypertension", CLIN SCI (LOND, vol. 114, no. 2, 2008, pages 165 - 71
KIM J.: "Apelin-APJ signaling: a potential therapeutic target for pulmonary arterial hypertension", MOL CELLS, vol. 37, no. 3, 2014, pages 196 - 201
KUMAR A; LIN Z; SENBANERJEE S; JAIN MK: "Tumor necrosis factor alpha-mediated reduction of KLF2 is due to inhibition of MEF2 by NF-kappaB and histone deacetylases", MOL CELL BIOL, vol. 25, no. 14, 2005, pages 5893 - 5903
KWAPISZEWSKA G; RODRIGUEZ VIALES R; EHLKEN N; EICHSTAEDT C; RIEMKASTEN G; GRÜNIG G ET AL.: "Epigenetik und Genetik der pulmonal arteriellen Hypertonie - neue Erkenntnisse der letzten Jahre", DTSCHMED WOCHENSCHR, vol. 139, no. 04, 2014, pages 111 - 5, XP002764713
LANE KB; MACHADO RD; PAUCIULO MW; THOMSON JR; PHILLIPS JA; LOYD JE ET AL.: "Heterozygous germline mutations in BMPR2, encoding a TGF-beta receptor, cause familial primary pulmonary hypertension", NAT GENET, vol. 26, no. 1, 2000, pages 81 - 4
LARKIN EK; NEWMAN JH; AUSTIN ED; HEMNES AR; WHEELER L; ROBBINS IM ET AL.: "Longitudinal analysis casts doubt on the presence of genetic anticipation in heritable pulmonary arterial hypertension", AM J RESPIR CRIT CARE MED., vol. 186, no. 9, 2012, pages 892 - 6
LEE JS; YU Q; SHIN JT; SEBZDA E; BERTOZZI C; CHEN M; MERICKO P; STADTFELD M; ZHOU D; CHENG L ET AL.: "Klf2 is an essential regulator of vascular hemodynamic forces in vivo", DEV CELL, vol. 11, no. 6, 2006, pages 845 - 857
LEK M; KARCZEWSKI KJ; MINIKEL EV; SAMOCHA KE; BANKS E; FENNELL T; O'DONNELL-LURIA AH; WARE JS; HILL AJ; CUMMINGS BB ET AL.: "Analysis of protein-coding genetic variation in 60,706 humans", NATURE, vol. 536, no. 7616, 2016, pages 285 - 291
LEVY M; EYRIES M; SZEZEPANSKI I; LADOUCEUR M; NADAUD S; BONNET D ET AL.: "Genetic analyses in a cohort of children with pulmonary hypertension", EUR RESPIR J., vol. 48, no. 4, 2016, pages 1118 - 26
LYLE MA; FENSTAD ER; MCGOON MD; FRANTZ RP; KROWKA MJ; KANE GC; SWANSON KL: "Pulmonary Hypertension in Hereditary Hemorrhagic Telangiectasia", CHEST, vol. 149, no. 2, 2016, pages 362 - 371
MACHADO RD; SOUTHGATE L; EICHSTAEDT CA; ALDRED MA; AUSTIN ED; BEST DH ET AL.: "Pulmonary Arterial Hypertension: A Current Perspective on Established and Emerging Molecular Genetic Defects", HUM MUTAT., vol. 36, no. 12, 2015, pages 1113 - 27
MILLER SA; DYKES DD; POLESKY HF: "A simple salting out procedure for extracting DNA from human nucleated cells", NUCLEIC ACIDS RES, vol. 16, no. 3, 1988, pages 1215, XP001314960
MONTANI D; ACHOUH L; DORFMULLER P; LE PAVEC J; SZTRYMF B; TCHERAKIAN C; RABILLER A; HAQUE R; SITBON O; JAIS X ET AL.: "Pulmonary veno-occlusive disease: clinical, functional, radiologic, and hemodynamic characteristics and outcome of 24 cases confirmed by histology", MEDICINE (BALTIMORE, vol. 87, no. 4, 2008, pages 220 - 233
MONTANI D; LAU EM; DORFMULLER P; GIRERD B; JAIS X; SAVALE L; PERROS F; NOSSENT E; GARCIA G; PARENT F ET AL.: "Pulmonary veno-occlusive disease", EUR RESPIR J, vol. 47, no. 5, 2016, pages 1518 - 1534
NAGEL C; HENN P; EHLKEN N; D'ANDREA A; BLANK N; BOSSONE E; BOTTGER A; FIEHN C; FISCHER C; LORENZ HM ET AL.: "Stress Doppler echocardiography for early detection of systemic sclerosis-associated pulmonary arterial hypertension", ARTHRITIS RES THER, vol. 17, 2015, pages 165
NARASIMHAN J; STASCHKE KA; WEK RC: "Dimerization is required for activation of eIF2 kinase Gcn2 in response to diverse environmental stress conditions", J BIOL CHEM, vol. 279, no. 22, 2004, pages 22820 - 22832
NASIM MT; GHOURI A; PATEL B; JAMES V; RUDARAKANCHANA N; MORRELL NW ET AL.: "Stoichiometric imbalance in the receptor complex contributes to dysfunctional BMPR-II mediated signalling in pulmonary arterial hypertension", HUM MOL GENET, vol. 17, no. 11, 2008, pages 1683 - 94, XP002764712
NEWMAN JH; WHEELER L; LANE KB; LOYD E; GADDIPATI R; PHILLIPS JA ET AL.: "Mutation in the gene for bone morphogenetic protein receptor II as a cause of primary pulmonary hypertension in a large kindred", N ENGL J MED., vol. 345, no. 5, 2001, pages 319 - 24
PADYANA AK; QIU H; ROLL-MECAK A; HINNEBUSCH AG; BURLEY SK: "Structural basis for autoinhibition and mutational activation of eukaryotic initiation factor 2alpha protein kinase GCN2", J BIOL CHEM, vol. 280, no. 32, 2005, pages 29289 - 29299
PFARR N; SZAMALEK-HOEGEL J; FISCHER C; HINDERHOFER K; NAGEL C; EHLKEN N ET AL.: "Hemodynamic and clinical onset in patients with hereditary pulmonary arterial hypertension and BMPR2 mutations", RESPIR RES., vol. 12, 2011, pages 99, XP021104569, DOI: doi:10.1186/1465-9921-12-99
PIAO C; ZHU Y; ZHANG C; XI X; LIU X; ZHENG S; LI X; GUO J; JIA L; NAKANISHI T: "Identification of multiple ACVRL1 mutations in patients with pulmonary arterial hypertension by targeted exome capture", CLIN SCI (LOND, vol. 130, no. 17, 2016, pages 1559 - 69
PIVA R; DEAGLIO S; FAMA R; BUONINCONTRI R; SCARFO I; BRUSCAGGIN A; MEREU E; SERRA S; SPINA V; BRUSA D ET AL.: "The Kriippel-like factor 2 transcription factor gene is recurrently mutated in splenic marginal zone lymphoma", LEUKEMIA, vol. 29, no. 2, 2015, pages 503 - 507
REMILLARD CV; TIGNO DD; PLATOSHYN O; BURG ED; BREVNOVA EE; CONGER D ET AL.: "Function of Kvl.5 channels and genetic variations of KCNA5 in patients with idiopathic pulmonary arterial hypertension", AM J PHYSIOL CELL PHYSIOL., vol. 292, no. 5, 2007, pages C1837 - 53, XP002764714
RICHARDS S; AZIZ N; BALE S; BICK D; DAS S; GASTIER-FOSTER J ET AL.: "Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology", GENET MED., vol. 17, no. 5, 2015, pages 405 - 24, XP055331624, DOI: doi:10.1038/gim.2015.30
RODRIGUEZ VIALES R; EICHSTAEDT CA; EHLKEN N; FISCHER C; LICHTBLAU M; GRIINIG E ET AL.: "Mutation in BMPR2 Promoter: A 'Second Hit' for Manifestation of Pulmonary Arterial Hypertension?", PLOS ONE., vol. 10, no. 7, 2015, pages e0133042
SCHROEDER C; FAUST U; STURM M; HACKMANN K; GRUNDMANN K; HARMUTH F ET AL.: "HBOC multi-gene panel testing: comparison of two sequencing centers", BREAST CANCER RES TREAT., vol. 152, no. 1, 2015, pages 129 - 36, XP036249470, DOI: doi:10.1007/s10549-015-3429-9
SENBANEIJEE S; LIN Z; ATKINS GB; GREIF DM; RAO RM; KUMAR A; FEINBERG MW; CHEN Z; SIMON DI; LUSCINSKAS FW ET AL.: "KLF2 Is a novel transcriptional regulator of endothelial proinflammatory activation", J EXP MED, vol. 199, no. 10, 2004, pages 1305 - 1315
SHINTANI M; YAGI H; NAKAYAMA T; SAJI T; MATSUOKA R: "A new nonsense mutation of SMAD8 associated with pulmonary arterial hypertension", J MED GENET, vol. 46, no. 5, 2009, pages 331 - 7
SONG J; EICHSTAEDT CA; RODRIGUEZ VIALES R; BENJAMIN N; HARUTYUNOVA S; FISCHER C; GRUNIG E; HINDERHOFER K: "Identification of genetic defects in pulmonary arterial hypertension by a new panel diagnostic", CLIN SCI (LOND, vol. 22, 2016, pages 2043 - 2052
SOUBRIER F; CHUNG WK; MACHADO R; GRIINIG E; ALDRED M; GERACI M ET AL.: "Genetics and genomics of pulmonary arterial hypertension", J AM COLL CARDIOL, vol. 62, no. 25, 2013, pages D13 - 21, XP028803104, DOI: doi:10.1016/j.jacc.2013.10.035
SZTRYMF B; YAICI A; GIRERD B; HUMBERT M: "Genes and pulmonary arterial hypertension", RESPIRATION, vol. 74, no. 2, 2007, pages 123 - 32
TENORIO J; NAVAS P; BARRIOS E; FERNANDEZ L; NEVADO J; QUEZADA CA ET AL.: "A founder EIF2AK4 mutation causes an aggressive form of pulmonary arterial hypertension in Iberian Gypsies", CLIN GENET, vol. 88, no. 6, 2014, pages 579 - 83
AUTON A; BROOKS LD; DURBIN RM; GARRISON EP; KANG HM; KORBEL JO; MARCHINI JL; MCCARTHY S; MCVEAN GA ET AL.: "A global reference for human genetic variation", NATURE, vol. 526, no. 7571, 2015, pages 68 - 74
TORRING PM; BRUSGAARD K; OUSAGER LB; ANDERSEN PE; KJELDSEN AD: "National mutation study among Danish patients with hereditary haemorrhagic telangiectasia", CLIN GENET, vol. 86, no. 2, 2014, pages 123 - 133
TREMBATH RC; THOMSON JR; MACHADO RD; MORGAN NV; ATKINSON C; WINSHIP I ET AL.: "Clinical and molecular genetic features of pulmonary hypertension in patients with hereditary hemorrhagic telangiectasia", N ENGL J MED., vol. 345, no. 5, 2001, pages 325 - 34
WALLIS Y; PAYNE S; MCANULTY C; BODMER D; SISTERMANS E; ROBERTSON K ET AL.: "Practice Guidelines for the Evaluation of Pathogenicity and the Reporting of Sequence Variants in Clinical Molecular Genetics", ACGS/ VKGL, 2013
WANG G; KNIGHT L; JI R; LAWRENCE P; KANAAN U; LI L ET AL.: "Early onset severe pulmonary arterial hypertension with 'two-hit' digenic mutations in both BMPR2 and KCNA5 genes", INT J CARDIOL., vol. 177, no. 3, 2014, pages e167 - 9, XP029099807, DOI: doi:10.1016/j.ijcard.2014.08.124
XI Q; LIU Z; ZHAO Z; LUO Q; HUANG Z: "High Frequency of Pulmonary Hypertension-Causing Gene Mutation in Chinese Patients with Chronic Thromboembolic Pulmonary Hypertension", PLOS ONE, vol. 11, 2016, pages e0147396
YEO JC; JIANG J; TAN ZY; YIM GR; NG JH; GOKE J; KRAUS P; LIANG H; GONZALES KA; CHONG HC ET AL.: "Klf2 is an essential factor that sustains ground state pluripotency", CELL STEM CELL, vol. 14, no. 6, 2014, pages 864 - 872
Attorney, Agent or Firm:
BOEHMERT & BOEHMERT ANWALTSPARTNERSCHAFT MBB (GRAHN, Sibylla M.Pettenkoferstraße 22, Munich, 80336, DE)
Download PDF:
Claims:
Claims

1. Use of a gene panel or combination of genes comprising at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 in the in vitro or ex vivo diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH).

2. The use of claim 1, wherein the gene panel or combination of genes comprises the at least 14 genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and up to the 50 genes comprising genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

3. The use of claim 1 or 2, wherein the gene panel or combination of genes comprises at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 36, preferably comprises the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

4. The use according to any one of claims 1 to 3, wherein the gene panel or combination of genes comprises the at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42.

5. The use according to any one of claims 1 to 4, comprising the in vitro or ex vivo diagnosis of a genetic disposition to pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

6. The use according to any one of claims 1 to 5, comprising sequencing of the exons and exon-intron boundaries of the genes and determining whether at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes is present,

preferably comprising the use of next generation sequencing,

optionally further comprising an additional sequencing, preferably Sanger sequencing, or an analysis technique, preferably multiplex ligation-dependent probe amplification or quantitative polymerase chain reaction.

7. The use according to any one of claims 1 to 6, comprising simultaneous testing of at least two patient samples,

wherein a patient sample is preferably whole blood, peripheral blood or tissue.

8. The use according to any one of claims 1 to 7, comprising

- diagnostic genetic testing in subjects, preferably PAH/CTEPH/PVOD/HHT patients and/or their family members;

- screening of newborns; and/or

- pre-implantation diagnostics.

9. A method for the diagnosis of genetic defects in pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH), comprising the following steps:

(a) providing at least one sample,

preferably at least two samples,

(b) extracting the genomic DNA from said sample(s),

(c) determining whether at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 is present by using next generation sequencing,

wherein the presence of said at least one such mutation is a genetic confirmation of existing PAH or indicative for the increased probability for PAH/CTEPH to manifest in not yet affected relatives of PAH/CTEPH patients, and

(d) optionally, determining whether detected mutations/gene variants have

pathological consequences either predicted with in silico prediction programmes and/or functional studies wherein the sample(s) is/are patient sample(s) or sample(s) from a relative of a PAH/CTEPH patient.

10. The method of claim 9, wherein in step (c) the presence of at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 36 is determined, preferably in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

11. The method of claim 9 or 10, wherein in step (c) the presence of at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42 is determined.

12. The method of any one of claim 9 to 11, wherein the diagnosis of genetic defects in pulmonary arterial hypertension comprises the diagnosis for pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

13. The method of any one of claim 9 to 12, wherein the presence of at least two mutations is indicative for the existence of PAH/CTEPH/PVOD/HHT or the increased probability for PAH/CTEPH/PVOD/HHT to become manifest.

14. The method of any one of claims 9 to 13, wherein the (patient) sample is whole blood, peripheral blood or tissue,

and/or wherein at least two, preferably up to about 96 (patient) samples are tested

simultaneously.

15. The method of any one of claims 9 to 14, wherein the method is used for

- diagnostic genetic testing in subjects, preferably PAH CTEPH/PVOD/HHT patients and/or its family members;

- screening of newborns; and/or

- pre-implantation diagnostics.

16. The method of any one of claims 9 to 15, comprising the further step of

(d) carrying out an additional sequencing,

preferably Sanger sequencing,

or an analysis technique,

preferably multiplex ligation-dependent probe amplification or quantitative polymerase chain reaction.

17. Kit for the diagnosis of genetic defects in pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH), comprising

(i) means for carrying out next generation sequencing and detecting at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14,

(ii) optionally, means for processing genomic DNA,

(iii) optionally, means for carrying out an additional sequencing, preferably Sanger sequencing, or an analysis technique, preferably multiplex ligation-dependent probe amplification or quantitative polymerase chain reaction.

18. The kit of claim 17, comprising means for carrying out next generation sequencing and detecting at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 36, preferably in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

19. The kit of claim 17 or 18, comprising means for carrying out next generation sequencing and detecting at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42.

20. The kit of any of claims 17 to 19, wherein the diagnosis of genetic defects in pulmonary arterial hypertension comprises the diagnosis for pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

Description:
Gene panel specific for pulmonary hypertension and its uses

The present invention relates to a gene panel of at least 14 genes or the combination of said at least 14 genes for use in a method of diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH). The present invention relates to using said gene panel or combination of genes in the in vitro or ex vivo diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH). The present invention relates to a method and a kit for the diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH). The present invention further relates to said gene panel, method and kit with respect to a genetic disposition to pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

BACKGROUND OF THE INVENTION

Pulmonary arterial hypertension (PAH) is characterised by plexiform lesions of the small pulmonary arteries leading to an increase in pulmonary vascular resistance and right heart failure (Galie et al , 2016; Griinig et al, 2011). The recent decade witnessed the discovery of hereditary predisposition to PAH. In 2000, mutations in the bone morphogenic protein receptor type 2 (BMPR2) gene, a member of the transforming growth factor-beta (TGF-β) super family, have been identified in families with autosomal dominantly inherited PAH (hereditary PAH, HP AH) (see e.g. Deng et al, 2000; Griinig et al, 2000; Lane et al, 2000). Defects of the BMPR2 gene have been detected to be the major heritable cause for development of PAH (Machado et al, 2015; Soubrier et al, 2013) albeit having an incomplete penetrance of about 20-40% (Larkin et al, 2012; Sztrymf et al, 2007) in single families up to 50% (Newman et al, 2001 ; Frydman et al, 2012). In approximately 85% of familial PAH and 14-35% of sporadic idiopathic PAH (IP AH) cases, mutations of BMPR2 gene were identified (Soubrier et al, 2013; Pfarr et al, 2011; Kabata et al, 2013; Girerd et al, 2016). In PAH patients with hereditary haemorrhagic telangiectasia (HHT) mutations in the activin receptor-like kinase 1 (ALK1 or ACVRL1) (Trembath et al, 2001) and endoglin (ENG) (Chaouat et al, 2004; Harrison et al, 2003) gene were documented. Therefore, diagnostic genetic testing within the last decade has concentrated on these 3 genes and is usually performed by direct Sanger sequencing in a sequential manner, terminating the sequencing as soon as a mutation has been identified in one of these genes. However, within the last years further genes belonging to the BMPR2/Alkl -signalling pathway have been detected by whole exome next generation sequencing (NGS) to be involved in the pathogenesis of PAH and/or pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT). HHT often lead to pulmonary arterial hypertension which drastically worsens patients' survival (Lyle et al, 2016). In hereditary PVOD cases 100% of hereditary patients carried two mutations in the gene EIF2AK4 (Girerd et al, 2016). The ERS/ESC guidelines thus suggest a mutation analysis to be preferred to a biopsy to ascertain the diagnosis of PVOD (Galie et al, 2016).

Recently mutations and large deletions were also discovered in the three major genes BMPR2, ENG and ALK1 in patients with chronic thromboembolic pulmonary hypertension (CTEPH) (Feng et al., 2014, Xi et al, 2016). Therefore, it is likely that genetic defects also play a role in the manifestation of CTEPH.

The availability of genetic testing including genetic counselling has become more and more important for patient care and for family members of PAH patients. Therefore, genetic testing and counselling has been addressed and recommended in the new European Respiratory Society/ European Society of Cardiology (ERS/ESC)-guidelines for selected PAH patients and their family member (Galie et al, 2016). The most common molecular approach is genetic testing by Sanger technique of only 3 genes. This might no longer be appropriate, since today at least 14 PAH/CTEPH/PVOD/HHT genes are known and the Sanger technique assessing one gene at a time is a very time consuming and expensive method (at least 11 h analysis time -in reality 1-2 weeks turnaround time for the three major genes). Furthermore, there is growing evidence that in some patients at least 2 gene defects are necessary for disease manifestation (second hit hypothesis) (Eichstaedt et al, 2016; Rodriguez Viales et al, 2015; Wang et al, 2014).

There is a need in the art for improved means and methods for diagnosing PAH/CTEPH and screening of PAH/CTEPH, including PVOD and/or HHT.

SUMMARY OF THE INVENTION According to the present invention this object is solved by providing a gene panel or combination of genes comprising at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 for use in a method of diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH).

According to the present invention this object is solved by using a gene panel or combination of genes comprising at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 in the in vitro or ex vivo diagnosis of a genetic disposition to pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH).

According to the present invention this object is solved by a method for the diagnosis of genetic defects in pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH), comprising the following steps:

(a) providing at least one sample,

preferably at least two samples,

(b) extracting the genomic DNA from said sample(s),

(c) determining whether at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 is present by using next generation sequencing,

wherein the presence of said at least one such mutation is a genetic confirmation of existing PAH or indicative for the increased probability for PAH/CTEPH to manifest in not yet affected relatives of PAH/CTEPH patients, and

(d) optionally, determining whether detected mutations/gene variants have

pathological consequences either predicted with in silico prediction programmes and/or functional studies wherein the sample(s) is/are patient sample(s) or sample(s) from a relative of a PAH patient.

According to the present invention this object is solved by providing a kit for the diagnosis of genetic defects in pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH), comprising (i) means for carrying out next generation sequencing and detecting at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14,

(ii) optionally, means for processing genomic DNA,

(iii) optionally, means for carrying out an additional sequencing, preferably Sanger sequencing, or an analysis technique, preferably multiplex ligation-dependent probe amplification or quantitative polymerase chain reaction.

DESCRIPTION OF THE PREFERRED EMBODIMENTS OF THE INVENTION

Before the present invention is described in more detail below, it is to be understood that this invention is not limited to the particular methodology, protocols and reagents described herein as these may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention which will be limited only by the appended claims. Unless defined otherwise, all technical and scientific terms used herein have the same meanings as commonly understood by one of ordinary skill in the art. For the purpose of the present invention, all references cited herein are incorporated by reference in their entireties.

Concentrations, amounts, and other numerical data may be expressed or presented herein in a range format. It is to be understood that such a range format is used merely for convenience and brevity and thus should be interpreted flexibly to include not only the numerical values explicitly recited as the limits of the range, but also to include all the individual numerical values or sub-ranges encompassed within that range as if each numerical value and sub-range is explicitly recited. As an illustration, a numerical range of "1 to 96" or "2 to 96" should be interpreted to include not only the explicitly recited values of 1 to 96, but also include individual values and sub-ranges within the indicated range. Thus, included in this numerical range are individual values such as 1, 2, 3, 4, 5 .... 91, 92, 93, 94, 95, 96 and sub-ranges such as from 2 to 10, 15 to 50, 1 to 90, etc. This same principle applies to ranges reciting only one numerical value, such as "at least 2". Furthermore, such an interpretation should apply regardless of the breadth of the range or the characteristics being described.

Use of the PAH-specific panel In this disclosure we disclose the development of a PAH/CTEPH- specific gene diagnostic panel using NGS and including 14 known PAH and further candidate genes. The new procedure is widely available, easy to perform and will allow assessing up to 50 genes and up to 96 patients at once in a short time at reduced costs. Furthermore, it is possible to assess sensitivity and specificity of this new panel in a cohort of patients/family members using additional Sanger sequencing.

Preferably, the use comprises the in vitro or ex vivo diagnosis of a genetic disposition to pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

The terms "PAH/CTEPH" or "PAH/CTEPH/PVOD/HHT", such as when referring to gene(s) and/or patient(s), are used interchangeably throughout the specification.

As discussed above, the present invention provides a gene panel or combination of genes comprising at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 for use in a method of diagnosis of pulmonary arterial hypertension (PAH) and/or chronic

thromboembolic pulmonary hypertension (CTEPH), in particular the diagnosis of a genetic predisposition to PAH and/or CTEPH.

As discussed above, the present invention provides the use of a gene panel or combination of genes comprising at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 in the in vitro or ex vivo diagnosis of pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH), in particular the diagnosis of a genetic predisposition to PAH and/or CTEPH.

Preferably, the present invention provides the use of the gene panel or combination of genes in the in vitro or ex vivo diagnosis of pulmonary arterial hypertension (PAH), chronic thromboembolic pulmonary hypertension (CTEPH), pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT), in particular the diagnosis of a genetic predisposition to PAH and/or CTEPH and/or PVOD and/or HHT.

In a preferred embodiment, the gene panel or combination of genes of the present invention is used which comprises the at least 14 genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and up to the 50 genes, wherein said 50 genes comprise the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

In a preferred embodiment, the gene panel or combination of genes comprises the at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42.

Preferably a range of at least 14 genes and up to 50 genes are used. In one embodiment 15 genes are used, in one embodiment 36 genes are used, in one embodiment 43 genes are used.

In a preferred embodiment, the gene panel or combination of genes is used which comprises at least the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42, more preferably comprises the genes with the nucleotide sequence of SEQ ID Nos. 1 to 36, more preferably comprises the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

The term "gene panel" or "combination of genes" or "gene set" or "set of genes" refers to the genes included on the panel which are either genes identified as mutated in PAH, CTEPH, PVOD and/or HHT patients or such genes which have been associated with PH in animal models and might contribute to disease manifestation in case of a genetic defect.

The inventors have found that the following set of 14 genes allows for the diagnosis of genetic defects of PAH and partly CTEPH, PVOD and/or HHT:

Gene Ensemble Gene ID SEQ ID NO.

ACVLR1 (ALK1) ENSG00000139567 1

BMPR1B ENSG00000138696 2

BMPR2 (+ promoter) ENSG00000204217 3

CAV1 ENSG00000105974 4

EIF2AK4 ENSG00000128829 5

ENG ENSG00000106991 6

GDF2 ENSG00000263761 7

KCNA5 ENSG00000130037 8

KCNK3 ENSG00000171303 9

KL 1 2 ENSG00000127528 10

SMAD1 ENSG00000170365 11 SMAD4 ENSG00000141646 12

SMAD9 ENSG00000120693 13

TOPBP1 ENSG00000163781 14

Mutations in these 14 genes or "core genes" have been shown to lead to PAH manifestation and partly to CTEPH, PVOD and/or HHT manifestation.

The genes ACVRLl, BMRP2, ENG (SEQ ID NOs. 1, 3, 6) have been found to be mutated in CTEPH.

The gene EIF2AK4 (SEQ ID NO 5) has been shown to be mutated in PVOD.

The genes ACVRLl, BMPR2, ENG, GDF2, SMAD4 (SEQ ID NOs. 1, 3, 6, 7, 12) have been shown to be mutated in HHT.

The inventors have found that the following set of 15 genes further allows for the diagnosis of genetic defects of PAH and partly CTEPH, PVOD and/or HHT:

Gene Ensemble Gene ID SEQ ID NO.

ACVLR1 (ALK1) ENSG00000139567 1

BMPR1B ENSG00000138696 2

BMPR2 (+ promoter) ENSG00000204217 3

CAV1 ENSG00000105974 4

EIF2AK4 ENSG00000128829 5

ENG ENSG00000106991 6

GDF2 ENSG00000263761 7

KCNA5 ENSG00000130037 8

KCNK3 ENSG00000171303 9

KLF2 ENSGOOOOO 127528 10

SMAD1 ENSG00000170365 11

SMAD4 ENSG00000141646 12

SMAD9 ENSG00000120693 13

TOPBP1 ENSG00000163781 14

TBX4 ENSG00000121075 42 Within the last years genes belonging to the BMPR2/Alkl -signalling pathway have been detected by whole exome next generation sequencing (NGS) to be involved in the pathogenesis of PAH, pulmonary veno-occlusive disease (PVOD) and/or HHT. In hereditary PVOD cases 100% of hereditary patients carried two mutations of the gene EIF2AK4 (Girerd et al, 2016). The ERS/ESC guidelines thus suggest a mutation analysis to be preferred to a biopsy to ascertain the diagnosis of PVOD (Galie et al, 2016). Defects in genes apart from BMPR2 leading to PAH manifestation have been described so far in 0.5-4% of PAH patients (Machado et al, 2015; Soubrier et al, 2013). A mutation in the gene KLF2 has been shown by the inventors to cause hereditary PAH (HP AH) (Eichstaedt et al, 2017) and mutations in the gene TBX4 have been identified in several cases of paediatric PAH, idiopathic PAH (IP AH) and HP AH (Levy et al, 2016). Moreover, mutations in two additional genes are now considered responsible for the onset of HHT: the bone morphogenic protein 9 (BMP9 or GDF2) (Wooderchak et al, 2013) and the SMAD Family member 4 (SMAD4) (Torring et al, 2014). HHT often lead to pulmonary arterial hypertension which drastically worsens patients' survival (Lyle et al, 2016).

The inventors have further found that the following set of 43 genes, which comprise the 14 "core genes" (in grey), as well as the set of 15 genes, and further genes are even more preferred for the diagnosis of a genetic predisposition to PAH, PVOD, HHT and partly CTEPH:

The geos& ACVRl, BMP2, BMPRIA, IDl, ID2, ID3, ID4, SMAD5, SMAD6, and SMAD7 (SEQ ID NOs. 15-17, 21-24, 29-31) are part of the BMPR2 pathway. As discussed above, the genes ACVRL1, BMRP2, ENG (SEQ ID NOs. 1, 3, 6) have been found to be mutated in CTEPH.

As discussed above, the gene EIF2AK4 (SEQ ID NO 5) has been shown to be mutated in PVOD.

As discussed above, the genes ACVRL1, BMPR2, ENG, GDF2, SMAD4 (SEQ ID NOs. 1, 3, 6, 7, 12) have been shown to be mutated in HHT.

The genes CREB1, FOXOl, HRG, IL6, KLF4, KL5, VCAN, and ZFYVE16 (SEQ ID NOs. 18- 20, 25-27, 34, 36) are known from PAH animal models.

The gene NOTCH3 (SEQ ID NO. 28) is involved in pediatric PAH manifestation.

The gene SOD2 (SEQ ID NO. 32) is known from a PH animal model and is epigenetically changed in PAH patients and PH animal model.

The gene THBS1 (SEQ ID NO. 33) is involved in hereditary PAH (HP AH) manifestation. The gene VHL (SEQ ID NO. 35) is known from a PH animal model and involved in Chuvash- associated PAH (Chuvash-AP AH) manifestation.

The gene BTNL2 (SEQ ID NO. 37) is involved in sarcoidosis associated PAH.

The gene CYP1B1 (SEQ ID NO. 38) has a decreased expression in BMPR2 mutation carriers.

The gene EPASl (SEQ ID NO. 39) is involved in HP AH manifestation and is associated with erythrocytosis.

The gene JAK2 (SEQ ID NO. 40) is involved in myeloproliferative disease (MDS) and chronic thromboembolic pulmonary hypertension (CTEPH).

The genes TBX2 and TBX4 (SEQ ID Nos. 41-42) are involved in pediatric PAH manifestation associated with microcephaly thyroid and sensorineural abnormalities or small patella syndrome.

The gene TMEM70 (SEQ ID NO. 43) is involved in persistent neonatal PAH with ATPase synthase deficiency. In one embodiment the following set of 36 genes, which comprise the 14 "core genes" (in grey) and further genes are preferred for the diagnosis of a genetic predisposition to PAH and partly CTEPH, PVOD and/or HHT:

SMAD7 ENSG00000101665 31

SMAD9 ENSG00000120693 13

SOD2 ENSG00000112096 32

THBS1 ENSG00000137801 33

TOPBP1 ENSG000OO .163781. 14

VCAN ENSG00000038427 34

VHL ENSG00000134086 35

ZFYVE16 ENSG00000039319 36

The diagnosis of genetic defects / a genetic predisposition comprises sequencing of target genomic regions of the genes of the gene panel, which can be the exons (preferably all the exons), exon-intron boundaries of the genes, and/or base pairs at the 5' and 3' untranslated region (UTR).

Said sequencing is preferably carried out or comprises next generation sequencing.

"Next generation sequencing" refers to high-throughput sequencing based on different technologies, which enable the generation of a great amount of sequence data in a short time frame opposed to the conventional, slower and more expensive direct Sanger sequencing.

Next-generation sequencing (NGS), also known as high-throughput sequencing, include e.g. the following sequencing technologies:

• Illumina (Solexa) sequencing

• Roche 454 sequencing

• Ion torrent: Proton / PGM sequencing

• SOLiD sequencing

These recent technologies allow to sequence DNA and RNA more quickly and cheaply than the previously used Sanger sequencing.

In one embodiment, the diagnosis optionally further comprises an additional sequencing, preferably Sanger sequencing, or an analysis technique, preferably multiplex ligation- dependent probe amplification (MLPA) or quantitative polymerase chain reaction

(quantitative PCR).

In embodiments where large(r) deletions or insertions in the PAH/CTEPH genes are determined, an additional analysis technique (such as MLPA or quantitative PCR) is useful for confirmation.

The sample(s) is/are patient sample(s) or sample(s) from a relative of a PAH/CTEPH patient or a PAH/CTEPH/PVOD/HHT patient, respectively.

The terms "PAH/CTEPH patient" and "PAH/CTEPH/PVOD/HHT patient" are used interchangeably throughout the specification.

In one embodiment, at least two (patient) samples are tested simultaneously.

A (patient) sample is preferably whole blood, peripheral blood or tissue.

In further embodiments a higher number of (patient) samples are tested, such as up to e.g. 48 samples, 96 samples or up to 384 samples. The number of samples depends also on the type of sample plate used as well as on the type of sequencer.

The gene panel or combination of genes of the present invention can preferably be used for diagnostic genetic testing in subjects, preferably in PAH/CTEPH/PVOD/HHT patients and/or its family members.

Said diagnosis includes determining whether one mutation in the respective genes is present or a second mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions, wherein said mutation(s) is/are genetic confirmation of manifest or existing PAH or indicative for the increased probability for PAH/CTEPH/PVOD/HHT to occur or manifest in not yet affected family members of PAH/CTEPH/PVOD/HHT patients.

Patients with mutations have been shown to have more severe symptoms and shorter survival (Evans et al. , 2016), and thus these patients may be checked on their clinical symptoms in shorter intervals and their family members may be invited for genetic counselling and testing. The gene panel or combination of genes of the present invention can preferably be used for screening of newborns, such as of babies/newborns of patients with

PAH/CTEPH/PVOD/HHT or their family members, but also in a general newborn screening. The early detection of mutations may enable an early diagnosis and treatment as soon as symptoms occur.

The gene panel or combination of genes of the present invention can preferably be used for pre-implantation diagnostics, as currently offered in e.g. France (Girerd et al, 2015).

In particular in families, in which the disease penetrance is high, i.e. in which many mutation carriers develop the disease, pre-implanation diagnostics may be applied within the legal framework.

Diagnosis methods

As discussed above, the present invention provides a method for the diagnosis pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension (CTEPH), in particular for the diagnosis of genetic defects in PAH and/or CTEPH.

Preferably, the diagnosis of genetic defects in pulmonary arterial hypertension comprises the diagnosis for pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

Said method comprises the following steps:

(a) providing at least one sample,

preferably at least two, preferably up to 96 samples,

(b) extracting the genomic DNA from said sample(s),

(c) determining whether at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 is present by using next generation sequencing, wherein the presence of said at least one such mutation is a genetic confirmation of existing PAH/CTEPH or indicative for the increased probability for PAH/CTEPH to manifest in not yet affected relatives of PAH/CTEPH patients, and

(d) optionally, determining whether detected mutations/gene variants have pathological consequences either predicted with in silico prediction programmes and/or functional studies.

The sample(s) provided in step (a) is/are patient sample(s) or sample(s) from a relative of a PAH/CTEPH patient or a PAH/CTEPH/PVOD/HHT patient, respectively.

Preferably, the (patient) sample is whole blood, peripheral blood or tissue.

As discussed above, the terms "PAH/CTEPH patient" and "PAH/CTEPH/PVOD/HHT patient" are used interchangeably throughout the specification.

In one embodiment, in step (c) the presence of at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the 14 genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and in up to 50 genes is determined, wherein said 50 genes comprise the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

Preferably, a range of at least 14 genes and up to 50 genes are used. In one embodiment 15 genes are used, in one embodiment 36 genes are used, in one embodiment 43 genes are used.

In a preferred embodiment, in step (c) the presence of at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42.

In one embodiment, in step (c) the presence of at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 36 is determined.

In a preferred embodiment, in step (c) the presence of at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43 is determined. In one embodiment, the presence of at least two mutations in terms of one or more altered base pairs, smaller and larger deletions or insertions is indicative for the existence of PAH or the increased probability for PAH to become manifest.

In one embodiment, in step (b) the genomic DNA is extracted from peripheral blood using procedures known in the art.

Preferably, at least two (patient) samples are tested simultaneously. In further embodiments a higher number of (patient) samples are tested, such as up to e.g. 48 samples, 96 samples or up to 384 samples. The number of samples depends also on the type of sample plate used as well as on the type of sequencer.

The genomic DNA can be tagged, such as with a barcode. The DNA of each patient / each subject can be tagged differently allowing multiple samples to be tested in parallel / simultaneously.

The genomic DNA can be digested e.g. with restriction enzymes and the desired genes can be captured by 50 to 500 bp biotinylated probes annealing to the respective genomic sequence. The pull-down of desired fragments can be achieved via biotin-streptavidin beads.

The fragments can be amplified via PCR and loaded onto a sequencer for sequencing.

In one embodiment, the method comprises the further step of

(d) carrying out an additional sequencing,

preferably Sanger sequencing,

or an analysis technique,

preferably multiplex ligation-dependent probe amplification or quantitative polymerase chain reaction.

In embodiments where large(r) deletions or insertions in the PAH/CTEPH/PVOD/HHT genes are determined, an additional analysis technique (such as MLPA or quantitative PCR) is useful for confirmation.

In one embodiment, the method is used for - diagnostic genetic testing in subjects, preferably in PAH/CTEPH/PVOD/HHT patients and/or its family members;

- screening of newborns; and/or

- pre-implantation diagnostics;

Diagnostic PAH kit

As discussed above, the present invention provides a kit for the diagnosis of pulmonary arterial hypertension (PAH) and/or chronic thromboembolic pulmonary hypertension

(CTEPH), in particular for the diagnosis for a genetic predisposition to PAH and/or CTEPH.

Preferably, the diagnosis of genetic defects in pulmonary arterial hypertension comprises the diagnosis for pulmonary veno-occlusive disease (PVOD) and/or hereditary haemorrhagic telangiectasia (HHT).

Said kit comprises

(i) means for carrying out next generation sequencing and detecting at least one mutation in terms of one or more altered base pairs, smaller and larger deletions or insertions in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14.

In one embodiment, the means (i) are means for carrying out next generation sequencing and detecting at least one such mutation in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 14 and 42.

In one embodiment, the means (i) are means for carrying out next generation sequencing and detecting at least one such mutation in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 36, preferably in the genes with the nucleotide sequence of SEQ ID Nos. 1 to 43.

Said means comprise probes suitable for sequencing target genomic regions of the respective genes and for determining whether at least one such mutation in said genes is present.

Said target genomic regions can be the exons (preferably all the exons), exon-intron boundaries of the genes, and/or base pairs at the 5' and 3' untranslated region (UTR). Said probes can have a length of 50 to 500 nucleotides. Said probes can be labelled, such as via biotin, and/or fluorophores.

Said means can, for example, be designed and generated using HaloPlex technology or SureSelectXT technology (Agilent Technologies, Santa Clara, USA) or using the in silico tool SureDesign (Agilent Technologies, Santa Clara, USA).

Said kit can optionally further comprise

(ii) means for processing the genomic DNA.

Said processing means can be for tagging, digesting, capturing etc.

The genomic DNA can be tagged, such as with a barcode. The DNA of each patient can be tagged differently allowing multiple samples to be tested in parallel / simultaneously.

The genomic DNA can be digested with e.g. restriction enzymes and the desired genes can be captured by 50 to 500 bp biotinylated probed annealing to the respective genomic sequence. The pull-down of desired fragments can be achieved e.g. via biotin-streptavidin beads.

The fragments can be amplified via PCR and loaded onto a sequencer for sequencing.

Said kit optionally further comprises

(iii) means for carrying out an additional sequencing,

preferably Sanger sequencing,

or for carrying out an analysis technique,

preferably multiplex ligation-dependent probe amplification or quantitative polymerase chain reaction.

Said means (iii), for example, comprise dNTPs, polymerases, buffer, magnesium chloride, specific primers and probes.

In embodiments where large(r) deletions or insertions in the PAH/CTEPH/PVOD/HHT genes are determined, an additional analysis technique (such as MLPA or quantitative PCR) is useful for confirmation. Preferred embodiments

- Abstract

In this study we developed a new specific gene panel for pulmonary arterial hypertension (PAH), chronic thromboembolic pulmonary hypertension (CTEPH), pulmonary veno- occlusive disease (PVOD) and hereditary haemorrhagic telangiectasia (HHT) including major disease genes and further candidates. The new PAH-specific gene panel developed in this study allowed for the first time the assessment of all known PAH genes and further candidates at once and markedly reduced overall sequencing time and costs. Sensitivity and specificity reached 100% when Sanger technique was additionally applied. Thus, this technique will potentially change the routine diagnostic genetic testing in PAH patients.

- Discussion

We developed a PAH/CTEPH/PVOD/HHT-specific gene panel based on NGS and tested sensitivity and specificity including 43 PAH/CTEPH/PVOD/HHT genes and candidates in up to 96 patients and family members. A pilot study, including 29 genes, revealed BMPR2, ALKl, ENG and EIF2AK4 mutations in 59% of patients and documented a 100% sensitivity and 100% specificity of the panel, when Sanger technique was additionally applied in a "two step" procedure. The study showed that mutations in "new" genes such as EIF2AK4 could be frequently detected in PAH patients which would have been overlooked by the commonly used standard procedure addressing the 3 major PAH/CTEPH/PVOD/HHT genes (BMPR2, ALKl, ENG) only. Therefore, this technique will completely change the usual molecular diagnostic approach. NGS enables the screening of many genomic regions at once, Sanger sequencing of the pathologic variants as second step enables a 100% specificity.

Very recently another study was published by Piao and colleagues (2016) investigating mutations in 22 PAH associated genes in a cohort of IP AH/HP AH patients. They could only identify mutations in the genes BMPR2 and ALKl in 25% of the patients. No mutations in other candidate genes were uncovered. While 11 genes overlapped with our panel we also present data for 34 distinct candidate genes. EIF2AK4 was not sequenced by Piao et al. and thus potential mutations might have been overlooked. This exemplifies how crucial the selection of candidate genes is to detect PAH causing mutations.

Technical advantages of the new PAH/CTEPH-specific gene panel as diagnostic tool The PAH/CTEPH-specific gene panel is much more time and cost efficient than the conventional Sanger sequencing. The time per patient can be drastically reduced even further with different hardware analysing up to 96 patients at once. The number of genes could be increased up to 50, albeit lowering the average coverage of analysed genes.

The newly developed panel generates results for all genes in the same process. In contrast, Sanger sequencing is performed sequentially, one gene at a time. Hence, Sanger sequencing would be terminated as soon as a single mutation was identified excluding the possibility of detecting additional mutations as second hits (Rodriguez Viales et al, 2015). Therefore, a similar NGS panel approach is already in use for common diseases such as familiar breast and ovarian cancer (Schroeder et al, 2015).

Alternatively to Sanger technique whole exome NGS has been previously applied in PAH patients and detected 4 new PAH genes: the membrane protein caveolin-1 (Austin et al, 2012), the potassium channel KCNK3, the translation factor EIF2AK4 and the topoisomerase binding protein TOPBP1 (de Jesus Perez et al, 2014). However, whole exome NGS requires such an enormous amount of work (approximately several months to identify putative PAH genes in one patient) in terms of bioinformatics analyses, data processing and storage that this technique is currently no option for the routine diagnostic setting. It is only feasible for scientific use.

Further methodological considerations

Additional 5 candidate genes identified with conventional methods included BMPRIB (Chida et al, 2012), KCNA5 (Remillard et al, 2007), SMAD1 (Nasim et al, 2008), SMAD4 (Nasim et al, 2008) and SMAD9 (Shintani et al, 2009). These genes represent the most promising candidates to be mutated in IP AH/HP AH patients with no mutations in BMPR2, ENG or ALKl (Kwapiszweska et al, 2014). Hence, a targeted screening of all of these genes increases the probability of a disease causing mutation to be detected. Moreover, the continuous inclusion of putative candidate genes in the same panel will advance our knowledge of the PAH aetiology and highlight new genes involved in disease manifestation. The new PAH/CTEPH/PVOD/HHT-specific gene panel presented in this application will allow to better identify additional mutations, acting as modifiers for disease manifestation. Genetic assessment might receive a more prominent role within the actual and future diagnostic algorithm as indicated in the new ESC/ERS-guidelines and may even be useful for risk stratification. At the same time, the use of the PAH/CTEPH/PVOD/HHT- specific gene panel diagnostic requires a more comprehensive genetic counselling before and after the molecular analysis, since more genes are analysed and variants of unknown significance will also have to be explained. Once mutations have been identified in PAH/CTEPH PVOD/HHT patients the genetic assessment and counselling of family members is furthermore complicated by the yet unknown penetrance of mutations in less common PAH genes (Girerd et al, 2016).

Mutations and variants of uncertain significance

Both newly identified heterozygous mutations of the pilot study were located within EIF2AK4. Mutations in EIF2AK4 have been previously described in families with PVOD (Eyries et al, 2014) and pulmonary capillary haemangiomatosis (Best et al, 2014). Whereas we included one patient with PVOD this patient showed no mutation or variant in EIF2AK4 but a BMPR2 mutation. Recently, mutations in EIF2AK4 were also identified in 5 families of an Iberian population suffering from an aggressive form of HP AH (Tenorio et al, 2014) and two additional families (Gomez et al, 2015). Thus, this is the third study reporting mutations of EIF2AK4 in I/HPAH-patients.

Twelve variants were classified as variants of unknown significance in a pilot study analysing a subset of 29 genes in 37 patients and 5 family members of other PAH patients since not all in silico prediction programmes characterised them as "pathogenic" and/or they were present in a public database. Nevertheless, variants, which were classified as "pathogenic" by at least one prediction programme and are absent in non-PAH patients, represent interesting follow- up candidates for functional studies such as the variants in exon 23 of EIF2AK4, in exon 3 of SMAD7 or in SMAD6 exon 4. Due to the low frequency of PAH in the population (15:1,000,000) already two individuals with the same variant in the public ExAC database rise the population frequency of the variant above 0.0015%, the conservative cut-off expected for mutations causing PAH (Machado et al, 2015). Considering this level, a variant at a frequency of 0.0016%, which occurs in two individuals in the database, such as the variant in exon 3 of the VCAN gene might still represent an interesting follow-up candidate.

Conclusions The new approach of a panel diagnostic including a vast array of PAH/CTEPH/PVOD/HHT associated genes has shown to have a high sensitivity and specificity together with confirmatory Sanger sequencing. In already a small subset of patients two mutations in EIF2AK4 were identified, which would have not been detected with the previous routine procedure. Therefore, for patients and for practitioners this approach offers a comprehensive, cost and time efficient way to investigate genetic influences of PAH/CTEPH/PVOD/HHT and can be continuously adapted to include newly detected causative PAH/CTEPH/PVOD/HHT genes.

Further preferred embodiments

1) The inventors have found evidence that in some patients at least 2 gene defects are necessary for disease manifestation (second hit hypothesis) (Eichstaedt et at, 2016; Rodriguez Viales et al, 2015).

- Abstract

Mutations in the EIF2AK4 gene have recently been identified in recessively inherited VOD. In this study we assessed if EIF2AK4 mutations occur also in a family with autosomal dominantly inherited pulmonary arterial hypertension (HP AH) and incomplete penetrance of BMPR2 mutations.

Clinical examinations in a family with 10 members included physical examination, electrocardiogram, (stress)-echocardiography and lung function. Manifest PAH was confirmed by right heart catheterisation in three affected subjects. Genetic analysis was performed using a new PAH-specific gene panel analysis with next generation sequencing of all known PAH and further candidate genes. Identified variants were confirmed by Sanger sequencing.

All living family members with manifest HP AH carried two pathogenic heterozygous mutations: a frame shift mutation in the BMPR2 gene and a novel splice site mutation in the EIF2AK4 gene. Two family members who carried the BMPR2 mutation only did not develop manifest HP AH.

This is the first study suggesting that EIF2AK4 can also contribute to autosomal dominantly inherited HP AH. Up to now it has only been identified in a recessive form of HP AH. Only those family members with a co-occurrence of two mutations developed manifest HP AH. Thus, the EIF2AK4 and BMRPR2 mutations support the "second hit" hypothesis explaining the variable penetrance of HP AH in this family. Hence, the assessment of all known PAH genes in families with a known mutation might assist in predictions about the clinical manifestation in so far non-affected mutation carriers.

- Discussion

This is the first report of an autosomal dominantly inherited EIF2AK4 mutation as second hit in a family with HP AH and known BMPR2 mutation. Only those family members with a cooccurrence of a mutation in BMPR2 and EIF2AK4 were clinically affected and developed manifest HP AH, whereas carriers of the BMPR2 mutation only had no symptoms of PAH. Thus, the results of this study offer an explanation for the reduced penetrance of the disease in this family and show that EIF2AK4 may play a role also in families with autosomal dominantly inherited PAH.

EIF2AK4 mutation in autosomal dominant HP AH

EIF2AK4 was first described in the autosomal recessively inherited pulmonary veno- occlusive disease (PVOD) (Eyries et al, 2014) and pulmonary capillary haemangiomatosis (Best et al, 2014). Recently a single recessively inherited EIF2AK4 mutation (c.3344C>T, p.(P115L)) was repeatedly identified in six consanguineous HP AH families with autosomal recessive mode of inheritance (Gomez et al, 2014; Tenorio et al, 20105). Only homozygous mutation carriers developed the disease plus a single heterozygous carrier of a distinct EIF2AK4 mutation, in whom the authors suspected a second non-identified mutation in the same gene (Gomez et al, 2015). Therefore, up to now EIF2AK4 mutations have been believed to be a very rare in HP AH. Apart from the mentioned family we were able to identify a nonsense mutation in exon 8 in the EIF2AK4 gene in another PAH patient with sporadic IP AH who had no other mutation in known candidate genes (data not shown). Thus, this gene might be more often affected than initially thought and contributes to the disease in an autosomal dominant manner. In contrast, BMPR2 mutations occur in up to 85% of familial cases and are autosomal dominantly inherited (Machado et al, 2015; Pfarr et al, 2011). However, many BMPR2 gene carriers have no clinical symptoms and do not develop manifest PH even during a more than 10 year follow-up period (Hinderhofer et al, 2014). Hence, the family described here provides an explanation for the decreased penetrance and suggests an autosomal dominantly contribution of EIF2AK4 to disease manifestation.

EIF2AK4 mutation as "second hit" may explain variable penetrance Up to date only four families with second hits have been described (Rodriguez Viales et al , 2015; Wang et al, 2014). This might be due to the fact that usually only 3 genes (BMPR2, ACVRL1, ENG) are analyzed routinely in PAH patients in a sequential processes, i.e. if one mutation is discovered the other genes are not assessed. Thus, second hit mutations might be overlooked in general in the current routine diagnostic setting and particularly in genes such as EIF2AK4, which are usually not included in the diagnostic analysis.

While second hits are still rarely described in PAH this model is often found in other diseases such as the nephrotic syndrome or the long QT-syndrome. At the same time the decreased penetrance in PAH is an acknowledged pattern. Thus, second hits or modifier genes might be more common in PAH than known to date. We therefore contrast two genetic models: Firstly, we propose the "second hit model" to explain the low disease penetrance in PAH. In this model a single mutation in each gene on its own has a very low penetrance. Two mutations however, lead to a synergistic effect resulting in a high disease penetrance. The second model is the "single gene model", representing the classical view for PAH suggesting BMPR2 mutations alone are responsible for disease manifestation. Under this assumption, the EIF2AK4 mutation would randomly occur in this family and not impact PAH manifestation. In the latter model the penetrance for the BMPR2 variant must be moderate, since 4 (obligate) carriers of the mutation did not develop PAH up to ages 31, 37, 49 and 59.

Considering both models, it is significantly unlikely that both mutations in two known PAH genes occurred by chance in this family. Moreover, the EIF2AK4 mutation clearly co- segregates with the disease in BMPR2 positive family members suggesting a second hit model.

We have not observed an EIF2AK4 mutation alone within this family, albeit in a different IP AH patient (data not shown) indicating at least a low penetrance to be present. Disease severity might moreover be influenced by the location of the respective mutations within the protein and thus their variable impact on protein function (Machado et al, 2015). Therefore, we hypothesize according to the second hit model the penetrance to be intermediate if only BMPR2 was positive, very low if only EIF2AK4 was positive, and very high if EIF2AK4 and BMPR2 each harbor a mutation.

Loss of protein function by EIF2AK4 mutation

The gene EIF2AK4 encodes a kinase termed general control nonderepressable 2 (GCN2) which phosphorylates the eukaryotic translation initiation factor 2a leading to a global down regulation of protein synthesis in response to amino acid starvation, hypoxia and viral infection but the up-regulation of specific stress response proteins (Montani et al, 2016). Gene expression is increased in smooth muscle cells in the vessel wall and interstitial tissue (Eyries et al, 2014). While the gene function has been studied a clear link to PVOD or PAH still remains to be detected. However, an interaction between EIF2AK4 and the BMPR2 pathway genes SMADl, SMAD4, ACVRLl and ENG has been observed (Barrios-Rodiles et al, 2005; Eyries et al, 2014). Thus, an impaired functioning of both, BMPR2 and GCN2 (EIF2AK4), might potentiate its effect on the transcription of target genes of the BMPR2 pathway.

The EIF2AK4 mutation of this family leads to the loss of a splice site and subsequently the loss of exon 38, presumably a frame shift and premature stop codon. In the last exons of the functional gene (31-39) lies the ribosomal binding domain and the dimerisation domain between amino acids 1396-1643 (Padayana et al, 2005). The last 51 amino acids of this domain were missing or partly exchanged by wrong amino acids in the affected members of this HP AH family. The domain is essential to recruit ribosomes for protein synthesis (Narasimhan et al, 2004), thus a partial deletion will at least moderately affect protein- ribosome binding if not fully impair it. Moreover, in the same region the dimerisation domain is located. This facilitates the formation of a homodimer (2 EIF2AK4 proteins bind to each other) and thus a functional protein (Narasimhan et al, 2004). The formation of homodimers has been shown to be conserved in mice and yeast (He et al, 2014). Single amino acid substitutions in the C-terminal domain in yeast already led to an inability of the protein to dimerise and to be functionally active (Narasimhan et al, 2004). The gene sequence of the C- terminal domain is highly conserved from mice to mammals suggesting corresponding functional impairments in humans (Berlanga et al, 1999). A total deletion of this region in our HP AH family thus likely leads to a loss of function in the mutated gene.

Conclusions

We were able to show EIF2AK4 contributes to disease manifestation in this HP AH family in an autosomal dominant manner. We report a new mutation within EIF2AK4 leading to HP AH as a second hit together with a mutation in BMPR2 providing an explanation for the observed penetrance in this family. Only those family members with a co-occurrence of two mutations developed manifest HP AH. The occurrence of several mutations in PAH associated genes might be more frequent than initially thought. Thus, a simultaneous assessment of all PAH associated genes in more patients might shed light on the long standing question surrounding the reduced penetrance. 2) A mutation in the gene KLF2 has been shown by the inventors to cause hereditary

PAH (HP AH) (Eichstaedt et al, 2017).

-Abstract

Heritable pulmonary arterial hypertension (HP AH) is an autosomal dominantly inherited disease caused by mutations in the BMPR2 gene and/or genes of its signalling pathway in approximately 85% of patients. We clinically and genetically analysed an HP AH family without mutations in previously described PAH genes. Clinical assessment included electrocardiogram, lung function, blood gas analysis, chest X-ray, laboratory testing, echocardiography and right heart catheterization in case of suspected disease. Genetic diagnostics were performed using a PAH-specific gene panel including all known 12 PAH genes and 20 further candidate genes by next-generation sequencing (NGS). HP AH was invasively confirmed in two sisters and their father who died aged 32 years. No signs of HP AH were detected in five first-degree family members. Both sisters were lung transplanted and remained stable during a follow-up of >20 years. We detected a novel missense mutation in the Kruppel-like factor 2 (KLF2) likely leading to a disruption of gene function. The same KLF2 mutation has been described as a recurrent somatic mutation in B-cell lymphoma. Neither the healthy family members carried the mutation nor >120000 controls. These findings point to KLF2 as a new PAH gene.

- Discussion

In this study we detected a novel germline mutation in the KLF2 gene likely causing autosomal inherited HP AH in a family with three affected patients, a follow-up of >20 and no mutations in any of the previously described 12 PAH genes. The identification of KLF2 as potential PAH gene will generate new insights into the pathogenesis of the disease since it regulates pathways which have been shown to be involved in PAH development such as cell proliferation, inflammation and vasodilation.

Is the KLF2 gene mutation disease causing in this family?

KLF2 is a promising PAH gene, as Kruppel-like factors play an important role in many cellular functions which are also involved in the disease aetiology of HP AH. The pathogenicity of the detected KLF2 mutation was supported by several levels of evidence. Firstly, the functional spectrum of the KLF2 transcription factor, in particular its implication in endothelial activation and proliferation (Bhattacharya et al, 2005) and regulation of vasotonus points to an involvement in the development of PAH. Since KLF2 is able to inhibit a driver of endothelial cell proliferation, the VEGF receptor 2 (Bhattacharya et al, 2005), mutations which impair KLF2 functioning, may also lead to an increased cell proliferation. Similarly, functional KLF2 downregulates vasoconstrictors such as endothelin-1 and upregulates vasodilators such as eNOS (Dekker et al, 2005). Hence, a disturbance in this regulation is likely increasing vascular tonus, which is also observed in PAH.

Secondly, the mutation is significantly associated with PAH and co-segregated with the disease in our family. It has not been described before in PAH and was absent in unaffected family members as well as more than 120,000 controls.

Thirdly, the same mutation has been identified in splenic marginal zone lymphoma (Clipson et al, 2015) and functional studies clearly indicated a displacement from the nucleus and reduced transcriptional activity (Piva et ah, 2015). The lymphoma-associated mutations have been identified as somatic mutations, whereas the presumption in this study is that the KLF2 mutation is a germline event and thus present during development. This is a critical distinction, as homozygous germline deletion of KLF2 in mice has been published to be embryonic lethal or at least very deleterious to normal embryonic development (Yeo et al , 2014). The mechanism of embryonic lethality relates in part to loss of vascular integrity, lending some additional biological plausibility to KLF2 as a PAH-related gene. However, the published data suggest a specific activity of the mutant that is strongly reduced compared to the wild-type (Piva et al, 2015). This would fit with an incompletely penetrant, embryonically viable mutation that nonetheless manifests in disease. Thus, considering all evidence it is highly likely that the KLF2 mutation in this family led to PAH manifestation.

KLF2 gene is linked to the BMPR2-signalling

A closer review of KLF2 functionality and cellular localisation revealed a tight connection to the BMPR2 signalling pathway (Figure 3). We summarised interactions of KLF2 and important pathway members such as BMPs and apelin regulating vasodilation and cell proliferation known from the literature illustrating its role in this signalling network. KLF2 is not only upregulated by laminar blood flow in the pulmonary arteries but also by the BMPR2 ligand BMP4 and apelin, a small molecule acting as a vasodilator (Kim 2014). The functional BMPR2-apelin-KLF2 signalling axis leads to vasodilation by activating eNOS (SenBanerjee et al, 2004). Reduced apelin serum levels were identified in ΓΡΑΗ patients in comparison to controls (Chandra et al, 2011). Thus, an imbalance of the BMPPv2-apelin-KLF2 axis might contribute to dysfunctional endothelial and smooth muscle cells which are observed in PAH. This offers a possible explanation for the development of HP AH in the described family.

Conclusion

The findings of this study highlight for the first time KLF2 as a potential PAH gene. KLF2 functions are closely tied to the disease aetiology of PAH as it regulates vasotonus, cell proliferation and endothelial activation and the gene is linked to the BMPR2 pathway.

The following examples and drawings illustrate the present invention without, however, limiting the same thereto.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1. Two step sequencing procedure of the PAH specific gene panel diagnostic.

(A) In the first step the panel is designed in silico. The customised panel is manufactured and the desired PAH/CTEPH/PVOD/HHT genes are extracted from DNA of PAH/CTEPH patients and family members. PAH/CTEPH/PVOD/HHT genes from each patient are enriched leading to a high coverage of the regions of interest allowing 100% sensitivity to detect all true positive variants. Samples are pooled and loaded together onto a next generation sequencer.

(B) Resulting data is passed through quality control, the reads are aligned to a reference sequence and any variant from polymorphisms to mutations is identified. These variants are assessed regarding their clinical significance with comparative data bases and in silico prediction programs. To eliminate false positives direct Sanger sequencing is applied in a second sequencing step reaching 100% specificity.

Figure 2. Effect of the EIF2AK4 mutation c.4892G> T on cDNA level.

Next to the ladder the affected individual 11:4 shows a heterozygous PCR product for the cDNA of EIF2AK4 exons 36-39. The upper band shows the wildtype sequence (266 bp) while the lower band shows a product without exon 38 (147 bp). The healthy family member 111:4 is homozygous for the wild type PCR product indicating no loss of exon 38.

Figure 3. KLF2 as part of the BMPR2 signalling pathway.

KXF2 is upregulated by laminar blood flow, apelin and the bone morphogenic protein 4 (BMP4), which binds to the dimerised BMP receptor 2 (BMPR2) and the activin receptor like kinase (ALK or ACVRL1). Signals are transduced via the adenosine monophosphate kinase (AMP ), the mitogen activated protein kinase kinase 5 (MEK5 or MAP2K5) and subsequently the extracellular signal regulated kinase 5 (ERK5 or MAPK7). Apelin transcription is down regulated by BMP4, 7 and 9 orchestrated via the sma- and mad-related (SMAD) pathway. In contrast, BMP2 is able to induce apelin expression via the nuclear complex beta-catenin and peroxisome proliferator-activated receptor gamma (PPARy). Thus, the BMPR2 pathway can directly activate KLF2 and regulate apelin (APLN), an upstream regulator of KLF2. The KLF2 transcription factor inhibits endothelin-1 (ET-1 or EDN1) and vascular endothelial growth factor receptor 2 (VEGFR2 or KDR) expression while increasing endothelial nitric oxide synthase (eNOS or NOS3) transcription. These effects lead to a reduction in endothelial cell proliferation, the generation of NO and subsequent vasodilation of pulmonary artery smooth muscle cells (PASMCs). With a dysfunction of the KLF2 gene caused by a germline mutation as detected in this study, several PAH pathways will be activated. (Eichstaedt et al , 2017).

EXAMPLES

EXAMPLE 1

1. Materials and Methods

1.1 Subjects and clinical characterisation

In all PAH patients of the pilot study diagnosis was performed according to current ERS ESC-guidelines. All patients underwent a detailed clinical examination including right heart catheterisation as described previously (Grunig et al, 2009). Testing for vasoreactivity and left heart catheterisation were performed when clinically indicated. Clinical assessment of family members included taking medical history, lung function, six minute walking distance, physical examination, 12-lead electrocardiogram, echocardiography at rest and during supine bicycle exercise (Grunig et al, 2009; Kabitz et al, 2008). Acute or chronic pulmonary and cardiac diseases were ruled out in all family members. Blood samples were collected from all patients and relatives of other PAH patients. The protocol of this study confirms to the ethical guidelines of the Declaration of Helsinki. It was approved by the Ethic Committee of Heidelberg University and participants or their parents gave written informed consent.

1.2 Development of the PAH/CTEPH/PVOD/HHT-specific gene panel We developed a technique which in general would allow to asses up to 50 genes in up to 96 patients/family members simultaneously. In brief, after DNA is extracted, genomic regions of interest were enriched with a self-designed customised PAH panel, sequenced with NGS and possible pathogenic variants confirmed with targeted Sanger sequencing (Figure 1).

1.3 Implementation of the PAH/CTEPH/PVOD HHT-specific gene panel

The new gene panel was manually designed with the in silico tool SureDesign (Agilent Technologies, Santa Clara, USA). While the gene panel may assess up to up to 50 genes in 96 patients we concentrated on 43 genes and 37 patients and 5 relatives of other PAH patients to evaluate the sensitivity and specificity of this approach in the presented pilot study.

For this pilot study, a list of 29 genes including 12 PAH causal genes, was created after extensive literature research (Table 1 lists these 29 genes). The respective genomic regions, i.e. all exons plus 25 base pairs at 5' and 3' untranslated region and adjacent exon-intron boundaries, were extracted in silico from the human genome (GhR37/hgl9). Subsequently, probes were designed which covered each single DNA base within the desired genomic regions by on average of 7 different probes. Based on the in silico design a customised gene panel was manufactured by Agilent Technologies (HaloPlex).

DNA from subjects was extracted from peripheral blood using standardised procedures (Qiagen, Hilden, Germany) and tagged with a bar code allowing multiple samples to be included in a single run. The library preparation in vitro included DNA digestion by 16 restriction enzymes and the capture of the desired target genes by biotinylated probes. After pull down of desired fragments with biotin-streptavidin beads fragments were amplified by PCPv and loaded onto the MiSeq (Illumina, San Diego, USA) for subsequent sequencing. The kit may either be used entirely in one run on a NGS machine or split up in several runs. The latter option was used for the MiSeq and we performed four runs with 9-12 patients each.

1.4 Data analysis and setting adjustments

Data was imported into SeqPilot 4.1.2 (JSI medical systems GmbH, Kippenheim, Germany). Transcripts were loaded using the GhR37/hgl9 automated feature. Regions of interest were defined as coding exons including 20 base pairs of the 5' and 3' untranslated region. Default parameters were altered to highlighted changes in the sequence when >20 reads covered the specific base pair to account for non-random distributed reads over target regions in the HaloPlex design (Schroeder et al., 2015). While heterozygosity in Sanger sequencing is characterised by an equal frequency of the two variants, NGS is based on probes which amplify regions of interest. Differential amplification of specific probes might lead to a skewed ratio of the two variants. The initial heterozygosity cut-off of 35% to 65% for the two respective alleles was lowered to >10% and potential pathogenic variants were re-assessed with Sanger sequencing.

1.5 Variant classification

Each variant was classified as either clearly benign (polymorphism), likely benign, uncertain significance, likely pathogenic or clearly pathogenic as recommended by the Human Genome Variation Society (HGVS, http://www.hgvs.org/) (Richards et al, 2015). Each variant was evaluated in terms of minor allele frequency (MAF) in ENSEMBL and absolute frequency in the Exome Aggregation Consortium (ExAC) including more than 60,000 exomes from unrelated individuals (Lek et al, 2016). The consideration of this large database can prevent common variants from being classified as disease causing (Granzow et al, 2015). Polymorphisms were defined as a MAF >5% (Richards et al, 2015). All variants with a MAF <5% were sought in the Human Gene Mutation Database (HGMD Professional 2015.4). Additionally, for variants of BMPR2, ENG, ALKl and SMAD4 present in the ARUP data base (http://www.arup.utah.edu/database a literature search was conducted. Non-synonymous missense variants with MAF <5% were characterised using four in silico prediction programmes: MutationTaster, SIFT, Align GVGD and PolyPhen2 implemented in Alamut 2.7.1 (interactive biosoftware, Rouen, France). Variants were considered as likely pathogenic in case of non-sense, frameshift and splice site mutations not occurring in the last exon of a gene (Wallis et al, 2013) and are termed mutations hereafter. Variants which could not be clearly assigned with the majority of the in silico prediction tools were classified as having an "uncertain significance".

1.6 Sanger sequencing, multiplex ligand-dependent probe amplification and statistical evaluation

All variants of uncertain significance, likely pathogenic variants or mutations were reanalysed with Sanger sequencing after designing specific primers and evaluating the optimal polymerase chain reaction (PCR) conditions.

Gene Primer name Primer sequence 5 '-3' SEQ ID

NO. ACVRL1 ACVRLl -X3 M13Fnl TTCAAGGTGTTTGTCTGAGGG 44

ACVRL1 ACVRLl -X3 P172Rnl C C AGAGC AT GAG AG GAAAG G 45

ACVRL1 ACVRLl -X5 M13f GGATAGAGAAGGGGGCTGTG 46

ACVRL1 ACVRLl -X5 P172rn TAGCCAAAAACTCCCTCACC 47

ACVRLl ACVRLl -X6 M13fn CCCAGTGTGTAACCCTCACC 48

ACVRL1 ACVRLl -X6 PI 72rn GGAGGTCTGCAAACTT GAGC 49

ACVRLl ACVRLl -X7 M13fn GCTGAGTCACCCAACCTTTC 50

ACVRLl ACVRLl -X7 P172rn AGACAACTCGTGGGGTCTTG 51

ACVRLl ACVRLl -X8 M13fn GATCCCAGGTTTGGGAGAG 52

ACVRLl ACVRLl -X8 P172rn AACAGGCTGATTCCCCTTTC 53

ACVRLl ACVRLl-X10 M13fn2 TGTCTTTCCTCTCGCTCTCC 54

ACVRLl ACVRLl-X10 P172rn2 AC C AG C AC AC AC C AC AC T C AC 55

BMPR2 BMPR2-X1 f-M13 GTGATACGGGCAGGATCAGT 56

BMPR2 BMPR2-X1 r-P172 ATTTCCCTGGAAGGCATGG 57

BMPR2 BMPR2-X3 f-M13 TAGCTTACACGTACTCTCAC 58

BMPR2 BMPR2-X3 rl-P172 CATCACGCCTGGCTTCAAC 59

BMPR2 BMPR2-X6 f-M13 CAGAGAGCTGTAGCATTCTG 60

BMPR2 BMPR2-X6 r-P172 GCTGGAGTACGGCTGTACAAT 61

BMPR2 BMPR2-X7 Seqf CGCATTTTTTCCTCTATATAG 62

BMPR2 BMPR2-X7 r-P172 TTCCTGTTGTGAATTTTGAACC 63

BMPR2 BMPR2-X9F1-M13 TTCAGGAAGGGCATTTTATAGG 64

BMPR2 BMPR2-X9R1-M13 CATCCTGCTGCTAATAATGTTTC 65

BMPR2 BMPR2-X10 f-M13 TTGGTATCAGAAATACCCCTGTT 66

BMPR2 BMPR2-X10 r-P172 CAAACAACAT AAAACAT AT T CAGT C A 67

BMPR2 BMPR2-X11 Seqf CACAT GGT T T GAC AT GT ACT T T G 68

BMPR2 BMPR2-X11 r-P172 TCATTGAACTATTAGGCTGGTT 69

BMPR2 BMPR2-X12-3 f2 M13 AGC AGAAC C T T C C C AAGAGAC 70

BMPR2 BMPR2-X12-3 r2 P172 TCTGAACATGGATTGCTGTTG 71

BMPR2 BMPR2-X12-4 f2 M13 T GAGC AT GAGC C T T T AC T GAG 72

BMPR2 BMPR2-X12-4 r3 PI 72 TAGTTATTTAAATGGCCCCA 73

BMPR2 BMPR2-X13 f-M13 CACCCTCCTGAGACATTGGT 74

BMPR2 BMPR2-X13 r-P172 CATCTTCTGCATGTTTAAATGA 75

EIF2AK4 EIF2AK4 X6 M13 GTAATTAGCACATCCGTCACTGC 76 EIF2AK4 EIF2AK4X6-35 PI 72 GGAGTTTGCCCGATGTTTACC 77

EIF2AK4 EIF2AK4X8-2M13 ACTTTCTGTTTAATGTGCAGGC 78

EIF2AK4 EIF2AK4X8-4P172 CACCTTGGATGCTTACCTGC 79

EIF2AK4 EIF2AK4X12M13 TGACTGTAGCTGTGGGACTC 80

EIF2AK4 EIF2AK4X12-354 GTGTCACTTCGCCCTTGATC 81

P172

EIF2AK4 EIF2AK4X23 Ml 3 GACTTCAATGGTCCCAGTAGC 82

EIF2AK4 EIF2AK4X23P172 TTCCTCCACCCCAGTAACAC 83

EIF2AK4 EIF2AK4X38M13 AACCCCAGCAGTCTCCTAAC 84

EIF2AK4 EIF2AK4X38P172 GGGACAGCTACTCCTAGGAC 85

ENG ENG-X2 f C C T CAT AAGGT GGCT GT GAT GAT G 86

ENG ENG-X2 r CATCTGCCTTGGAGCTTCCTCT 87

ENG ENG-X9M13& TGGGTTGTGGTCAGTCCTTG 88

ENG ENG-X9P172rn TGCTCTCCCAAACACACCTC 89

ENG ENG-X13 M13fn CTCCCAAAGGTGCCACATAC 90

ENG ENG-X13 P172rn CTAGGCTGCTATGGCTCTGG 91

HRG HRGX1-66M13 CAGTGGCAGATCATAGCAAGG 92

HRG HRG XI PI 72 AGCCATTCATTGTGCAAAGC 93

SMAD1 SMAD1-X3F GCAGCAGGACAGGGATCAG 94

SMAD1 SMAD1-X3R GTTGACCCAGCTTTTCCG 95

SMAD4 SMAD4 X3-43M13 CTCATGTGATCTATGCCCGTC 96

SMAD4 SMAD4 X3 PI 72 ACTACAATACTCGGTTTTAGCAGTC 97

SMAD6 SMAD6 X4 Ml 3 GTTGTGCGCCATATTTCCTGAG 98

SMAD6 SMAD6X4-347P172 CGATCTTGCTGCGCGTTC 99

SMAD7 SMAD7X1-232 M13 CTTCTTCATGGTGTGCGGAG 100

SMAD7 SMAD7X1-314P172 GCCGCTCCTTCAGTTTCTTG 101

VCAN VCANX3-117M13 GTTACAACACCAGTGAATTTCTCC 102

VCAN VCANX3 PI 72 TTTTCCGCTCATCCAAACCC 103

VCAN VCANX7-735 M13 C AG AAG AC AC CAT CCACACTC 104

VCAN VCANX7-1938P172 TCTGTTCTCATCTCTGGTATTAGTG 105

VCAN VCANX7-2748M13 TGTTCCTCCCACTACCCTTG 106

VCAN VCAN X7 PI 72 ACTCCAGTTATCTTCTAATAGCAGC 107 Sensitivity and the specificity were estimated using BMPR2, ALKl and ENG genes fully sequenced with Sanger and NGS technique. Sensitivity is defined in our case as the percentage of mutations identified by Sanger (gold standard) which were also detected by NGS. By the set-up of NGS being followed by Sanger validation this two-step procedure has a specificity of 100%, since all NGS false positives are removed in the Sanger validation step.

Patients who showed no mutations within BMPR2, ALKl or ENG were additionally assessed with multiplex ligand-dependent probe amplification (MLPA, it P093-C1, MRC-Holland, Amsterdam, Netherlands) to detect large deletions or duplications encompassing exonic regions of BMPR2, ALKl and ENG.

1.7 Splice site mutation assessment

Suspected splice site mutations were investigated on RNA level. RNA was extracted following standard procedures. Complementary DNA was generated with a reverse transcriptase assay. Exons of interest were amplified in samples and controls with PCR and splice site alterations were visualised by agarose gel electrophoresis and Sanger sequencing; conditions are available upon request.

2. Results

2.1 Patient population

We included 37 patients and 5 first degree family members of affected individuals in the panel. Of the patients 19 suffered from IP AH, 8 had HP AH, one patient had PAH associated with congenital heart defects (CHD-APAH) and one patient APAH with pulmonary veno- occlusive disease. Eight patients had PAH and hereditary haemorrhagic telangiectasia (HHT) (Table 2). In the 5 family members no pulmonary hypertension or any other cardio-pulmonary disorder has been detected.

2.2 Clinical findings

Table 3 summarises the main clinical findings in the 37 PAH patients. Patients had severe PAH with impaired right ventricular function, lung function, lowered oxygen saturation and elevated NT-proBNP levels. 2.3 Results of PAH/CTEPH/PVOD/HHT-specific gene panel confirmed by direct Sanger sequencing

Figure 1 shows how the 42 subjects have been genetically assessed followed by bioinformatic processing. In 22 individuals of the 37 patients (59%) mutations in the BMPR2, ALK1, EIF2AK4 or ENG genes (Table 4) and 12 heterozygous variants of uncertain significance (UVs, Table 5) in 6 further candidate genes were identified by NGS and validated by conventional Sanger sequencing. One patient carried a large heterozygous deletion of exon 6 to exon 7 in BMPR2, identified by MLPA (Table 4).

Two new heterozygous mutations in EIF2AK4 gene were identified in a H/IPAH patient, respectively. The first EIF2AK4 mutation led to an introduction of a stop codon (exon 8, c.933T>A p.(Y311*)). The second EIF2AK4 mutation (exon 38, c.4892+lG>T) led to a loss of a splice site and subsequent RNA analysis confirmed the loss of exon 38. Twelve UVs were identified in the following PAH genes: EIF2AK4, HRG, SMAD1, SMAD4, SMAD6, SMAD7 and VCAN (Table 5). Of the 12 UVs, four have not yet been identified in healthy individuals. However, these variants were only classified as "pathogenic" by 1-2 of the four in silico prediction programmes.

2.4 Sensitivity and specificity of the PAH-specific gene panel

The first of four runs of the panel diagnostic experienced technical errors during the sequencing by synthesis on the MiSeq; only 0.8 gigabases (Gb) were sequenced albeit with an average base call error rate <0.1% ( Q30) of 91.2%. This drastically reduced the overall coverage leading to a lack of detection of 2 mutations previously identified with Sanger sequencing. These errors were clearly visible in quality parameters during sequencing and were addressed in the subsequent runs (run 2: 5.5 Gb, >Q30=90.5%; run 3: 5.8 Gb, >Q30=92.1%; run 4: 5.4 Gb, >Q30=90.6%). Hence, 100% sensitivity could be obtained in the following runs with an average coverage of approximately 800x. Nevertheless, 14 false positive mutations/variants were initially found with NGS panel which could not be confirmed by Sanger sequencing. These variants were either characterised by "short reads" of 25-36 bp (n=4), a very low heterozygosity of 10-15% (n=5) or other sequencing artefacts (n=5). Several of these artefacts were not confined to single patients and thus clearly identifiable as technical artefacts. Since in routine diagnostics all NGS mutations are verified with Sanger as a second step all false positives would be discovered. Therefore, a specificity of 100 is reached. 2.5 Comparison of sequencing and analysis methods

With the ultimate goal detecting new variants/mutations in PAH/CTEPH/PVOD/HHT related genes efficiently, the approach of NGS for a specific PAH/CTEPH/PVOD/HHT gene panel enabled highly sensitive, cost- and time-saving sequencing. Technical specifications of the commonly used Sanger sequencing and the new PAH/CTEPH/PVOD/HHT-specific gene panel diagnostic with NGS were compared in Table.

The panel diagnostic in the pilot study allowed sequencing all exons in 29 genes at the same time mstead of only one direction of one exon per reaction by Sanger. Not only each exon has to be sequenced separately with Sanger sequencing but also each patient. Meanwhile, the panel diagnostic allows assessing up to 96 patients at the same time albeit keeping the data storage requirements at a moderate level.

The Sanger technique requires approximately 11 h assessment time/per patient for the 3 major PAH/ CTEPH/HHT genes BMPR2, ALK1 and ENG. In contrast, the new panel technique in our diagnostic setting allowed the assessment of 29 genes within 5 h assessment time/per patient plus the time required for confirmatory Sanger sequencing. This huge time advantage was enabled by processing several patient samples and PAH/CTEPH/PVOD/HHT genes simultaneously in the laboratory (48 h sample processing in the laboratory for 12 samples at once, see Table 6). While data generation is faster than Sanger sequencing, data analysis and bioinformatics processing is prolonged as any possible pathogenicity of rare variants has to be investigated by in silico prediction programmes and literature research. Nevertheless, once a data base has been established classifying the effect of variants data analysis can be accelerated.

When large deletions and insertions are identified with the PAH/CTEPH/PVOD/HHT- specific gene panel based on NGS, it is preferred to confirm such findings with a second method such as MLPA or quantitative PCR. The PAH/CTEPH/PVOD/HHT-specific gene panel is not limited to the sequence data analysis regarding mutations but also enables the detection of large deletions or insertions in the routine diagnostic setting.

Table 1: PAH/CTEPH causal genes and candidate genes (of the pilot study)

Gene size Exon Transcribed

Gene name ENSEMBL Gene ID

(bp) number exons ACVR1 ENSG00000115170 139418 12 4-12

ACVRL1

16453 10 2-10

(ALK1) ENSG00000139567

BMP! ENSG00000125845 12616 3 2-3

BMPR1A ENSG00000107779 176188 13 3-13

BMPR1B ENSG00000138696 400480 13 4-13

BMPR2 ENSG00000204217 190815 13 1-13

CAV1 ENSG00000105974 36399 3 1-3

CREB ENSG00000118260 73694 9 3-9

EIF2AK4 ENSGOOOO0128829 101445 39 1-39

ENG ENSGO0OO0106991 39744 15 1-15

HRG ENSG00000113905 18024 7 1-7

ID1 ENSG00000125968 1232 2 1-2

ID2 ENSG00000115738 5608 5 2-3

ID3 ENSG00000117318 1876 3 1-2

ID4 ENSG00000172201 3298 3 1-2

IL6 ENSG00000136244 6118 6 2-6

KCNA5 ENSG00000130037 1842 6 1

KCNK3 ENSG00000171303 40730 2 1-2

SMAD1 ENSG00000170365 76885 7 2-7

SMAD4 ENSG00000141646 56651 12 2-12

SMAD5 ENSG00000113658 55902 8 3-8

SMAD6 ENSG00000137834 80620 4 1-4

SMAD7 ENSG00000101665 30858 4 1-4

SMAD9 ENSGOOOOO 120693 75934 7 2-7

SOD2 ENSGOOOOO 112096 93472 6 1-5

TOPBP1 ENSGOOOOO 163781 63718 28 2-28

VCAN ENSG00000038427 110838 15 2-15

VHL ENSG00000134086 11212 3 1-3

ZFYVE16 ENSG00000039319 71337 19 3-19

Bold genes indicate 12 of the 14 known PAH genes. Table 2: Characteristics of study population Characteristics of study

population

Gender, n (%) female 35 (83%)

Age (years) 48 ± 13

Disease

IP AH 19 (45%)

HP AH 8 (19%)

CHD-APAH 1 (2%)

PVOD-APAH 1 (2%)

PAH and HHT 8 (19%)

Family member of PAH patient 5 (12%)

Values are given as n (%) or mean ± standard deviation IP AH: idiopathic pulmonary arterial hypertension,

HP AH: hereditary pulmonary arterial hypertension,

CHD-APAH: congenital heart defect with associated PAH, PVOD: pulmonary veno-occlusive disease,

HHT: hereditary haemorrhagic telangiectasia

Table 3: Clinical characteristics of the 37 PAH patients Mean ± Standard

Characteristic* , .

deviation

Age at first diagnosis of PAH [years],

50 ± 13 n=37

Age at first diagnosis of HHT [years],

9 ± 3 n=8

6-minute walking test

6MWD [m] 415 ± 53

Borg Scale out of 20 13 ± 2

Sa0 2 after 6MWD [%] 92 ± 2

Lung function

Vital capacity max [%] 79 ± 17

Forced vital capacity [%] 88 ± 9

FEV1 [%] 72 ± 17 Peak expiratory flow [%] 83 ± 11

Sa0 2 at rest [%] 96 ± 1

Echocardiography at rest and during

exercise

Right atrial area [cm ] 23 ± 8

Right ventricular area [cm ] 22 ± 4

Vena cava inferior [cm] 1.9 ± 0.1

sP AP at rest [mmHg] 64 ± 19

TAPSE [cm] 2.2 ± 0.5

TDI-s [cm/s] 12 ± 3

Left ventricular eccentricity index 1.3 ± 0.3

Workload during exercise [Watt] 79 ± 23

sPAP during exercise [mmHg] 97 ± 23

Right heart catheter

mPAP [mmHg] 53 ± 11

PAWP [mmHg] 10 ± 4

Cardiac output [1/min] 4.3 ± 1.4

Cardiac index [1/min/m 2 ] 2.5 ± 0.8

PVR [dynes] 1045 ± 517

Laboratory

NT-proBNP [pg/ml] 1800 ± 228S

*not all measurements were obtained from each patient

data are given as mean ± standard deviation

Sa0 2 : arterial oxygen saturation, 6MWD: 6-minute walking distance

FEVl: Forced expiratory volume 1st second, sPAP: systolic pulmonary arterial pressure,

TAPSE: Tricuspid annular plane systolic excursion

mPAP: Mean pulmonary artery pressure, PAWP: Pulmonary arterial wedge pressure, PVR: Pulmonary vascular resistance

Table 4: Variants/mutations detected with Sanger and NGS-gene panel

Gene Exon Variant name Impact Sanger Panel

ACVRL1 3 c. l28_132delGGCCT deletion yes yes p.(G43D)fs*124

ACVRL1 5 c.595G>C p.(A199P) missense yes yes

ACVRL1 6 c.662G>A p.(W221*) nonsense yes yes

ACVRL1 7 c.788A>G p.(D263G) missense yes yes

ACVRL1 7 c.950T>C p.(I317T) missense yes yes

ACVRL1 8 c.l055C>A .(A352D) missense yes yes

ACVRL1 8 c.l231C>T .(R411W) missense yes yes

ACVRL1 10 c.l451G>A .(R484Q) missense yes yes

BMPR2 1 c.76+lG>T intronic yes yes

BMPR2 3 c.377A>G, p.(N126S) missense yes

BMPR2 3 c.418+5G>A intronic yes yes

BMPR2 6 c.6310T p.(R211*) nonsense yes yes

BMPR2 6 c.659dupG p.(G220fs*4) duplication yes yes

BMPR2 7 c.967+5G>A intronic yes yes

6-7 large

BMPR2 deletion exon 6-7** no no deletion

c.l l29-l_1129dupGG

BMPR2 9 duplication yes yes p.(V377Gfs*13)

BMPR2 10 c.l 277- A>G splice defect yes *

BMPR2 10 C.12970T p.(Q433*) nonsense yes yes

BMPR2 11 c.l453G>A p.(D485N) missense yes yes

BMPR2 12 c.2308delC p.(R770Gfs*2) deletion yes yes

BMPR2 12 C.26950T p.(R899*) nonsense yes yes c.3062_3064delAAG

BMPR2 13 deletion yes yes p.(E1021..1022G)

EIF2AK4 8 c.933T>A p.(Y311*) nonsense yes yes

EIF2AK4 38 c.4892+lG>T splice defect yes yes

ENG 2 c.90T>G p.(C30W) missense yes yes

ENG 9 c.l268A>G p.(N423S) missense yes yes

13 c.l741_1742dupTCTG

ENG duplication yes yes p.(G581fs)

* Technical errors during the run were evident during the data generation.

These samples would be repeated during diagnostics due to low quality values.

*This large deletion was detected with MLPA and was not visible with Sanger nor NGS Table 5: New variants of unknown significance detected by NGS and confirmed with Sanger sequencing

Exon % in

Gene Variant name Impact MutationTaster SIFT PolyPhen2 Align GVGD

ExAC

EIF2AK4 6 c.627A>C p.(Q209H) missense benign benign pathogenic benign 0.0041%

EIF2AK4 12 C.1819-160G intronic benign NA NA NA -

EIF2AK4 23 c.3329TT>G p.(M1110R) missense pathogenic benign pathogenic benign -

HRG 1 c.l67C>T p.(A56V) missense pathogenic pathogenic pathogenic pathogenic 0.0568%

SMAD1 3 c.549G>A .(P183P) synonymous pathogenic NA NA NA 0.0016%

SMAD4 3 c.354G>A p.(A118A) synonymous benign NA NA NA 0.0016%

SMAD6 4 C.1730T p.(A58V) missense benign pathogenic benign benign -

SMAD7 1 c.l l5G>A p.(G39R) missense pathogenic pathogenic pathogenic benign 0.028%

SMAD7 3 c.709G>A p.(G237R) missense pathogenic pathogenic benign uncertain -

VCAN 3 c.301G>T .(V101L) missense pathogenic pathogenic pathogenic benign 0.0016%

VCAN 7 c.l045A>G p.(K349E) missense benign pathogenic pathogenic pathogenic 3.106%

VCAN 7 C.4003+16OG intronic pathogenic NA NA NA 0.1087%

ExAC: Exome Aggregation Consortium

Table 6: Comparison of common Sanger sequencing with the PAH-specific gene panel in our diagnostic setting

Characteristic Sanger Sequencing PAH-specific gene panel by NGS

(3 genes) (29 genes)

BMPR2, ALK1, ENG, EIF2AK4,

Genes BMPR2, ALK1, ENG

KCNK3, CA V1, ...

Time expense

Preparation time/gene 8 hours 24 hours

Sequencing time/gene 2 hours 24 hours

Analysis time of data/patient 1 hour 3 hours

Total time effort 11 hours 51 hours

Maximum patients per run 1 patient 12 patients

Exons per patient per reaction 1 exon All exons of 29 genes

Total time per patient 11 hours 5 hours*

Data storage

Implementation and handling Easy Moderate

*these data refer to average values per patient considering a joined preparation of 12 samples

EXAMPLE 2 EIF2AK4 mutation as "second hit" in hereditary pulmonary arterial hypertension.

1. Materials and Methods

1.1 Subjects and clinical characterisation

Members of a family with autosomal dominantly inherited HP AH were clinically and genetically assessed. All living genetically related family members were invited to participate in a clinical and genetic evaluation. After written informed consent was obtained family members underwent clinical assessment and genetic counseling. A three generation pedigree was drawn including nine family members of the index patient. EDTA-blood was taken for genetic analysis.

Clinical procedures consisted of recording the family and medical history, physical examination, laboratory parameters including N-type pro brain natriuretic peptide (NT- proBNP), 12-lead electrocardiogram, lung function test, arterial blood gases, 6-minute walking distance, echocardiography, stress-Dopplerechocardiography and cardiopulmonary exercise testing as described previously (Hinderhofer et al, 2014). High resolution computer tomography of the lung was conducted to exclude pulmonary veno-occlusive disease. Left heart catheterisation was performed in all patients with suspected left heart diseases and when clinically indicated. Manifest HP AH was diagnosed according to the current guidelines (Galie et al, 2016). Right heart catheterisation was performed in the living HP AH patients to confirm diagnosis and for follow-up.

1.2 Genetic assessment

Genomic DNA was isolated from peripheral blood using a salting out procedure (Miller et al, 1988) (Autopure, LGC, Germany). Sanger sequencing for BMPR2 (ENST00000374580) was conducted in the index patient using Big Dye Terminator Vl.l cycle sequencing kit and ABI 3130x1 genetic analyzer (ThermoFisher Scientific, USA). Duplications and deletions were screened by multiplex ligation-dependent probe amplification (MLPA, kit P093-C2, MRC- Holland, the Netherlands).

A new PAH gene panel diagnostic based on next-generation sequencing was designed to analyse second hit mutations in 11 PAH (ACVRL1 or ALK1, BMP RIB, BMPR2, CAV1, EIF2AK4, ENG, KCNA5, KCNK3, SMAD1, SMAD4, SMAD9) and 20 further candidate genes in the index patient. DNA was enriched with a customised SureDesign panel (Agilent Technologies, USA) and sequenced on the MiSeq (Illumina, USA). Exonic regions and exon- intron boundaries were analysed with SeqPilot 4.1.2 (JSI medical systems GmbH, Germany). Variants were characterised following the recommendations of the Human Genome Variation Society (HGVS version 2.15.11) (den Dunnen et al, 2016). Non-synonymous missense variants with a population frequency <5% were assessed regarding their evolutionary conservation, location within functional gene domains and functional consequence using four in silico prediction programs: MutationTaster, SIFT, Align GVGD and PolyPhen2 implemented in Alamut Visual 2.7.1 (interactive biosoftware, France). Variants were confirmed by Sanger sequencing in the index patient and assessed in family members to clarify mutation status. Any variants disrupting gene function were considered mutations.

1.3 Functional assessment of mutations

RNA was isolated from EDTA blood using standard procedures. Copy DNA (cDNA) was generated with a reverse transcriptase reaction adding hexamers for 10 min at 65 °C, a cDNA- Mix (Invitrogen, USA) for 2 hours at 37°C and a final reaction for 10 min at 65°C. A PCR was designed to assess the cDNA corresponding to the messenger RNA of EIF2AK4 (ENSG00000128829; SEQ ID NO. 5) The PCR product span the exon 38 using a forward primer annealing in exon 36 (5' GACCTCCCTTGCCAACTTAC 3'; SEQ ID NO. 108) and a reverse primer annealing in exon 39 (5' AGAT TCTGTAGTAGTCATCTCTATAGC 3'; SEQ ID NO. 109). The expected size of the intact PCR product was 266 bp and the one of the PCR product skipping exon 38 was 147 bp. cDNA was denatured for 5 min at 95°C, and subsequently amplified in 35 cycles (1 min at 95°C, 1 min at 56.5°C, 1.5 min at 72°C; final elongation 10 min at 72°C). While several transcripts exist for EIF2AK4 the considered isoform is the most common one in humans since it is referred to as reference sequence by NCBI RefSeq. NCBI RefSeq is a database which we used as reference standard for reporting the location of medically important variations. PCR products were sequenced with Sanger sequencing to identify the altered base pair sequence of the messenger RNA.

1.4 Statistical analyses

Significance of co-occurance of BMPR2 and EIF2AK4 was calculated by using an estimated heterozygote frequency of EIFAK4 mutations retrieved from the Exome Aggregation Consortium (ExAC) database (Lek et al, 2016) and taking into account the number of genes on the panel by correcting for multiplicity. A p-value lower than 5% was considered statistically significant.

2. Results

2.1 Clinical characterisation

Clinical parameters are presented in Table 7. PAH was excluded in healthy family members by regular clinical assessments including physical examination, lung function tests, ECG, and in particular by echocardiography, stress-Doppler-echocardiography, spiroergometry and NT- proBNP values. Diagnosis of PAH was confirmed by right heart catheterisation in patients 11:4, 111:2 and 111:3. The disease was very severe in all three patients but could be stabilised with medication in patients 11:4, and 111:2. Patient 111:3 showed a rapid progression and received a lung transplantation 1.5 years after diagnosis. She died only one year after transplantation due to a rejection of the donor organ. Patient 11:4 and 111:2 were under dual therapy at the time of this writing. Stable haemodynamic parameters were observed in the latest catheter of patient 11:4 with a mean pulmonary artery pressure (mPAP) of 46 mmHg, pulmonary arterial wedge pressure (PAWP) of 12 mmHg, cardiac output 4.6 1/min, cardiac index 2.3 1/min/m 2 and pulmonary vascular resistance of 591 dynes. Patient 111:2 has improved under therapy to a mPAP of 55 mniHg, PAWP of 14 mmHg, cardiac output 6.0 1/min, cardiac index 2.9 1/min m 2 and pulmonary vascular resistance of 547 dynes.

Pulmonary veno-occlusive disease (PVOD) was excluded in the patients on three grounds. Firstly, high resolution computer tomography showed no morphological changes typical for PVOD. Secondly, diffusion capacity of the lung for carbon monoxide (DLCO) values were greater than 50% predicted. Values around 50% are often seen in PVOD (Montani et at, 2008). Thirdly, patients 11:4 and 111:2 have received PAH medication for eight years and were stable under dual therapy. Whereas in PVOD a worsening of symptoms is often observed, once PAH medication has been given.

Table 7: Clinical parameters

mPAP >25 mmHg characterises pulmonary hypertension 2 PAWP >15 mmHg together with mPAP >25 nimHg characterises post-capillary pulmonary hypertension due to left heart disease; PAWP <15 mmHg together with mPAP >25 mmHg characterizes pre-capillary PH

3 sPAP >40 mmHg at rest and sPAP >45 mmHg at low workloads is considered here as abnormal and exercise induced pulmonary hypertension, respectively (Nagel et al, 2015). However, cut-offs are not clearly defined in current guidelines.

mPAP, (sPAP): mean (systolic) pulmonary arterial pressure, PAWP: pulmonary arterial wedge pressure, CO: cardiac output, CI: cardiac index, Sa0 2 : oxygen saturation, V0 2 : oxygen uptake, PVR: pulmonary vascular resistance, RV: right ventricular, TAPSE: tricuspid annular plane systolic excursion, DLCO: diffusion capacity of the lung for carbon monoxide, NT- proBNP: N-type pro brain natriuretic peptide, 6-MWD: 6 minute walking distance

2.2 Genetic findings

All living family members with manifest HP AH (11:4, 111:2) carried a heterozygous mutations in BMPR2 and EIF2AK4. In contrast, two non-diseased family members (111:1 and 111:4) carried only the BMPR2 mutation and no mutation in EIF2AK4. None of these family members developed manifest HP AH at of the time of this writing.

The first familial mutation lay within exon 12 of the BMPR2 gene (c.2308delC, p.(Arg770Glyfs*2)) and led to the deletion of a cytosine resulting presumably in a premature stop codon two amino acids downstream. The second mutation was located one base pair behind the end of exon 38 of the gene EIF2AK4 (c.4892+lG>T) resulting in the loss of the complete exon 38 (Figure 2). Due to this exon loss sequencing results suggested a frame shift and subsequent introduction of a premature stop codon in exon 39 at amino acid position 1599 instead of position 1650 in the regular protein; hence, a disrupted protein after the end of exon 37 is predicted.

While DNA was only available from five family members the pedigree analysis revealed two further obligate carriers of the BMPR2 mutation. The grandfather (1:1) and the aunt (11:2) of the index patient must have been carriers for the cousin (111:1) to harbour the mutation. At the same time, the EIF2AK4 mutation was most likely also present in the grandfather (1:1), who had died aged 49 years due to liver cirrhosis. Since the mother of the index patient (11:4) only developed manifest PAH at the age of 49 years, it is likely that the grandfather would have developed PAH due to the inferred presence of both mutations at a later stage in his life or had already developed the disease but had not been diagnosed until his death. Alternatively, the EIF2AK4 mutation might have arisen de novo in 11:4 or as a germ line mosaicism in either grandparent of the index patient.

In HP AH we expect a BMPR2 mutation with a probability of 85% (Machado et al, 2015; Pfarr et al, 2011). Under the null hypothesis stating that the mutation in EIF2AK4 does not contribute to disease manifestation but instead represents a random event for the proband, the chance to observe the association of the two mutations has the probability of 0.00046. Taking the number of genes on the panel into account this association of both mutations under the null hypothesis reveals p=0.00046*30=0.014, which is significant below the 5% level. Hence, the co-occurrence of both mutations in affected family members is a significant association. Moreover, EIF2AK4 co-segregates with disease conditioned on all BMPR2 positive family members supporting the hypothesis of a second hit model, in which the diplotype of mutations in both genes has a high penetrance for PAH.

EXAMPLE 3 Identification KLF-2 mutation in heritable pulmonary arterial hypertension.

1. Materials

1.1 Subjects and clinical characterisation

Members of a HP AH family were genetically and clinically assessed after providing their written informed consent for genetic and clinical analysis. The study was approved by the Ethics Committee at Heidelberg University and carried out in accordance with the Declaration of Helsinki (2013) of the World Medical Association. Diagnosis of PAH was confirmed by right heart catheterisation in all affected family members. Family members with no symptoms or signs of PAH were assessed by obtaining medical history, physical examination, 12-lead ECG, lung function test, chest X-ray, echocardiography at rest and during exercise and laboratory assessment as described previously (Ehlken et al, 2016).

1.2 Sanger sequencing and MLPA

DNA was extracted from peripheral blood using standardised procedures (Autogene Qiagen, Germany). Sanger sequencing using Big Dye Terminator VI .1 cycle sequencing kit and ABI 3130x1 genetic analyser and multiplex ligation-dependent probe amplification (MLPA, kit P093-C2, MRC-Holland, the Netherlands) was conducted for the index patient for the genes BMPR2 (ENSG00000204217) [SEQ ID NO. 3], ACVRL1 (ENSG00000139567) [SEQ ID NO. 1] and ENG (ENSG00000106991) [SEQ ID NO. 6].

1.3 Next-generation sequencing and variant analysis

Next-generation sequencing (NGS) was carried out to investigate potential mutations in PAH and candidate genes as described previously (Song et al, 2016). All known PAH genes (ACVRL1, BMPR1B, BMPR2, CAV1, EIF2AK4, ENG, KCNA5, KCNK3, SMAD1, SMAD4, SMAD9 and TOPBP1) and further candidate genes from the BMPR2 pathway and genes which were shown to have a PAH relevance in animal models such as KLF2, KLF4 and KLF5 were included in a PAH-specific gene panel. DNA was enriched with a customised SureDesign panel (Agilent Technologies), sequenced on the MiSeq and analysed with SeqPilot 4.1.2 as described previously (Song et al, 2016). Variants in exonic regions and exon-intron boundaries were characterised following the recommendations of the Human Genome Variation Society (HGVS, http://www.hgvs.org;version 2.15.11) (den Dunnen et al, 2016). Non-synonymous missense variants with a population frequency of less than 5% were assessed regarding their evolutionary conservation, location within functional gene domains and their functional consequence using four in silico prediction programmes: MutationTaster, SIFT, Align GVGD and PolyPhen2 implemented in Alamut Visual 2.7.1. Furthermore, in order to determine gene function, a systematic literature search was performed to investigate mutations, their functions within the cell and their involvement in the BMPR2 pathway, which is affected in most HP AH families (Machado et al, 2015). Any variants disrupting the function of a gene were considered mutations.

The COSMIC data base (Forbes et al, 2015) for somatic mutations and HGMD for germline mutations, were used respectively together with a systematic literature search in PubMed to list previously reported mutations. Cellular and molecular functions of affected genes relevant to phenotypes observed in PAH were also investigated by a broad literature search.

Potential mutations were confirmed with Sanger sequencing guaranteeing a 100% specificity. Family members of the index patient were assessed with Sanger sequencing to clarify mutation status.

1.4 Statistical analyses

Thirteen unrelated IP AH/ HP AH patients without mutations in the genes BMPR2, ENG and ACVRLl were screened for the presence of rare mutations using NGS assessing all exons and exon-intron boundaries. The Fisher's exact test was used to compare mutations in our sample to 126,216 controls (Lek et al, 2016) calculated with BIAS v.l 1.02.

2. Results

2.1 Clinical characteristics

Three family members of the HP AH family were diagnosed with invasively confirmed manifest PAH. The father (11:4) of the index patient (111:3) had died one year after diagnosis of severe and rapidly progressive HP AH and right heart failure aged 32 years. His two daughters (111:2 and 111:3) were diagnosed with HP AH in 1993 and suffered from severe and rapidly progressive disease unresponsive to medical therapy (Table 8). They underwent lung and heart/lung transplantation, respectively, shortly after diagnosis both at the age of 25 years. Both of them are still alive and are doing well as of the time of this writing having been clinically followed for more than 20 years after transplantation. Neither of the sisters had any children. The brother (111:1) and further family members remained unaffected up to the present day with a clinical follow-up of >20 years as well.

Table 8 Clinical characterization of affected family members

Parameter 111:2 111:3

Age at diagnosis 25 25

Age at transplantation 28 27

Heart rate [min "1 ] 85 92

Blood pressure [mmHg] 115/80 110/80

Lung function

FEV1 % 94 60

Total resistance [kPa*s/l] 0.29 0.19

Sa0 2 % 98 97

Blood gases

P0 2 [mmHg] 89 91

PC0 2 [mmHg] 23 27

Radionuclide ventriculography

LVEF % 60 60

PvVEF % 34 32

Echocardiography

sPAP [mmHg] 67 110

Right heart catheter

mPAP [mmHg] 48 72

PAWP [mmHg] 10 10

PVR [dynes*sec*cm ~5 ] 880 768

CO [1/min] 3.9 5.9

CI [1/min/kg] 2.6 3.7 FEV1: forced expiratory volume in the first second, Sa0 2 : arterial oxygen saturation, P0 2 : partial pressure of oxygen, PC0 2 : partial pressure of carbon dioxide, LVEF: left ventricular ejection fraction, RVEF: right ventricular ejection fraction, sPAP: systolic pulmonary artery pressure, mPAP: mean pulmonary artery pressure, PAWP: pulmonary artery wedge pressure, PVR: pulmonary vascular resistance, CO: cardiac output, CI: cardiac index

2.2 Genetic analyses

In the genetic analysis of the two affected sisters, no disease-causing mutation, deletion or duplication was found in the known and previously published PAH genes (Table 9). By including new candidate genes in the NGS approach, we identified a new, germline heterozygous missense mutation in exon 2, c.862C>T p.H288Y in the Kruppel-like factor 2 (KLF2) gene on chromosome 19 (ENSG00000127528) [SEQ ID NO. 10] in both affected sisters (Table 9).

Table 9 Genetic analysis

Genetic analysis Genes included Results

Sanger sequencing Major PAH BMPR2, ACVRL1, ENG Negative

/ MLPA genes

Next-generation Further known BMP RIB, CAV1, EIF2AK4,

sequencing candidate genes KCNA5, KCNK3, SMADl, Negative

SMAD4, SMAD9, TOPBP1

Next-generation New candidate Germline sequencing genes ACVR1, BMP2, BMPR1A, heterozygous

CREB, HRG, ID1, ID2, ID3, ID4, mutation in exon 2,

116, KLF2, KLF4, KLF5, c.862C>T p.H288Y

SMAD5, SMAD6, SMAD7, va KLF2, on

SOD 2, VCAN, VHP, ZFYVE16 chromosome

19pl3.11

No DNA was available from the father who died early due to HP AH. Since the mutation was absent in the healthy mother (11:5) we infer its presence in the deceased father (11:4). We screened all first degree related family members of the father for the presence of the mutation in KLF2 with Sanger sequencing. The mutation was absent in all paternal siblings (11:1-11:3). None of them nor the grand-parents (1: 1, 1:2) of the index-patient developed PAH.

This germline mutation was absent in exomes of >120,000 control subjects assessed by the Exome Aggregation Consortium and the genome Aggregation Database (Lek et al, 2016) . Similarly, KLF2 was entirely absent from the germline mutation data bases HGMD and ClinVar. The Fisher's exact test showed that the absence of the mutation in 126,216 controls compared to our sample (1/14, 2-sided p-value=0.0001) demonstrated a significant association of the KFL2 variant with PAH. The effect of the mutation was classified as pathogenic by four in silico prediction programmes (respective scores: MutationTaster: 1, SIFT: 0, PolyPhen2: 0.927, Align GVGD: C65). The mutation led to the substitution of a highly conserved nucleotide and subsequently the exchange of a highly conserved amino acid within a zinc finger protein domain. This domain is characterised by two cysteine and two histidine residues (2Cys-2His) forming two beta sheets and one alpha helix.

The mutation might have occurred de novo in the father, who could not be analysed, or was inherited by one of the grandparent presenting with reduced penetrance. Under both assumptions KLF2 co-segregates with the disease in this family based on the genetically analysed family members. So far we could not identify further KLF2 mutations in 13 other unrelated IP AH/ HP AH patients without mutations in BMPR2, ENG orACVRLL

2.3 Involvement of the KLF2 gene in PAH pathways:

KLF2 is highly important for lung functioning, represented by its previous name "Lung KLF" and its high expression in the adult mouse lung (Anderson et al, 1995). We summarised the diverse array of cellular processes regulated by KLF2 such as cell differentiation, migration, coagulation and tissue development (Kumar et al, 2005), which are all involved in PAH pathogenesis. Studies implicated KLF2 as a key transcriptional regulator of endothelial proinflammatory activation (Bhattacharya et al, 2005; SenBanerjee et al, 2004). KLF2 also inhibited endothelial activation and proliferation (Bhattacharya et al, 2005) as well as the expression of endothelin-1, adrenomedullin and angiotensin converting enzyme, all of which increase vascular contractile tone (Dekker et al , 2005).

Mice with homozygous germline deletions of KLF2 die around day 14 during development due to heart failure preceded by a high cardiac output state (Lee et al, 2006). In contrast, heterozygous mice are viable and fertile (Yeo et al, 2014). KLF2 overexpression in a PH model of hypoxic rats was able to reduce right ventricular systolic pressure (RVSP) while its knock down increased RVSP and reduced the expression of the vasodilator endothelial nitric oxide synthase (eNOS) in normoxia (Dungey et al, 2011). The features disclosed in the foregoing description, in the claims and/or in the accompanying drawings may, both separately and in any combination thereof, be material for realizing the invention in diverse forms thereof.

REFERENCES

Anderson KP, Kern CB, Crable SC, and Lingrel JB. 1995. Isolation of a gene encoding a functional zinc finger protein homologous to erythroid Kruppel-like factor:

identification of a new multigene family. Mol Cell Biol 15(11):5957-5965.

Austin ED, Ma L, LeDuc C, Berman Rosenzweig E, Borczuk A, Phillips JA, 3rd, et al. Whole exome sequencing to identify a novel gene (caveolin-1) associated with human pulmonary arterial hypertension. Circ Cardiovasc Genet. 2012;5(3):336-43.

Barrios-Rodiles M, Brown KR, Ozdamar B, Bose R, Liu Z, Donovan RS, Shinjo F, Liu Y, Dembowy J, Taylor IW et al. . 2005. High-throughput mapping of a dynamic signaling network in mammalian cells. Science 307(5715):1621-1625.

Berlanga JJ, Santoyo J, and De Haro C. 1999. Characterization of a mammalian homolog of the GCN2 eukaryotic initiation factor 2alpha kinase. Eur J Biochem 265(2):754- 762.

Best DH, Sumner KL, Austin ED, Chung WK, Brown LM, Borczuk AC, et al.

EIF2AK4 mutations in pulmonary capillary hemangiomatosis. Chest. 2014;145(2):231-6.

Bhattacharya R, Senbanerjee S, Lin Z, Mir S, Hamik A, Wang P, Mukherjee P, Mukhopadhyay D, and Jain MK. 2005. Inhibition of vascular permeability factor/vascular endothelial growth factor-mediated angiogenesis by the Kruppel-like factor KLF2. J Biol Chem 280(32):28848-28851.

Chandra SM, Razavi H, Kim J, Agrawal R, Kundu RK, de Jesus Perez V, Zamanian RT, Quertermous T, and Chun HJ. 2011. Disruption of the apelin-APJ system worsens hypoxia-induced pulmonary hypertension. Arterioscler Thromb Vase Biol 31(4):814-820.

Chaouat A, Coulet F, Favre C, Simonneau G, Weitzenblum E, Soubrier F, et al.

Endoglin germline mutation in a patient with hereditary haemorrhagic telangiectasia and dexfenfluramine associated pulmonary arterial hypertension. Thorax. 2004;59(5):446-8.

Chida A, Shintani M, Nakayama T, Furutani Y, Hayama E, Inai K, et al. Missense mutations of the BMPR1B (ALK6) gene in childhood idiopathic pulmonary arterial hypertension. Circ J. 2012;76(6): 1501-8. Clipson A, Wang M, de Leval L, Ashton-Key M, Wotherspoon A, Vassiliou G, Bolli N, Grove C, Moody S, Escudero-Ibarz L et al. . 2015. KLF2 mutation is the most frequent somatic change in splenic marginal zone lymphoma and identifies a subset with distinct genotype. Leukemia 29(5): 1 177-1185.

Dekker RJ, van Thienen JV, Rohlena J, de Jager SC, Elderkamp YW, Seppen J, de Vries CJ, Biessen EA, van Berkel TJ, Pannekoek H et al. . 2005. Endothelial KLF2 links local arterial shear stress levels to the expression of vascular tone-regulating genes. Am J Pathol 167(2):609-618.

Deng Z, Morse JH, Slager SL, Cuervo N, Moore KJ, Venetos G, et al. Familial primary pulmonary hypertension (gene PPH1) is caused by mutations in the bone

morphogenetic protein receptor-II gene. Am J Hum Genet. 2000;67(3):737-44.

de Jesus Perez VA, Yuan K, Lyuksyutova MA, Dewey F, Orcholski ME, Shuffle EM, et al. Whole-Exome Sequencing Reveals TopBPl as a Novel Gene in Idiopathic Pulmonary Arterial Hypertension. Am J Respir Crit Care Med. 2014;189(10): 1260-72.

den Dunnen JT, Dalgleish R, Maglott DR, Hart RK, Greenblatt MS, McGowan- Jordan J, Roux AF, Smith T, Antonarakis SE, Taschner PE et al. . 2016. HGVS Recommendations for the Description of Sequence Variants: 2016 Update. Hum Mutat 37(6):564-569.

Dungey A, Deng Y, Yin J, Rozowsky S, and Stewart DJ. 2011. Abstract 17982:

Kruppel-Like Transcription Factor-2 Preserves Endothelial Function and Protects Against Pulmonary Hypertension. Circulation 124(Suppl 21):A17982.

Ehlken N, Lichtblau M, Klose H, Weidenhammer J, Fischer C, Nechwatal R, Uiker S, Halank M, Olsson K, Seeger W et al. . 2016. Exercise training improves peak oxygen consumption and haemodynamics in patients with severe pulmonary arterial hypertension and inoperable chronic thrombo-embolic pulmonary hypertension: a prospective, randomized, controlled trial. Eur Heart J 37(l):35-44.

Eichstaedt CA, Song J, Benjamin N, Harutyunova S, Fischer C, Griinig E, and

Hinderhofer K. EIF2AK4 mutation as "second hit" in hereditary pulmonary arterial hypertension. Respir Res. 2016;17(1):141.

Eichstaedt CA, Song J, Rodriguez Viales R, Pan Z, Benjamin N, Fischer C, Hoeper M, Ulrich S, Hinderhofer K, and Griinig E. First identification of Kriippel-like factor 2 mutation in heritable pulmonary arterial hypertension. Clin Sci. 2017;131 (8):689-698.

Evans JD, Girerd B, Montani D, Wang XJ, Galie N, Austin ED, et al. BMPR2 mutations and survival in pulmonary arterial hypertension: an individual participant data meta-analysis. Lancet Respir Med. 2016;4(2):129-37. Eyries M, Montani D, Girerd B, Perret C, Leroy A, Lonjou C, et al. EIF2AK4 mutations cause pulmonary veno-occlusive disease, a recessive form of pulmonary hypertension. Nat Genet. 2014;46(l):65-9.

Forbes SA, Beare D, Gunasekaran P, Leung K, Bindal N, Boutselakis H, Ding M, Bamford S, Cole C, Ward S et al. . 2015. COSMIC: exploring the world's knowledge of somatic mutations in human cancer. Nucleic Acids Res 43(Database issue) :D805-811.

Frydman N, Steffann J, Girerd B, Frydman R, Munnich A, Simonneau G, et al. Pre- implantation genetic diagnosis in pulmonary arterial hypertension due to BMPR2 mutation. Eur Respir J. 2012;39(6):1534-5.

Galie N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119.

Girerd B, Montani D, Coulet F, Sztrymf B, Yaici A, Jais X, Tregouet D, Reis A, Drouin-Garraud V, Fraisse A et al. . 2010. Clinical outcomes of pulmonary arterial hypertension in patients carrying an ACVRL1 (ALK1) mutation. Am J Respir Crit Care Med 181 :851-861.

Girerd B, Coulet F, Jais X, Eyries M, Van Der Bruggen C, De Man F, et al.

Characteristics of pulmonary arterial hypertension in affected carriers of a mutation located in the cytoplasmic tail of bone morphogenetic protein receptor type 2. Chest. 2015;147(5):1385- 94.

Girerd B, Montani D, Jais X, Eyries M, Yaici A, Sztrymf B, et al. Genetic counselling in a national referral centre for pulmonary hypertension. Eur Respir J. 2016;47(2):541-52.

Gomez J, Reguero JR, Alvarez C, Junquera MR, Arango A, Moris C, Coto E. A Semiconductor Chip-Based Next Generation Sequencing Procedure for the Main Pulmonary Hypertension Genes. Lung. 2015;193(4):571-4.

Granzow M, Paramasivam N, Hinderhofer K, Fischer C, Chotewutmontri S,

Kaufmann L, et al. Loss of function of PGAPl as a cause of severe encephalopathy identified by Whole Exome Sequencing: Lessons of the bioinformatics pipeline. Mol Cell Probes.

2015;29(5):323-9. Griinig E, Janssen B, Mereles D, Barth U, Borst MM, Vogt IR, et al. Abnormal pulmonary artery pressure response in asymptomatic carriers of primary pulmonary hypertension gene. Circulation. 2000;102(10):1145-50.

Griinig E, Weissmann S, Ehlken N, Fijalkowska A, Fischer C, Fourme T, et al. Stress Doppler echocardiography in relatives of patients with idiopathic and familial pulmonary arterial hypertension: results of a multicenter European analysis of pulmonary artery pressure response to exercise and hypoxia. Circulation. 2009;119(13):1747-57.

Griinig E, Barner A, Bell M, Claussen M, Dandel M, Dumitrescu D, et al. Noninvasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated

Commentary of the Cologne Consensus Conference 2011. Int J Cardiol. 2011;154 Suppl 1 :S3-12.

Harrison RE, Flanagan JA, Sankelo M, Abdalla SA, Rowell J, Machado RD. et al. Molecular and functional analysis identifies ALK-1 as the predominant cause of pulmonary hypertension related to hereditary haemorrhagic telangiectasia. J Med Genet.

2003;40(12):865-71.

Fie H, Singh I, Wek SA, Dey S, Baird TD, Wek RC, and Georgiadis MM. 2014. Crystal structures of GCN2 protein kinase C-terminal domains suggest regulatory differences in yeast and mammals. J Biol Chem 289(21):15023-15034.

Hinderhofer K, Fischer C, Pfarr N, Szamalek-FIoegel J, Lichtblau M, Nagel C, Egenlauf B, Ehlken N, and Griinig E. 2014. Identification of a new intronic 5 Pi?2-mutation and early diagnosis of heritable pulmonary arterial hypertension in a large family with mean clinical follow-up of 12 years. PLoS One 9(3):e91374.

Kabata H, Satoh T, Kataoka M, Tamura Y, Ono T, Yamamoto M, et al. Bone morphogenetic protein receptor type 2 mutations, clinical phenotypes and outcomes of Japanese patients with sporadic or familial pulmonary hypertension. Respirology.

2013;18(7):1076-82.

Kabitz HJ, Schwoerer A, Bremer HC, Sonntag F, Walterspacher S, Walker D, et al. Impairment of respiratory muscle function in pulmonary hypertension. Clin Sci (Lond). 2008;114(2):165-71.

Kim J. 2014. Apelin-APJ signaling: a potential therapeutic target for pulmonary arterial hypertension. Mol Cells 37(3): 196-201.

Kumar A, Lin Z, SenBanerjee S, and Jain MK. 2005. Tumor necrosis factor alpha- mediated reduction of KLF2 is due to inhibition of MEF2 by NF-kappaB and histone deacetylases. Mol Cell Biol 25(14):5893-5903. Kwapiszewska G, Rodriguez Viales R, Ehlken N, Eichstaedt C, Riemkasten G, Grunig G, et al. Epigenetik und Genetik der pulmonal arteriellen Hypertonic - neue Erkenntnisse der letzten Jahre. Dtsch Med Wochenschr. 2014;139(S 04): 111-5.

Lane KB, Machado RD, Pauciulo MW, Thomson JR, Phillips JA, 3rd, Loyd JE, et al. Heterozygous germline mutations in BMPR2, encoding a TGF-beta receptor, cause familial primary pulmonary hypertension. Nat Genet. 2000;26(l):81-4.

Larkin EK, Newman JH, Austin ED, Hemnes AR, Wheeler L, Robbins ΓΜ, et al. Longitudinal analysis casts doubt on the presence of genetic anticipation in heritable pulmonary arterial hypertension. Am J Respir Crit Care Med. 2012;186(9):892-6.

Lee JS, Yu Q, Shin JT, Sebzda E, Bertozzi C, Chen M, Mericko P, Stadtfeld M, Zhou D, Cheng L et al. . 2006. Klf2 is an essential regulator of vascular hemodynamic forces in vivo. Dev Cell l l(6):845-857.

Lek M, Karczewski KJ, Minikel EV, Samocha KE, Banks E, Fennell T, O'Donnell- Luria AH, Ware JS, Hill AJ, Cummings BB, et al. Analysis of protein-coding genetic variation in 60,706 humans. Nature. 2016;536(7616):285-291.

Levy M, Eyries M, Szezepanski I, Ladouceur M, Nadaud S, Bonnet D, et al. Genetic analyses in a cohort of children with pulmonary hypertension. Eur Respir J. 2016;48(4):1118- 26.

Lyle MA, Fenstad ER, McGoon MD, Frantz RP, Krowka MJ, Kane GC, and Swanson KL. Pulmonary Hypertension in Hereditary Hemorrhagic Telangiectasia. Chest.

2016;149(2):362-371.

Machado RD, Southgate L, Eichstaedt CA, Aldred MA, Austin ED, Best DH, et al. Pulmonary Arterial Hypertension: A Current Perspective on Established and Emerging Molecular Genetic Defects. Hum Mutat. 2015;36(12):1113-27.

Miller SA, Dykes DD, and Polesky HF. 1988. A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res 16(3):1215.

Montani D, Achouh L, Dorfmuller P, Le Pavec J, Sztrymf B, Tcherakian C, Rabiller A, Haque R, Sitbon O, Jais X et al. . 2008. Pulmonary veno-occlusive disease: clinical, functional, radiologic, and hemodynamic characteristics and outcome of 24 cases confirmed by histology. Medicine (Baltimore) 87(4):220-233.

Montani D, Lau EM, Dorfmuller P, Girerd B, Jais X, Savale L, Perros F, Nossent E, Garcia G, Parent F et al. . 2016. Pulmonary veno-occlusive disease. Eur Respir J 47(5):1518- 1534. Nagel C, Henn P, Ehlken N, D'Andrea A, Blank N, Bossone E, Bottger A, Fiehn C, Fischer C, Lorenz HM et al. . 2015. Stress Doppler echocardiography for early detection of systemic sclerosis-associated pulmonary arterial hypertension. Arthritis Res Ther 17:165.

Narasimhan J, Staschke KA, and Wek RC. 2004. Dimerization is required for activation of eIF2 kinase Gcn2 in response to diverse environmental stress conditions. J Biol Chem 279(22):22820-22832.

Nasim MT, Ghouri A, Patel B, James V, Rudarakanchana N, Morrell NW, et al.

Stoichiometric imbalance in the receptor complex contributes to dysfunctional BMPR-II mediated signalling in pulmonary arterial hypertension. Hum Mol Genet. 2008;17(11):1683- 94.

Newman JH, Wheeler L, Lane KB, Loyd E, Gaddipati R, Phillips JA, 3rd, et al.

Mutation in the gene for bone morphogenetic protein receptor II as a cause of primary pulmonary hypertension in a large kindred. N Engl J Med. 2001;345(5):319-24.

Padyana AK, Qiu H, Roll-Mecak A, Hinnebusch AG, and Burley SK. 2005. Structural basis for autoinhibition and mutational activation of eukaryotic initiation factor 2alpha protein kinase GCN2. J Biol Chem 280(32):29289-29299.

Pfarr N, Szamalek-Hoegel J, Fischer C, Hinderhofer K, Nagel C, Ehlken N, et al. Hemodynamic and clinical onset in patients with hereditary pulmonary arterial hypertension and BMPR2 mutations. Respir Res. 2011;12:99.

Piao C, Zhu Y, Zhang C, Xi X, Liu X, Zheng S, Li X, Guo J, Jia L, Nakanishi T, Cai T, Gu H, Du J. Identification of multiple ACVRLl mutations in patients with pulmonary arterial hypertension by targeted exome capture. Clin Sci (Lond). 2016;130(17):1559-69.

Piva R, Deaglio S, Fama R, Buonincontri R, Scarfo I, Bruscaggin A, Mereu E, Serra S, Spina V, Brusa D et al. . 2015. The Kriippel-like factor 2 transcription factor gene is recurrently mutated in splenic marginal zone lymphoma. Leukemia 29(2):503-507.

Remillard CV, Tigno DD, Platoshyn O, Burg ED, Brevnova EE, Conger D, et al. Function of Kvl.5 channels and genetic variations of KCNA5 in patients with idiopathic pulmonary arterial hypertension. Am J Physiol Cell Physiol. 2007;292(5):C1837-53.

Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster J, et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med. 2015;17(5):405-24. Rodriguez Viales R, Eichstaedt CA, Ehlken N, Fischer C, Lichtblau M, Griinig E, et al. Mutation in BMPR2 Promoter: A 'Second Hit' for Manifestation of Pulmonary Arterial Hypertension? PLoS One. 2015;10(7):e0133042.

Schroeder C, Faust U, Sturm M, Hackmann K, Grundmann K, Harmuth F, et al.

HBOC multi-gene panel testing: comparison of two sequencing centers. Breast Cancer Res Treat. 2015;152(l):129-36.

SenBanerjee S, Lin Z, Atkins GB, Greif DM, Rao RM, Kumar A, Feinberg MW, Chen Z, Simon DI, Luscinskas FW et al. . 2004. KLF2 Is a novel transcriptional regulator of endothelial proinflammatory activation. J Exp Med 199(10):1305-1315.

Shintani M, Yagi H, Nakayama T, Saji T, Matsuoka R. A new nonsense mutation of SMAD8 associated with pulmonary arterial hypertension. J Med Genet. 2009;46(5):331-7.

Song J, Eichstaedt CA, Rodriguez Viales R, Benjamin N, Harutyunova S, Fischer C, Griinig E, and Hinderhofer K. 2016. Identification of genetic defects in pulmonary arterial hypertension by a new panel diagnostic. Clin Sci (Lond) 22:2043-2052.

Soubrier F, Chung WK, Machado R, Griinig E, Aldred M, Geraci M, et al. Genetics and genomics of pulmonary arterial hypertension. J Am Coll Cardiol. 2013;62(25

Suppl):D13-21.

Sztrymf B, Yaici A, Girerd B, Humbert M. Genes and pulmonary arterial

hypertension. Respiration. 2007;74(2): 123-32.

Tenorio J, Navas P, Barrios E, Fernandez L, Nevado J, Quezada CA, et al. A founder EIF2AK4 mutation causes an aggressive form of pulmonary arterial hypertension in Iberian Gypsies. Clin Genet. 2014;88(6):579-83.

The 1000 Genomes Project Consortium, Auton A, Brooks LD, Durbin RM, Garrison EP, Kang HM, Korbel JO, Marchini JL, McCarthy S, McVean GA et al. . 2015. A global reference for human genetic variation. Nature 526(7571):68-74.

Torring PM, Brusgaard K, Ousager LB, Andersen PE, and Kjeldsen AD. National mutation study among Danish patients with hereditary haemorrhagic telangiectasia. Clin Genet. 2014;86(2):123-133.

Trembath RC, Thomson JR, Machado RD, Morgan NV, Atkinson C, inship I, et al. Clinical and molecular genetic features of pulmonary hypertension in patients with hereditary hemorrhagic telangiectasia. N Engl J Med. 2001;345(5):325-34.

allis Y, Payne S, McAnulty C, Bodmer D, Sistermans E, Robertson K, et al. Practice Guidelines for the Evaluation of Pathogenicity and the Reporting of Sequence Variants in Clinical Molecular Genetics. ACGS/ VKGL. 2013. Wang G, Knight L, Ji R, Lawrence P, Kanaan U, Li L, et al. Early onset severe pulmonary arterial hypertension with 'two-hit' digenic mutations in both BMPR2 and KCNA5 genes, hit J Cardiol. 2014;177(3):el67-9.

Xi Q, Liu Z, Zhao Z, Luo Q, Huang Z. High Frequency of Pulmonary Hypertension- Causing Gene Mutation in Chinese Patients with Chronic Thromboembolic Pulmonary Hypertension. PLoS One 2016; 11 : e0147396.

Yeo JC, Jiang J, Tan ZY, Yim GR, Ng JH, Goke J, Kraus P, Liang H, Gonzales KA, Chong HC et al. . 2014. Klf2 is an essential factor that sustains ground state pluripotency. Cell stem cell 14(6):864-872.