BMP9 regulates the endothelial secretome to drive pulmonary hypertension

BMP9, a pleiotropic growth factor cytokine that regulates endothelial function, is implicated in the pathogenesis of pulmonary arterial hypertension (PAH). Loss-of-function mutations in GDF2 are found in heritable PAH, suggesting its function as an endothelial quiescence factor, while agonizing or antagonizing BMP9 signaling are both reported to ameliorate experimental pulmonary hypertension (PH). This study sought to resolve the contribution of BMP9 to pulmonary vascular disease and its status as a potential therapeutic target. The function of BMP9 in experimental PH was interrogated using recombinant BMP9, BMP9/BMP10 ligand trap ALK1-Fc, two anti-BMP9 neutralizing antibodies, and the activin/GDF/BMP ligand trap ACTRIIA-Fc (a.k.a., sotatercept). Disulfide-linked, prodomain complexed BMP9 was not protective in SUGEN-hypoxia or monocrotaline-induced PH models, in contrast to previous studies using incompletely disulfide-linked BMP9. In comparison, selective and non-selective BMP9 antagonism exerted prophylactic and therapeutic effects across PH models. Anti-BMP9 and ACTRIIA-Fc had comparable impact on hemodynamics, RV hypertrophy, and vascular remodeling, while single nucleus RNA-Seq revealed similar inhibition of SMAD1/5 and SMAD2/3 transcriptional activity, and highly overlapping DEGs, particularly in the endothelial compartment (r=0.83, p=2.54e-43, Spearman), suggesting overlap of mechanism in targeting BMP9. A multi-omic approach using lung tissues from human PAH, experimental models of pulmonary hypertension, and transcriptomic analysis of pulmonary microvascular endothelial cells from PAH patients revealed that BMP9 is critical for regulating several endothelial gene products that are overexpressed in human and experimental disease and implicated in disease pathogenesis including CXCL12, PDGF-BB, EDN1, COL18A1, and IGFBP4, and are inhibited by administering anti-BMP9 neutralizing antibodies or ligand traps. Co-culture studies revealed paracrine effects of BMP9-stimulated PMVEC on pulmonary arterial smooth muscle cell (PASMC) phenotypic plasticity, which could be attributed in large part to endothelial-derived CXCL12. In summary, endothelial BMP9 signaling is a key coordinator of vasoactive endothelial gene products that modulate PASMC phenotype and appears to be a shared target of anti-BMP9 and ACTRIIA-Fc. Selective targeting of endothelial BMP9 angiogenic signaling represents a potential therapeutic strategy for human PAH.