Mutations in transforming growth factor- (TGF-
Pulmonary arterial hypertension (PAH)3 and hereditary hemorrhagic telangectasia (HHT) are diseases characterized by dysregulated smooth muscle and endothelial cell proliferation in the pulmonary circulation. In PAH, progressive muscularization of arterial vessels decreases the luminal area and elasticity of these vessels (1). Mutations in the gene (BMPR2) encoding the bone morphogenetic type II receptor (BMPR-II), a member of the transforming growth factor (TGF) receptor superfamily, underlie most familial PAH cases and a quarter of idiopathic PAH cases (2-4). HHT involves a progressive loss of capillaries and the emergence of directly linked dilated arterioles and venules, termed arteriovenous malformations (5). Although this mainly occurs in nasal and dermal blood vessels, pulmonary arteriovenous malformations occur in more than 20% of HHT patients (5, 6). The two main forms of HHT arise due to mutations in two other TGF receptor superfamily members, endoglin (HHT1) and ALK1 (HHT2) (7,8). Although the pathologies of PAH and HHT differ, mutations in ALK1 are associated with severe PAH in some HHT2 families, suggesting overlapping characteristics (9 -11). HHT1 is not associated with PAH, but pulmonary arteriovenous malformations are more prevalent than in HHT2 patients (5).TGF superfamily receptors form heteromeric receptor complexes of type I and type II receptors in combinations that dictate the ligand selectivity of the complex (12). There are 7 known type I receptors (ALK1-7) and 5 type II receptors (ActR-II, ActR-IIB, BMPR-II, TGFR-II, and AMHR-II). Activated BMP receptors mediate signaling via C-terminal phosphorylation of the receptor Smad (R-Smad) proteins, Smad1, Smad5,. In contrast, TGF receptors typically phosphorylate and activate Smad2 and Smad3. Upon phosphorylation, both the BMP and TGF R-Smads associate with the co-Smad, Smad4, and the R-Smad⅐Smad4 complex translocates and associates with other specific transcription factors to modulate the expression of specific genes (16 -19).ALK1, in complex with ALK5 and TGFR-II in endothelial cells, is reported to mediate TGF receptor signaling via the Smad1/5/8 pathway rather than the Smad2/3 pathway (20, 21). More recently, BMP9 and BMP10 have been identified as ALK1 ligands, stimulating the Smad1/5/8 pathway and transcription