Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic vascular disorder inherited in an autosomal dominant fashion. On average, approximately one in 5000 to 8000 people are affected, while the founder effect has contributed to a higher prevalence in certain regions, such as the Netherlands Antilles, Jura in France and Funen in Denmark
[1]. Vascular malformations in HHT include skin and mucocutaneous telangiectasias, and pulmonary, cerebral, hepatic and spinal arteriovenous malformations (AVMs)
[2][3], all of which are susceptible to rupture with resultant spontaneous hemorrhage. Epistaxis is the most common symptom and is present in approximately 95% of patients
[4][5]. HHT is a progressive disorder with significant morbidities and mortality, and lacks a universally effective pharmacological therapy
[2].
HHT is caused by heterozygous mutations in at least three known genes: endoglin (
ENG, chromosomal locus 9q34)
[6], activin receptor-like kinase 1 (
ACVRL1, also known as
ALK1, chromosomal locus 12q1)
[7] and mothers against decapentaplegic homolog 4 (
SMAD4, chromosomal locus 18q21)
[8]. Each gene encodes for a protein in the transforming growth factor beta (TGFβ)/bone morphogenetic protein (BMP) signaling pathway. This pathway is responsible for many cellular functions, including growth, differentiation and apoptosis, and is critical in angiogenesis and normal endothelial cell (EC) function
[9]. The pathogenic role of these genes has been demonstrated in the adult mouse where the homozygous knockout of
ENG,
ACVRL1 or
SMAD4 resulted in various vascular defects, including AVMs
[10][11].
ENG encodes for a TGFβ co-receptor that enhances the affinity of ligand binding to TGFβI and II receptors. This co-receptor is predominately expressed on the endothelium, activated monocytes and macrophages
[2].
ACVRL1 encodes for a TGFβ1 receptor that is predominately expressed on endothelial, lung and placental cells
[2]. Mutations in
ENG and
ACVRL1 result in HHT1 and HHT2, respectively, and on average display distinct clinical manifestations, but overlap is not uncommon. Sabbà et al. demonstrated a higher prevalence of pulmonary (75.5% vs. 44.1%) and cerebral AVMs (20.9% vs. 0%) in HHT1, while liver manifestations were higher in HHT2 (83.1% vs. 60%)
[12]. SMAD4 is a signal transducer in the TGFβ signaling pathway that directly regulates gene expression. Mutations in
SMAD4 not only result in HHT, but juvenile polyposis (JP), culminating in a combined syndrome designated as JP/HHT
[8].
ENG and
ACVRL1 mutations are responsible for 90% of HHT cases, while
SMAD4 contributes to only 2%
[13][14]. A small percentage of cases have been attributed to novel disease loci, HHT 3 (chromosomal locus 5q31)
[15] and HHT 4 (chromosomal locus 7p14)
[16], but these genes have yet to be identified. Over 700 pathogenic mutations have been identified in
ENG and
ACVRL1 patients (
https://arup.utah.edu/database/HHT/, access date: 20/04/2020), comprising single base pair changes, large deletions, duplications, substitutions and missense mutations
[13][17]. Interestingly, disease severity and the presentation of clinical manifestations vary drastically between patients and this is further demonstrated in affected family members. This discrepancy suggests that the genetic mutations alone are not entirely responsible for disease characteristics and raises the question: what other biological factors could be at play?
Non-coding RNAs (ncRNAs) are functional ribonucleic acid (RNA) sequences that are transcribed from DNA, but not translated into protein. NcRNAs can be divided into three categories based on their length: (1) ncRNAs longer than 200 nucleotides (nts), including ribosomal RNA (rRNA), long non-coding RNA (lncRNA) and circular RNA (circRNA); (2) ncRNAs shorter than 200 nts, but longer than 40 nts, such as transfer RNA (tRNA), small nucleolar RNA (snoRNA), Ro-associated Y RNA (YRNA) and small nuclear ribonucleic acid RNA (snRNA); and (3) ncRNA shorter than 40 nts like microRNA (miRNA), piwi-interacting RNA (piRNA), short interfering RNA (siRNA) and tRNA-derived small RNA (tsRNA)
[18]. NcRNAs regulate gene expression at the transcriptional and post-transcriptional levels, and are involved in a wide array of cellular processes. In particular, snRNAs and snoRNAs are involved in mRNA maturation; rRNAs and tRNAs are important components for protein translation and miRNAs, piRNAs and lncRNAs are involved in the regulation of target gene expression.