Stuti Agarwal

All Publications

• Loss of ROR2 Tyrosine Kinase Receptor Is Associated With Endothelial Dysfunction in PAH via Inappropriate Integrin β1 Activation. Hypertension (Dallas, Tex. : 1979) Mitra, A., Agarwal, S., Chakraborty, A., Zhong, B. L., Heo, L., Roy, A., Bankar, A., Pacheco, A., Auer, N., Dunn, A., Chelladurai, P., Jain, A., Matos Muñoz, J. A., Guardado, E. S., Yi, D., Zhao, H., Man, K. W., Nair, R., Hong, J., Kuebler, W. M., Guenat, O. T., Dai, Z., de Jesus Perez, V. A. 2026

  Abstract

  Endothelial dysfunction is a key feature of pulmonary arterial hypertension (PAH). Previously, we demonstrated decreased Wnt7a transcript levels, causing reduced angiogenesis in PAH. Wnt7a expression correlates with tip formation via ROR2 (receptor tyrosine kinase-like orphan receptor 2), a tyrosine kinase receptor. We hypothesized that ROR2 activation in pulmonary microvascular endothelial cells (PMVECs) promotes angiogenesis, particularly endothelial barrier establishment, and its loss causes PAH.Endothelial-specific ROR2 knockout (ROR2 ECKO) and wild-type mice were studied under normoxia and chronic hypoxia using echocardiography, hemodynamics, and lung morphometry. PMVECs from healthy and PAH lungs were transfected with ROR2 siRNA/constructs for functional and molecular studies. Focal adhesion activation and force generation were assessed via Förster resonance energy transfer-based methods. Bulk and single-cell transcriptomic analyses were performed on siROR2 (ROR2 siRNA) PMVECs and ROR2 ECKO lungs.ROR2 ECKO mice exacerbated pulmonary hypertension and vascular remodeling in hypoxia. Single-cell RNA-sequencing of lung endothelial cells revealed dysregulated barrier formation and angiogenesis. Evans blue dye extravasation confirmed reduced endothelial barrier integrity in ROR2 ECKO mice. ROR2-deficient PAH PMVECs displayed increased adhesion, permeability, and focal adhesion numbers, with reduced VE-cadherin at cell junctions. Confocal imaging and foster resonance energy transfer revealed ROR2 localization in focal adhesions, interacting with ITGB1 (integrin β1) which remained in an active, adhesion-promoting state in ROR2-deficient cells. Restoring ROR2 in PAH PMVECs normalized adhesion, barrier function, and focal adhesion abundance. Transcriptomic analysis revealed Rab12 mediated ROR2-ITGB1 crosstalk, whose knockdown mimicked ROR2 deficiency in PMVECs.ROR2 regulates pulmonary angiogenesis by maintaining endothelial barrier integrity and facilitating integrin recycling. ROR2 restoration could be a potential therapeutic approach for PAH.

  View details for DOI 10.1161/HYPERTENSIONAHA.125.25881

  View details for PubMedID 41636059

• Pulmonary Hypertension Exhibits The Loss Of Capillaries, Leading To a Shift Toward Proliferative, Mesenchymal, and Hematopoietic Phenotypes James, J., Kacar, S., Agarwal, S., Valuparampil Varghese, M., Sano, T., Bharti, D., Niihori, M., Gao, A., Gaston, B., Tepper, R., Dejesus, V., Rafikova, O., Rafikov, R. LIPPINCOTT WILLIAMS & WILKINS. 2025

  View details for DOI 10.1161/circ.152.suppl_3.4366782

  View details for Web of Science ID 001613801100010

• C-type natriuretic peptide attenuates enhanced glycolysis and de novo pyrimidine synthesis in pericytes of patients with pulmonary arterial hypertension. Communications biology Noh, M., Mitra, A., Krebes, L., Schmitz, W., Dudek, J., Agarwal, S., Maack, C., Arias-Loza, P., Higuchi, T., Aleksic, I., de Jesus Perez, V. A., Kuhn, M., Dabral, S. 2025; 8 (1): 1199

  Abstract

  Metabolic reprogramming of vascular cells plays a crucial role in Pulmonary Arterial Hypertension (PAH), marked by a shift from oxidative phosphorylation to glycolysis (Warburg effect), altered purine biosynthesis, impaired glutaminolysis and fatty acid oxidation, driving endothelial and smooth muscle cell hyperproliferation. The metabolic alterations underlying pericyte dysfunction in PAH remain largely unexplored. Here, we investigated the metabolic alterations in PAH lung pericytes and the impact of C-type natriuretic peptide (CNP) and Guanylyl Cyclase-B/cyclic GMP signaling on these changes. Our results demonstrate that PAH pericytes exhibit increased glucose uptake, glycolysis, and de novo pyrimidine synthesis, promoting their hyperproliferation. These changes are driven by the upregulated glucose transporter, GLUT-1 and Pyruvate dehydrogenase kinase 1, along with enhanced CAD (Carbamoyl-phosphate synthetase 2, Aspartate transcarbamoylase, and Dihydroorotase) activity, both in vitro and in situ. CNP counteracts these alterations through activation of cGMP-dependent kinase I, reducing HIF-1α and GLUT-1 expression and thereby glucose uptake. Additionally, CNP activates Phosphodiesterase 2 A and thereby inhibits CAD activation and de novo pyrimidine synthesis. Accordingly, CNP prevented growth factor-induced proliferation and metabolic changes in murine pericytes within precision-cut lung slices. This study highlights dysregulated metabolic pathways in PAH pericytes and the therapeutic potential of CNP.

  View details for DOI 10.1038/s42003-025-08661-0

  View details for PubMedID 40796654

  View details for PubMedCentralID 9458918

• A Cross-Species and Sex-Specific Meta-Analysis of Transcriptomic Studies of Pulmonary Hypertension. American journal of respiratory cell and molecular biology Zhao, L., Cunningham, C. M., Hong, J., Agarwal, S., Yuan, K., de Jesus Perez, V. A., Nicolls, M. R. 2025

  Abstract

  Pulmonary hypertension (PH) is a life-threatening disease characterized by pulmonary vascular remodeling and right ventricle (RV) dysfunction. Among the five PH groups, group 1 pulmonary arterial hypertension (PAH) is a particularly serious condition characterized by a poor prognosis. PAH can be in idiopathic (IPAH), associated (APAH), and heritable (HPAH) forms, and has a notable female predominance. A number of in vivo PH models in rodents together with in vitro cultured vascular cells such as pulmonary arterial endothelial cells (PAECs) and pulmonary arterial smooth muscle cells (PASMCs) derived from PAH patients have been widely used to reproduce the pathological disease features. To systematically evaluate the in vivo and in vitro efficacy of the existing PH model systems, publicly available whole transcriptome data from both humans and rodents were collected and analyzed. Subgroups of Schistosoma-induced female PH in mice and male chronic hypoxia (CH)-PH model in rats correlated well with human HPAH and IPAH lungs, respectively. A SU5416-CH (SuHx) PH model is well connected to the decompensated RVs of human PAH. Sex dimorphisms have been observed in PAH derived PAECs and PASMCs, independent of gonadal hormones. We conducted, for the first time, a meta-cohort and cross-species comparative study and identified optimal in vivo and in vitro PH model systems that recapitulate certain aspects of the human PH, which could provide novel insights into new therapeutic avenues in PH.

  View details for DOI 10.1165/rcmb.2024-0410OC

  View details for PubMedID 39928415

• VIEWING PULMONARY HYPERTENSION THROUGH A PEDIATRIC LENS. The European respiratory journal Agarwal, S., Fineman, J., Cornfield, D. N., Alvira, C. M., Zamanian, R. T., Goss, K., Yuan, K., Bonnet, S., Boucherat, O., Pullamsetti, S., Alcázar, M. A., Goncharova, E., Kudryashova, T. V., Nicolls, M. R., de Jesús Pérez, V. 2024

  View details for DOI 10.1183/13993003.01518-2023

  View details for PubMedID 38575157

• WNT7A deficit is associated with dysfunctional angiogenesis in pulmonary arterial hypertension. The European respiratory journal Chakraborty, A., Nathan, A., Orcholski, M., Agarwal, S., Shamskhou, E. A., Auer, N., Mitra, A., Guardado, E. S., Swaminathan, G., Condon, D. F., Yu, J., McCarra, M., Juul, N. H., Mallory, A., Guzman-Hernandez, R. A., Yuan, K., Rojas, V., Crossno, J. T., Yung, L., Yu, P. B., Spencer, T., Winn, R. A., Frump, A., Karoor, V., Lahm, T., Hedlin, H., Fineman, J. R., Lafyatis, R., Knutsen, C. N., Alvira, C. M., Cornfield, D. N., de Jesus Perez, V. A. 2023

  Abstract

  INTRODUCTION: Pulmonary arterial hypertension (PAH) is characterized by loss of microvessels. The Wnt pathways control pulmonary angiogenesis, but their role in PAH is incompletely understood. We hypothesized that Wnt activation in pulmonary microvascular endothelial cells (PMVECs) is required for pulmonary angiogenesis, and its loss contributes to PAH.METHODS: Lung tissue and PMVECs from healthy and PAH patients were screened for Wnt production. Global and endothelial-specific Wnt7a-/- mice were generated and exposed to chronic hypoxia and Sugen-hypoxia (SuHx).RESULTS: Healthy PMVECs demonstrated >6-fold Wnt7a expression during angiogenesis that was absent in PAH PMVECs and lungs. Wnt7a expression correlated with formation of tip cells, a migratory endothelial phenotype critical for angiogenesis. PAH PMVECs demonstrated reduced VEGF-induced tip cell formation as evidenced by reduced filopodia formation and motility, which was partially rescued by recombinant Wnt7a. We discovered that Wnt7a promotes VEGF signaling by facilitating Y1175 tyrosine phosphorylation in VEGFR2 through ROR2, a Wnt-specific receptor. We found that ROR2 knockdown mimics Wnt7a insufficiency and prevents recovery of tip cell formation with Wnt7a stimulation. While there was no difference between wild-type and endothelial-specific Wnt7a-/- mice under either chronic hypoxia and SuHx, global Wnt7a+/- mice in hypoxia demonstrated higher pulmonary pressures and severe right ventricular and lung vascular remodeling. Similar to PAH, Wnt7a+/- PMVECs exhibited insufficient angiogenic response to VEGF-A that improved with Wnt7a.CONCLUSIONS: Wnt7a promotes VEGF signaling in lung PMVECs and its loss is associated with insufficient VEGF-A angiogenic response. We propose that Wnt7a deficiency contributes to progressive small vessel loss in PAH.

  View details for DOI 10.1183/13993003.01625-2022

  View details for PubMedID 37024132

• Potential long-term effects of SARS-CoV-2 infection on the pulmonary vasculature: Multilayered cross-talks in the setting of coinfections and comorbidities. PLoS pathogens Kumar, R., Aktay-Cetin, Ö., Craddock, V., Morales-Cano, D., Kosanovic, D., Cogolludo, A., Perez-Vizcaino, F., Avdeev, S., Kumar, A., Ram, A. K., Agarwal, S., Chakraborty, A., Savai, R., de Jesus Perez, V., Graham, B. B., Butrous, G., Dhillon, N. K. 2023; 19 (1): e1011063

  Abstract

  The Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and its sublineages pose a new challenge to healthcare systems worldwide due to its ability to efficiently spread in immunized populations and its resistance to currently available therapies. COVID-19, although targeting primarily the respiratory system, is also now well established that later affects every organ in the body. Most importantly, despite the available therapy and vaccine-elicited protection, the long-term consequences of viral infection in breakthrough and asymptomatic individuals are areas of concern. In the past two years, investigators accumulated evidence on how the virus triggers our immune system and the molecular signals involved in the cross-talk between immune cells and structural cells in the pulmonary vasculature to drive pathological lung complications such as endothelial dysfunction and thrombosis. In the review, we emphasize recent updates on the pathophysiological inflammatory and immune responses associated with SARS-CoV-2 infection and their potential long-term consequences that may consequently lead to the development of pulmonary vascular diseases.

  View details for DOI 10.1371/journal.ppat.1011063

  View details for PubMedID 36634048

• Novel TRAF2 variant and KDR deletion are implicated in the pathogenesis of pulmonary arterial hypertension Gallego, N., Pienkos, S., Condon, D., Cruz, A., Ochoa, N., Nevado, J., Arias, P., Agarwal, S., Patel, H., Chakraborty, A., Lapunzina, P., Escribano, P., de Jesus, V., Tenorio, J. SPRINGERNATURE. 2022: 197-198

  View details for Web of Science ID 000779367700524

• "NOVEL MECHANISMS TARGETED BY DRUG TRIALS IN PULMONARY ARTERIAL HYPERTENSION". Chest Condon, D. F., Agarwal, S., Chakraborty, A., Auer, N., Vazquez, R., Patel, H., Zamanian, R. T., de Jesus Perez, V. A., Condon, D. F. 2021

  Abstract

  Pulmonary arterial hypertension (PAH) is a rare disease associated with abnormally elevated pulmonary pressures and right heart failure resulting in high morbidity and mortality. While PAH prognosis has improved with the introduction of pulmonary vasodilators, disease progression remains a major problem. Given that available therapies are inadequate for preventing small vessel loss and obstruction, there is an active interest in identifying drugs capable of targeting angiogenesis and mechanisms involved in regulation of cell growth and fibrosis. Among the mechanisms linked to PAH pathogenesis, recent preclinical studies have identified promising compounds that are currently being tested in clinical trials. These drugs target seven of the major mechanisms associated with PAH pathogenesis: BMP signaling, tyrosine kinase receptors, estrogen metabolism, extracellular matrix, angiogenesis, epigenetics, and serotonin metabolism. In this review, we will discuss the preclinical studies that led to prioritization of these mechanisms and will discuss recently completed and ongoing phase 2/3 trials using novel interventions such as sotatercept, anastrozole, rodatristat ethyl, tyrosine kinase inhibitors, and endothelial progenitor cells among others. We anticipate that the next generation of compounds will build upon the success of the current standard of care and improve clinical outcomes and quality of life of patients afflicted with PAH.

  View details for DOI 10.1016/j.chest.2021.10.010

  View details for PubMedID 34655569

• Lung Pericytes in Pulmonary Vascular Physiology and Pathophysiology. Comprehensive Physiology Yuan, K., Agarwal, S., Chakraborty, A., Condon, D. F., Patel, H., Zhang, S., Huang, F., Mello, S. A., Kirk, O. I., Vasquez, R., de Jesus Perez, V. A. 2021; 11 (3): 2227-2247

  Abstract

  Pericytes are mesenchymal-derived mural cells localized within the basement membrane of pulmonary and systemic capillaries. Besides structural support, pericytes control vascular tone, produce extracellular matrix components, and cytokines responsible for promoting vascular homeostasis and angiogenesis. However, pericytes can also contribute to vascular pathology through the production of pro-inflammatory and pro-fibrotic cytokines, differentiation into myofibroblast-like cells, destruction of the extracellular matrix, and dissociation from the vessel wall. In the lung, pericytes are responsible for maintaining the integrity of the alveolar-capillary membrane and coordinating vascular repair in response to injury. Loss of pericyte communication with alveolar capillaries and a switch to a pro-inflammatory/pro-fibrotic phenotype are common features of lung disorders associated with vascular remodeling, inflammation, and fibrosis. In this article, we will address how to differentiate pericytes from other cells, discuss the molecular mechanisms that regulate the interactions of pericytes and endothelial cells in the pulmonary circulation, and the experimental tools currently used to study pericyte biology both in vivo and in vitro. We will also discuss evidence that links pericytes to the pathogenesis of clinically relevant lung disorders such as pulmonary hypertension, idiopathic lung fibrosis, sepsis, and SARS-COVID. Future studies dissecting the complex interactions of pericytes with other pulmonary cell populations will likely reveal critical insights into the origin of pulmonary diseases and offer opportunities to develop novel therapeutics to treat patients afflicted with these devastating disorders. © 2021 American Physiological Society. Compr Physiol 11:2227-2247, 2021.

  View details for DOI 10.1002/cphy.c200027

  View details for PubMedID 34190345

• Novel TNIP2 and TRAF2 Variants Are Implicated in the Pathogenesis of Pulmonary Arterial Hypertension FRONTIERS IN MEDICINE Pienkos, S., Gallego, N., Condon, D. F., Cruz-Utrilla, A., Ochoa, N., Nevado, J., Arias, P., Agarwal, S., Patel, H., Chakraborty, A., Lapunzina, P., Escribano, P., Tenorio-Castano, J., de Jesus Perez, V. A., Spanish PAH Consortium 2021; 8: 625763

  Abstract

  Background: Pulmonary arterial hypertension (PAH) is a rare disease characterized by pulmonary vascular remodeling and right heart failure. Specific genetic variants increase the incidence of PAH in carriers with a family history of PAH, those who suffer from certain medical conditions, and even those with no apparent risk factors. Inflammation and immune dysregulation are related to vascular remodeling in PAH, but whether genetic susceptibility modifies the PAH immune response is unclear. TNIP2 and TRAF2 encode for immunomodulatory proteins that regulate NF-κB activation, a transcription factor complex associated with inflammation and vascular remodeling in PAH. Methods: Two unrelated families with PAH cases underwent whole-exome sequencing (WES). A custom pipeline for variant prioritization was carried out to obtain candidate variants. To determine the impact of TNIP2 and TRAF2 in cell proliferation, we performed an MTS [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] assay on healthy lung pericytes transfected with siRNA specific for each gene. To measure the effect of loss of TNIP2 and TRAF2 on NF-kappa-beta (NF-κB) activity, we measured levels of Phospho-p65-NF-κB in siRNA-transfected pericytes using western immunoblotting. Results: We discovered a novel missense variant in the TNIP2 gene in two affected individuals from the same family. The two patients had a complex form of PAH with interatrial communication and scleroderma. In the second family, WES of the proband with PAH and primary biliary cirrhosis revealed a de novo protein-truncating variant in the TRAF2. The knockdown of TNIP2 and TRAF2 increased NF-κB activity in healthy lung pericytes, which correlated with a significant increase in proliferation over 24 h. Conclusions: We have identified two rare novel variants in TNIP2 and TRAF2 using WES. We speculate that loss of function in these genes promotes pulmonary vascular remodeling by allowing overactivation of the NF-κB signaling activity. Our findings support a role for WES in helping identify novel genetic variants associated with dysfunctional immune response in PAH.

  View details for DOI 10.3389/fmed.2021.625763

  View details for Web of Science ID 000649921700001

  View details for PubMedID 33996849

  View details for PubMedCentralID PMC8119639

• THE CANCER HYPOTHESIS OF PULMONARY ARTERIAL HYPERTENSION: THE NEXT TEN YEARS. American journal of physiology. Lung cellular and molecular physiology Condon, D., Agarwal, S., Chakraborty, A., de Jesus Perez, V. A. 2020

  View details for DOI 10.1152/ajplung.00057.2020

  View details for PubMedID 32186209

• In Defense of the Nucleus: NUDT1 and Oxidative DNA Damage in Pulmonary Arterial Hypertension. American journal of respiratory and critical care medicine Agarwal, S. n., de Jesus Perez, V. A. 2020

  View details for DOI 10.1164/rccm.202009-3706ED

  View details for PubMedID 33095993

• Mural Cell SDF1 Signaling is Associated with the Pathogenesis of Pulmonary Arterial Hypertension. American journal of respiratory cell and molecular biology Yuan, K. n., Liu, Y. n., Zhang, Y. n., Nathan, A. n., Tian, W. n., Yu, J. n., Sweatt, A. J., Condon, D. n., Chakraborty, A. n., Agarwal, S. n., Auer, N. n., Zhang, S. n., Wu, J. C., Zamanian, R. T., Nicolls, M. R., de Jesus Perez, V. A. 2020

  Abstract

  Pulmonary artery smooth muscle cells (PASMCs) and pericytes are NG2+ mural cells that provide structural support to pulmonary arteries and capillaries. In pulmonary arterial hypertension (PAH), both mural cell types contribute to PA muscularization but whether similar mechanisms are responsible for their behavior is unknown.RNA-Seq was used to compare the gene profile of pericytes and PASMCs from PAH and healthy lungs. NG2-Cre-ER mice were used to generate NG2-selective reporter mice (NG2tdT) for cell lineage identification and tamoxifen-inducible mice for NG2-selective SDF1 knockout (SDF1NG2-KO).Hierarchical clustering of RNA-seq data demonstrated that the genetic profile of PAH pericytes and PASMCs is highly similar. Cellular lineage staining studies on NG2tdT mice in chronic hypoxia showed that similar to PAH, tdT+ cells accumulate in muscularized microvessels and demonstrate significant upregulation of SDF1, a chemokine involved in chemotaxis and angiogenesis. Compared to controls, SDF1NG2-KO mice in chronic hypoxia had reduced muscularization and lower abundance of NG2+ cells around microvessels. SDF1 stimulation in healthy pericytes induced greater contractility and impaired their capacity to establish endothelial-pericyte communications. In contrast, SDF1 knockdown reduced PAH pericyte contractility and improved their capacity to associate with vascular tubes in co-culture.SDF1 is upregulated in NG2+ mural cells and is associated with PA muscularization. Targeting SDF1 could help prevent and/or reverse muscularization in PAH.

  View details for DOI 10.1165/rcmb.2019-0401OC

  View details for PubMedID 32084325