The Endothelial-mesenchymal Transition in Systemic Sclerosis Is Induced by Endothelin-1 and Transforming Growth Factor-β and May Be Blocked by Macitentan, a Dual Endothelin-1 Receptor Antagonist.
OBJECTIVE
High endothelin-1 (ET-1) and transforming growth factor-β (TGF-β) levels may induce in healthy endothelial cells (EC) an endothelial-to-mesenchymal transition (EndMT). The same cytokines are associated with fibrosis development in systemic sclerosis (SSc). Although EndMT has not been definitively shown in SSc, this process, potentially induced by a stimulatory loop involving these 2 cytokines, overexpressed in this disease might contribute to fibroblast accumulation in affected tissues. Macitentan (MAC), an ET-1 receptor antagonist interfering with this loop, might prevent EndMT and fibroblast accumulation.


METHODS
EC, isolated from healthy controls (HC) and patients with SSc, were treated with ET-1 and TGF-β and successively analyzed for gene and protein expressions of endothelial and mesenchymal markers, and for Sma- and Mad-related (SMAD) phosphorylation. Further, in the supernatants, we evaluated ET-1 and TGF-β production by ELISA assay. In each assay we evaluated the ability of MAC to inhibit both the TGF-β and ET-1 effects.


RESULTS
We showed that both TGF-β and ET-1 treatments induced an activation of the EndMT process in SSc-EC as reported in HC cells. The ELISA assays showed a mutual TGF-β and ET-1 induction in both SSc-EC and HC-EC. A statistically significant increase of SMAD phosphorylation after treatment was observed in SSc-EC. In each assay, MAC inhibited both TGF-β and ET-1 effects.


CONCLUSIONS
Our work is the first demonstration in literature that SSc-EC, under the synergistic effect of TGF-β and ET-1, may transdifferentiate toward myofibroblasts, thus contributing to fibroblast accumulation. MAC, interfering with this process in vitro, may offer a new potential therapeutic strategy against fibrosis.
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila. paola.cipriani@cc.univaq.it.
Paola
P
Cipriani
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Paola
P
Di Benedetto
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Piero
P
Ruscitti
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Daria
D
Capece
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Francesca
F
Zazzeroni
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Vasiliki
V
Liakouli
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Ilenia
I
Pantano
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Onorina
O
Berardicurti
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Francesco
F
Carubbi
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Gianluca
G
Pecetti
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Stefano
S
Turricchia
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Edoardo
E
Alesse
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Marc
M
Iglarz
From the Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, and the Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila, L'Aquila; Medical and Scientific Direction, Actelion Pharmaceuticals Italy, Imola, Italy; Drug Discovery Department, Actelion Pharmaceuticals Ltd., Allschwil, Switzerland.P. Cipriani, MD, PhD; P. Di Benedetto, PhD; P. Ruscitti, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; D. Capece, PhD; F. Zazzeroni, PhD, Department of Applied Clinical Sciences and Biotechnology, General Phatology Unit, University of L'Aquila; V. Liakouli, MD, PhD; I. Pantano, MD; O. Berardicurti, MD; F. Carubbi, MD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila; G. Pecetti, MD; S. Turricchia, MD, Medical and Scientific Direction, Actelion Pharmaceuticals Italy; E. Alesse, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, General Pathology Unit, University of L'Aquila; M. Iglarz, PhD, Drug Discovery Department, Actelion Pharmaceuticals Ltd.; R. Giacomelli, MD, PhD, Department of Applied Clinical Sciences and Biotechnology, Rheumatology Unit, School of Medicine, University of L'Aquila.
Roberto
R
Giacomelli
D000328:Adult; D015415:Biomarkers / Q000378:metabolism; D016022:Case-Control Studies; D054338:Cell Transdifferentiation / Q000187:drug effects / Q000502:physiology*; D002478:Cells, Cultured / Q000187:drug effects / Q000378:metabolism; D042783:Endothelial Cells / Q000187:drug effects* / Q000378:metabolism*; D019332:Endothelin-1 / Q000378:metabolism*; D004797:Enzyme-Linked Immunosorbent Assay; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D011743:Pyrimidines / Q000494:pharmacology*; D012016:Reference Values; D012595:Scleroderma, Systemic / Q000097:blood / Q000188:drug therapy; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric; D013449:Sulfonamides / Q000494:pharmacology*; D016212:Transforming Growth Factor beta / Q000378:metabolism*; D055815:Young Adult
D015415:Biomarkers; D019332:Endothelin-1; D011743:Pyrimidines; D013449:Sulfonamides; D016212:Transforming Growth Factor beta; C533860:macitentan
ENDOTHELIAL CELLS; FIBROSIS; MACITENTAN; MESENCHYMAL TRANSITION; SYSTEMIC SCLEROSIS