In this study, genome-wide maps of Smad1/5 binding regions in human primary cells revealed how BR
-Smads recognize and regulate their target genes. Both HUVECs and PASMCs express Smad1, Smad5 and Smad8 (
Supplementary Figure S1E). However, redundant functions between Smad1 and Smad5 have been demonstrated
in vivo, especially in the vasculature (
39).
Smad1+/−;
Smad5+/− double heterozygous mutant mice are embryonic lethal and display defects, which closely resemble those seen in
Smad1- or
Smad5-null mice, whereas
Smad1 or
Smad5 single heterozygous mice show no overt phenotype.
Smad8-null mice additionally lacking one copy of
Smad1 or
Smad5 did not exhibit overt phenotypes, and the tissue disturbances seen in
Smad1- or
Smad5-null embryos are not exacerbated in the absence of
Smad8. These findings suggest that Smad1 and Smad5 possess equivalent biological functions especially in the vasculature, while Smad8 is dispensable.
The mapping data of Smad1/5 showed that ~30% of the binding sites were located in the introns of known genes. Smad1/5 binding peaks of 85.4% overlapped with enhancer regions in HUVECs, where histone modification markers in basal conditions were available. Motif analysis revealed that binding motifs for ETS, AP-1, AP-2 and SP-1 were enriched in Smad1/5 binding regions regardless of the cell types. These motifs were also enriched in the Smad4 binding regions in human keratinocyte HaCaT cells (
31). Other motifs occurred only in a small proportion of sequences analyzed. Recently, John and colleagues (
40) reported that cell type-specific glucocorticoid receptor binding patterns are comprehensively predetermined by cell-specific differences in baseline chromatin accessibility patterns, with secondary contributions from local sequence features. The similar motif occurrence patterns between HUVECs and PASMCs suggest that the binding regions of BR
-Smad are also predetermined in the specific cell types.
Smad1/5 reproducibly bound to some target sites such as
ID1 and
ID3 loci with comparable enrichment after BMP-9 and BMP-6 stimulation, while the total number of Smad1/5 binding sites was dramatically lower in HUVECs treated with BMP-6 compared to those with BMP-9 (3750 versus 880). Increasing the dose of BMP-6 up to 200

ng/ml was not enough to elicit comparable level of enhancer activities as 1

ng/ml BMP-9 (C and B). This suggests that each binding site has different binding affinity for Smad complex and that BR
-Smad signaling through ALK-2 was not enough to occupy full sets of target sites in ECs. This is consistent with the facts that HHT2 is the result of haploinsufficiency of ALK-1 (
6), and that ALK-2 signaling is not able to compensate for ALK-1 mutations in HHT patients even though BMP-9 can signal through ALK-2 (
1).
In
Drosophila, Ashe
et al. (
41) have reported that each enhancer element for Mad target genes has a different binding affinity for Smad/Mad. A gene with low-affinity Smad/Mad binding sites is transcribed only in response to high concentrations of Dpp, while a gene with higher affinity sites responds to a low dose of Dpp. Increasing the affinity of the Smad/Mad binding sites in the enhancer of the
Ance (also known as
Race) resulted in a wider expression pattern
in vivo (
42). We revealed that a mutation in our consensus GC
-SBE sequences attenuates BMP responsiveness of target genes (B and
Supplementary Figure S5B). In addition, a mutation of the
HAMP promoter from GG
CGCC to GG
TGCC, which was identified in a hemochromatosis patient, impairs the BMP responsiveness
in vivo and contributes to the severe phenotype (
43). These results suggest that the binding affinity for Smad complex is the sum of the affinities of GC
-SBEs, SBEs and other DNA binding proteins like Sox2 and Oct4 in mESCs (
16), and that unidentified mutations in the BR
-Smad binding regions will be implicated in HHT or PAH.
Collectively, our findings support the notion that BR
-Smad binding sites are predetermined in specific cell type and determined by the binding affinity of Smad complex to possible binding sites. It suggests that the strength of the BR
-Smad pathway is converted to the number and distribution of BR
-Smad binding sites over the genome. It does not necessarily exclude the possibilities that non-Smad pathways play important roles. Non-Smad pathways have been reported to affect the BR
-Smad pathway through degrading BR
-Smads or modulating binding affinity of Smad complexes [for review, see (
44)]. It is possible that they modulate the intensity of BR
-Smad pathway and affect the number and distribution of Smad1/5 binding sites in ECs (C).
Dysregulation of Notch signaling has been reported to cause AVM [for review, see (
45)] that is one of the major pathological features of HHT. JAG1 has been reported to cause differentiation of vascular smooth muscle cell (vSMC) precursor cells and induce vSMC-specific genes
in vitro through the JAG1-Notch3 signaling pathway (
46,
47). EC-specific deletion of
Jag1 showed defects in vSMC coverage in mice (
38,
48). Interestingly, genetic and pharmacological inhibition of ALK-1 signaling showed a severe vascular phenotype including lack of differentiation and recruitment of vSMCs and defects in the maturation phase of angiogenesis (
5,
49,
50). In the clinical settings, thalidomide has been shown to stimulate vessel maturation and have beneficial effects on HHT patients (
51). Therefore, our results suggested the important roles of ALK-1-Smad-JAG1 pathway in the pathogenesis of the vascular lesions of the HHT. They also suggest that this pathway will be a novel therapeutic target for treatment of HHT.