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Front. Endocrinol., 06 September 2023
Sec. Systems Endocrinology
This article is part of the Research Topic Genetic variants and metabolic diseases, volume II View all 13 articles

Plasma cortisol-linked gene networks in hepatic and adipose tissues implicate corticosteroid-binding globulin in modulating tissue glucocorticoid action and cardiovascular risk

Sean Bankier,,*Sean Bankier1,2,3*Lingfei WangLingfei Wang3Andrew Crawford,Andrew Crawford1,4Ruth A. Morgan,Ruth A. Morgan1,5Arno Ruusalepp,,Arno Ruusalepp6,7,8Ruth AndrewRuth Andrew1Johan L. M. Bjrkegren,,Johan L. M. Björkegren8,9,10Brian R. Walker,Brian R. Walker1,11Tom Michoel,Tom Michoel2,3
  • 1University/BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
  • 2Computational Biology Unit, Department of Informatics, University of Bergen, Bergen, Norway
  • 3Division of Genetics and Genomics, The Roslin Institute, The University of Edinburgh, Edinburgh, United Kingdom
  • 4MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
  • 5SRUC, The Roslin Institute, Edinburgh, United Kingdom
  • 6Department of Cardiac Surgery, Tartu University Hospital, Tartu, Estonia
  • 7Department of Cardiology, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
  • 8Clinical Gene Networks AB, Stockholm, Sweden
  • 9Department of Medicine, Karolinska Institutet, Karolinska Universitetssjukhuset, Huddinge, Sweden
  • 10Department of Genetics & Genomic Sciences, Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
  • 11Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom

Genome-wide association meta-analysis (GWAMA) by the Cortisol Network (CORNET) consortium identified genetic variants spanning the SERPINA6/SERPINA1 locus on chromosome 14 associated with morning plasma cortisol, cardiovascular disease (CVD), and SERPINA6 mRNA expression encoding corticosteroid-binding globulin (CBG) in the liver. These and other findings indicate that higher plasma cortisol levels are causally associated with CVD; however, the mechanisms by which variations in CBG lead to CVD are undetermined. Using genomic and transcriptomic data from The Stockholm Tartu Atherosclerosis Reverse Networks Engineering Task (STARNET) study, we identified plasma cortisol-linked single-nucleotide polymorphisms (SNPs) that are trans-associated with genes from seven different vascular and metabolic tissues, finding the highest representation of trans-genes in the liver, subcutaneous fat, and visceral abdominal fat, [false discovery rate (FDR) = 15%]. We identified a subset of cortisol-associated trans-genes that are putatively regulated by the glucocorticoid receptor (GR), the primary transcription factor activated by cortisol. Using causal inference, we identified GR-regulated trans-genes that are responsible for the regulation of tissue-specific gene networks. Cis-expression Quantitative Trait Loci (eQTLs) were used as genetic instruments for identification of pairwise causal relationships from which gene networks could be reconstructed. Gene networks were identified in the liver, subcutaneous fat, and visceral abdominal fat, including a high confidence gene network specific to subcutaneous adipose (FDR = 10%) under the regulation of the interferon regulatory transcription factor, IRF2. These data identify a plausible pathway through which variation in the liver CBG production perturbs cortisol-regulated gene networks in peripheral tissues and thereby promote CVD.

1 Introduction

The steroid cortisol is the major glucocorticoid hormone involved in mediating the human stress response, with effects on metabolism, cardiovascular homeostasis, and inflammation (1). Excessive cortisol production occurs in Cushing’s syndrome either in response to chronic activation of the hypothalamic-pituitary-adrenal (HPA) axis by increased adrenocorticotropic hormone (ACTH) secretion or through autonomous production of cortisol in an adrenocortical tumor (2). The incidence of Cushing’s syndrome is low, with the number of cases estimated to be between 0.7 and 2.4 cases per million (3). It results in insulin resistance, obesity and hypertension with increased risk of cardiovascular disease (CVD). Similarly, higher plasma cortisol within the population, in the absence of overt Cushing’s syndrome, is associated with risk factors for CVD such as hypertension (4) and type II diabetes (1, 5).

Interindividual variation in plasma cortisol levels has a genetic basis with heritability estimated between 30% and 60% (6). The Cortisol Network (CORNET) consortium conducted a genome-wide association meta-analysis (GWAMA) with the intention of uncovering genetic influences on the HPA axis function (7). This was followed in 2021 with an updated GWAMA of 25,314 individuals across 17 population-based cohorts of European ancestries (8), expanded from 12,597 individuals in the original GWAMA. In an additive genetic model, the new CORNET GWAMA identified 73 genome-wide significant single-nucleotide polymorphisms (SNPs) associated with variation for plasma cortisol at a single locus on chromosome 14. These SNPs were used in a two-sample Mendelian randomization analysis showing that higher cortisol is causative for CVD (8).

The locus on chromosome 14 spans the genes SERPINA6 and SERPINA1 that both play roles in the regulation of corticosteroid-binding globulin (CBG), a plasma protein produced in the liver that is responsible for binding 80%–90% of cortisol in the blood (9, 10). SERPINA6 encodes CBG (11), and SERPINA1 encodes α1-antitrypsin, an inhibitor of neutrophil elastase, a serine protease that can cleave the reactive center loop of CBG resulting in a 9–10-fold reduction in binding affinity to cortisol (12, 13).

The CORNET GWAMA showed that 21 cortisol-associated SNPs were also cis-expression Quantitative Trait Loci (eQTLs) for SERPINA6 in the liver and demonstrated that the genetic variation associated with plasma cortisol is driven by SERPINA6 rather than SERPINA1 (8). However, although variation in CBG production could explain changes in total plasma cortisol, it is the free fraction of cortisol that is considered to equilibrate with target tissue concentrations and signal through intracellular glucocorticoid receptors (GR) (14, 15). While CBG deficiency may be associated with symptoms (1618), variations in CBG have not been shown conclusively to influence the tissue response to cortisol in humans.

To test the hypothesis that cortisol-associated genetic variants in the SERPINA6/SERPINA1 locus influence cortisol delivery to, and hence action in, extrahepatic tissues, we investigated transcriptome-wide associations between cortisol-associated SNPs and gene transcripts across seven different vascular and metabolic tissues from the Stockholm Tartu Atherosclerosis Reverse Networks Engineering Task (STARNET) study (19). As well as conducting a multi-tissue eQTL analysis using STARNET transcriptomics and plasma cortisol-associated SNPs, we identified tissue-specific trans-eQTL-associated genes under the regulation of GR. Moreover, we used a causal inference framework, with cis-eQTLs as genetic instruments, for the reconstruction of causal gene networks within STARNET tissues.

These results provide evidence that genetic variations in CBG production in liver influence extra-hepatic cortisol signaling and provide plausible pathways leading to CVD.

2 Materials and methods

2.1 Data

STARNET is a cohort-based study of 600 individuals undergoing coronary artery bypass grafting (CABG) for coronary artery disease (CAD) and was used as the primary discovery cohort in this study. These individuals underwent blood genotyping preoperatively for 951,117 genomic markers, and during surgery, seven different tissue samples were obtained and underwent RNA-sequencing (RNA-seq): liver, skeletal muscle, atherosclerotic aortic root, internal mammary artery, visceral abdominal fat, subcutaneous fat, and whole blood. STARNET data are available through a database of Genotypes and Phenotypes (dbGaP) application (accession no. phs001203.v2.p1). A detailed description of data processing can be found in the Supplemental Material of this article (section S1.1).

The Stockholm Atherosclerosis Gene Expression (STAGE) study (n = 114) (20) and the Metabolic Syndrome in Man (METSIM) study (n = 982) (21) were used in the replication of causal gene networks identified using STARNET. Gene expression data for the METSIM and STAGE studies are available publicly at Gene expression omnibus (GEO) (accession no. GSE70353 and GSE40231, respectively). Microarray data for the liver, subcutaneous fat, and visceral abdominal fat were used from the STAGE study, and gene expression data from subcutaneous fat were measured in the METSIM study using RNA-seq.

2.2 Multi-tissue trans-eQTL discovery

A list of SNPs associated with plasma cortisol was obtained from the summary statistics of the 2021 GWAMA conducted by the CORNET consortium (available at (8). We filtered this list to obtain SNPs that were found to be associated with plasma cortisol at a level of genome-wide significance (p< 5 × 10-8) that were taken forward 68 and tested against all genes across STARNET tissues.

The secondary linkage test (P2) is a likelihood ratio test in the Findr package (22) (version 1.0.8) that was used to identify associations between a given SNP (E) and a gene (B) using categorical regression. P2 proposes a null hypothesis where E and B are independent and alternative hypotheses where E is causal for B (E →B). Maximum likelihood estimators are then used to obtain a log likelihood ratio (LLR) between the alternative and null hypotheses. The LLR is then converted to the posterior probability of the alternative hypothesis alt(P2) being true with empirical estimation of the local false discovery rate (FDR) as a value from 0 to 1 (Equation 1).


2.3 Identification of glucocorticoid-regulated trans-genes

Multiple datasets were used to identify genes that had prior evidence of putative regulation by GR (2327). These datasets have been filtered to include targets for NR3C1, the gene that encodes GR.

Trans-genes were categorized according to evidence of GR regulation from datasets shown in Supplementary Table S1. Genes were scored against these criteria: 1) appearing in a transcription factor database (ENCODE, TRANSFAC, CHEA); 2) identified as a GR target from chromatin immunoprecipitation sequencing (ChIP-seq) experiment in adipocytes from Yu et al. (23); 3) differentially expressed in response to dexamethasone treatment in adipocytes from Yu et al. (23); and 4) murine homolog of human gene differentially expressed in response to dexamethasone treatment using adrenalectomized mice (FC >1; p-value<0.05) (24). Genes were then ranked according to how well they met the criteria for GR regulation (+1 for each item matched from criteria 1–4).

2.4 Causal gene network reconstruction

Pairwise causal inference was used for the reconstruction of cortisol-responsive transcriptional networks across STARNET tissues using cis-eQTL genotypes as genetic instruments with gene expression data from STARNET, as implemented by the Findr software (22). A detailed description of these methods can be found in the Supplementary Material of this article (Section S1.2).

2.5 Transcription factor target enrichment

Lists of known transcription factor targets for both NR3C1 and IRF2 were obtained from ENCODE and TRANSFAC datasets, respectively. These datasets were used to test for an enrichment of known transcription factor targets within novel gene sets derived from gene network targets. This was performed using Fisher’s exact test from the Python module Scipy Stats (28) and involved the creation of a 2 × 2 contingency table based on a tissue-specific background consisting of all genes available in the corresponding tissue.

2.6 Gene network replication

Correlations between gene network targets were calculated using gene expression data from STARNET, STAGE, and METSIM. Gene expression matrices were filtered to only include the target genes under investigation. Correlation matrices of corresponding Pearson correlation coefficients as absolute values were constructed in Python.

A background gene set was constructed from the overlapping genes between the STARNET gene expression set that was used for network discovery and the corresponding gene expression set that was being used for replication. The previously described correlation analysis was then repeated using a random set of genes (the same size as the target set) selected from the background gene set. The Kruskal–Wallis test was implemented in Python using Scipy Stats (28) to test if the targeted and randomly sampled correlations follow the same distribution. Both the targeted and random correlations were then plotted as a boxplot using the Python plotting package Seaborn (29).

2.7 Gene expression clustering

Hierarchical clustering was performed on correlation values between network targets using the discovery (STARNET) gene expression data and hierarchical clustering from Scipy Stats (28) in Python. The leaves list that resulted from the clustering of the discovery dataset was then extracted and applied to the correlations between target genes from the corresponding replication dataset. Both sets of clustered correlation values were then plotted as opposing correlation heatmaps with Seaborn (29).

3 Results

3.1 Cortisol-associated trans-genes

SNPs associated with plasma cortisol at the SERPINA6/SERPINA1 locus have previously been linked as expression single-nucleotide polymorphisms (eSNPs) for SERPINA6 in the liver (8). Using genotype and tissue-specific RNA-seq data from the STARNET cohort, we explored the hepatic and extrahepatic consequences of genetic variation for plasma cortisol using 73 cortisol-associated SNPs at genome-wide significance (p< 5 × 10-8) identified from the CORNET GWAMA (8). We identified 704 eQTL associations in cis and trans between plasma cortisol-associated SNPs and genes measured across all STARNET tissues, composed of 262 unique genes and 72 SNPs at a 15% FDR threshold (Supplementary Tables S2, S3).

The tissues with the greatest number of trans-genes were the liver, subcutaneous fat, and visceral abdominal fat, with a combined total of 157 trans-genes and 422 total SNP–gene associations (FDR = 15%) (Figure 1A). The vast majority of trans-eQTL associations were specific to a single tissue. A single trans-gene, the glycosyltransferase-encoding gene OGT, was identified in both the liver and visceral abdominal fat. However, as this was the only cross-tissue trans-gene identified, suggesting that the transcriptional impact of genetic variation at the SERPINA6/SERPINA1 locus is highly tissue-specific. The CORNET GWAMA describes four blocks of SNPs in linkage disequilibrium (LD), which represent the cortisol-associated variation at the SERPINA6/SERPINA1 locus (8). We observed that LD blocks 2 and 4 represent the majority of the variation across all tissues in the trans-gene sets (Figures 1B, C).


Figure 1 Identification of cortisol-associated trans-genes across STARNET tissues (FDR = 15%). (A) Upset plot showing the distribution of trans-genes across STARNET tissues, including genes shared by multiple tissues. Tissues include the atherosclerotic aortic root (AOR), skeletal muscle (SKLM), internal mammary artery (MAM), blood (Blood), liver (LIV), subcutaneous fat (SF), and visceral abdominal fat (VAF). (B) Distribution of trans-eQTLs across tissues and colored by genomic locus (LD block) of associated SNP. (C) LocusZoom plot (30) showing the location of cortisol-associated SNPs within defined LD blocks. (D) Venn diagrams where groupings represent different sources used to identify GR-linked trans-genes in the liver, (E) visceral abdominal fat, and (F) subcutaneous fat. These sources include transcription factor databases (db), ChIP-seq from perturbation-based experiments (23), and differential expression of dexamethasone-treated mice (24).

3.2 GR-regulated trans-genes associated with plasma cortisol

As the GR is the primary mechanism by which cortisol influences transcription, we sought to identify a subset of cortisol-associated trans-genes that were also regulated by the GR. The cortisol-associated trans-genes identified in this study were compared to sets of known GR targets identified from different sources as described in Supplementary Table S1. This included large projects such as ENCODE, TRANSFAC, and CHEA that predict transcription factor-binding targets from high-throughput transcription factor-binding assays. We also included predicted GR targets from perturbation-based experiments in specific tissues. ChIP-seq and microarray analysis has been used to identify 274 glucocorticoid-regulated genes in 3TS-L1 adipocytes, a murine-derived cell line (23). In addition, RNA-seq data in subcutaneous fat from adrenalectomized mice treated with dexamethasone, a GR agonist, have been used to identify genes that are differentially expressed (24).

The greatest number of unique cortisol-associated trans-genes was identified in the liver (n = 43), subcutaneous fat (n = 54), and visceral abdominal fat (n = 59) at a 15% FDR threshold. The involvement of these tissues in glucocorticoid signaling and physiological effects has been well documented in the literature (3134); therefore, the identification of GR-regulated trans-genes was restricted to these tissues. Comparisons of genes identified as glucocorticoid-regulated in 3T3-L1 adipocytes were only made with subcutaneous and visceral adipose trans-genes. Likewise, as the murine RNA-seq experiments were restricted to subcutaneous adipose, only subcutaneous adipose trans-genes were compared to these differentially expressed genes.

In the liver trans-gene set, 19/43 genes were identified that were present in either the ENCODE, TRANSFAC, or CHEA datasets (FDR = 15%) (Figure 1D; Supplementary Table S4). This includes SERPINA6 that is cis-associated with genetic variation for plasma cortisol, as described previously (8). One gene, CPEB2, was identified in more than one dataset and was present in both ENCODE and CHEA. CPEB2 (posterior probability = 0.89) is a regulator of translation, splice variants of which have been linked to cancer metastasis (35).

Visceral adipose tissue had the largest number of cortisol-associated trans-genes. Here, 21/59 of these genes had some evidence of being targets of GR (Figure 1E; Supplementary Table S5). There were five genes that had been identified as GR targets from both high-throughput transcription factor-binding assays and adipose-specific experiments. These include CD163 and LUC7L3. CD163 is a hemoglobin scavenger protein that is expressed in macrophages and involved in the clearance of hemoglobin/haptoglobin complexes that may play a role in the protection from oxidative damage. It also plays a role in activating macrophages as part of the inflammatory response (36). LUC7L3, also known as CROP, encodes a protein that is involved in alternative splicing and is associated with human heart failure (37). It has also been shown to play a role in the inhibition of hepatitis B replication (38).

Of the cortisol-associated trans-genes identified in subcutaneous adipose (FDR = 15%), 28/54 genes were either present in a transcription factor dataset or identified from the adipose-specific perturbation datasets (Figure 1F; Supplementary Table S6). There were 13 genes that had been identified as GR targets from both high-throughput transcription factor-binding assays and adipose-specific experiments. These include RNF13 that encodes IRE1α-interacting protein that plays an important role in the endoplasmic reticulum (ER) stress response through regulation of IRE1α, a critical sensor of unfolded proteins (39). Also IRF2, encoding the transcription factor Interferon Regulatory Factor 2 that plays an important role as a repressor of IRF1 that in turn is involved in the interferon-mediated immune response (40). Furthermore, IRF1 has previously been identified as a marker for glucocorticoid sensitivity in peripheral blood (41).

3.3 Reconstruction of cortisol-associated gene networks

Having identified cortisol-associated trans-genes that are regulated by GR, causal estimates were obtained for pairwise relationships between GR-regulated trans-genes and all other genes within the given tissue. This was carried out for all GR-regulated trans-genes in the liver, subcutaneous fat, and visceral abdominal fat with a valid cis-eQTL instrument (12, 19, and 7 genes, respectively) (Supplementary Table S7). A 10% global FDR threshold was then imposed for each gene set (Table 1). Primary networks were obtained by filtering to include only GR trans-genes with a minimum of four target genes at the global FDR threshold.


Table 1 Number of network targets following FDR filtering.

In the liver, we identified a single gene network driven by CPEB2, which was found to be trans-associated with the cortisol-associated SNP rs4905194 (Figure 2A). This network contained 48 causal interactions driven by CPEB2 at a 10% FDR threshold (Figure 2D; Supplementary Table S9). It is notable that CPEB2 appears as the only network regulator in the liver considering it was also the cortisol-associated trans-gene with the strongest links to GR regulation from the liver trans-gene set. A detailed description of the CPEB2 network and all other networks identified can be found in the Supplementary Information (Section S2.1).


Figure 2 The 10% FDR gene networks in STARNET across different tissues. (A) Gene expression boxplot in the liver showing trans-association with cortisol-linked SNP rs4905194 and CPEB2, (B) in subcutaneous fat between rs11622665 and RNF13 and (C) rs8022616 and IRF2 (p-value obtained from Kruskal–Wallis test statistic). Box shows quarterlies of the dataset, with whiskers indicating the upper and lower variability of the distribution. (D) Causal gene network reconstructed from pairwise interactions from GR-regulated trans-genes against all other genes in the corresponding tissue for CPEB2, (E) RNF13, and (F) IRF2. Edges represent Bayesian posterior probabilities of pairwise interaction between genes (nodes) exceeding 10% global FDR. Arrow indicates direction of regulation, and interactions were only retained where parent node had at least four targets.

In subcutaneous fat, two major subnetworks were identified under the regulation of the genes RNF13 and IRF2. This includes a total of 343 causal relationships across both subnetworks, including two genes shared by both subnetworks. RNF13 was found to be trans-associated with the cortisol-associated SNP rs11622665 (Figure 2B) and represents the largest subcutaneous fat subnetwork with 215 gene targets at a 10% FDR threshold (Figure 2E; Supplementary Table S10).

The transcription factor IRF2, which was associated with the cortisol-linked SNP rs8022616 (Figure 2C), was found to putatively regulate a network of 128 genes (FDR = 10%) (Figure 2F). Some notable targets of IRF2 include LDB2 (posterior probability = 0.94) and LIPA (posterior probability = 0.91). GWAS suggests functions for LIPA related to CAD and ischemic cardiomyopathy (42), while LDB2 has been demonstrated to be involved in the development of atherosclerosis (43). Additionally, cortisol has been shown to induce a 5-fold reduction in LDB2 expression in adipocytes (44).

Predicted IRF2 transcription factor targets have been previously described as part of the TRANSFAC dataset. We examined the overlap between predicted IRF2 targets in TRANSFAC, and gene targets within the IRF2 causal networks were identified in subcutaneous fat. A true network of IRF2 targets would be expected to show an enrichment of predicted IRF2. Using Fisher’s exact test on data from subcutaneous fat, at a 10% FDR threshold, the IRF2 network had 128 target genes, 35 of which were also predicted IRF2 targets (p = 0.08); at a 15% FDR threshold, 104/247 causal targets were also predicted targets of IRF2 in TRANSFAC (p = 0.005). Decreasing the global FDR beyond this threshold increased the number of TRANSFAC targets within the pool of causal targets, however at a lower enrichment (p = 0.046) (Supplementary Table S12).

In addition to examining the prevalence of IRF2 targets within the IRF2 causal network, we investigated the overlap between network genes that are also regulated by GR. We observed an enrichment of ENCODE GR targets at 15% and 20% FDR thresholds (p< 0.05) including 68 and 138 GR targets, respectively. No GR enrichment was observed in either CHEA or TRANSFAC datasets for IRF2 networks.

3.4 Co-expression of cortisol network targets in independent datasets

Causal gene networks represent coordinated changes in gene expression in response to changes in the expression of network regulators. Therefore, it is possible to examine if these changes in gene expression are present in independent datasets using gene expression data alone. We used RNA-seq and microarray data from the METSIM and STAGE datasets, respectively, to compare patterns in gene expression within causal networks predicted from STARNET. As METSIM only contains gene expression data for subcutaneous fat, analysis was restricted to the causal networks identified in STARNET subcutaneous fat.

Absolute correlation coefficients between the targets of the previously described network regulators were calculated, and their distributions were compared to distributions of random sets of genes selected from the replication gene expression data, the same size as the corresponding target gene set. The difference between targeted and random distributions was formalized using the Kruskal–Wallis test for each subnetwork (Table 2).


Table 2 Correlations between network targets within replication datasets.

In the liver, correlations between network targets of the single subnetwork under the regulation of CPEB2 were observed in STARNET and STAGE. Hierarchical clustering within the STARNET liver also revealed clustering of correlated genes that were retained when the clustered gene order was then applied to the STAGE liver (Figure 3A). Correlations between the 44 CPEB2 target genes in the STAGE liver were stronger than their random counterparts (p = 8.2 × 10-32), with this shift also being observed in the STARNET liver (p = 2.32 × 10-197) (Figure 3D).


Figure 3 Replication of cortisol-associated gene networks in independent datasets. (A) Correlation heatmap showing pairwise Pearson correlations between CPEB2, (B) IRF2, and (C) RNF13 network targets. Hierarchical clustering of genes in STARNET (discovery) was applied to the same genes within replication datasets. (D) Correlations between network targets in discovery vs. replication datasets for CPEB2, (E) IRF2, and (F) RNF13 networks. The Kruskal–Wallis test calculated for the distribution of correlations between network targets compared to correlations within random gene sets of the same size.

In subcutaneous fat, correlations were observed between the network targets of RNF13 and IRF2, and hierarchical clustering patterns from STARNET were applied to the replication datasets of STAGE and METSIM (Figures 3B, C). For RNF13, similar patterns of co-expression were observed in the STAGE subcutaneous fat following clustering; however, this was not the case in the METSIM dataset (Figure 3B). Despite this, RNF13 targets appeared more highly correlated than their randomly selected counterparts in STARNET (p< 1.0 × 10-300), STAGE (p< 1.0 × 10-300) and to a lesser extent in METSIM (p = 2.3 × 10-7) (Figure 3E).

In subcutaneous fat, patterns of co-expression between IRF2 targets were conserved most prominently in METSIM; however, co-expression was less strongly correlated compared with RNF13 targets (Figure 3C). IRF2 subcutaneous fat subnetwork targets were more strongly correlated than their random counterparts in STARNET (p< 1.0 × 10-300), STAGE (p = 8.35 × 10-86), and METSIM (p< 1.0 × 10-300) (Figure 3F).

4 Discussion

In this study, we have characterized the impact that genetic variation for plasma cortisol has upon tissue-specific gene expression. We showed that cortisol-linked genetic variants at the SERPINA6/SERPINA1 locus mediate changes in gene expression in trans across multiple tissues, in addition to the cis-associations in the liver that have been described previously (8). We have scrutinized these trans-associations to identify a subset of genes that are regulated by glucocorticoids and in turn regulate downstream transcriptional networks, thus providing a deeper understanding of the transcriptional landscape driven by cortisol-linked genetic variation that may underpin the progression to CVD.

CBG, as encoded by SERPINA6, is responsible for binding cortisol in the blood. It has remained uncertain whether variation in CBG impacts the availability of cortisol within tissues, since any resulting change in free cortisol concentrations would be expected to be adjusted by negative feedback of the HPA axis (45). However, deleterious mutations in CBG are associated with dysfunction in animals and humans, suggesting an impact of CBG on cortisol signaling (45). Our major finding that downstream transcriptomic changes in extrahepatic tissues are associated with genetic variation at the SERPINA6 locus lends strong support to the hypothesis that CBG influences tissue delivery of cortisol and modulates glucocorticoid-induced changes in gene expression.

For the STARNET study, whole-blood samples were taken preoperatively and all other tissues including the liver were taken during the CABG surgery. In addition to any rise in cortisol due to anxiety and disturbed sleep in anticipation of surgery, the human stress response to surgery has been well characterized and results in stimulation of the HPA axis leading to high levels of cortisol in the blood both during and post-surgery (46). Surgery is also associated with a very rapid fall in CBG production. Therefore, it is uncertain if cortisol-associated gene expression patterns observed in STARNET would also be observed in an unstressed healthy population. It may be that CBG influences the dynamic range of alterations in free plasma cortisol during stress rather than affecting the delivery of cortisol to tissues in unstressed conditions. However, considering that co-expression of the network targets was reproducible within independent samples from the METSIM study, obtained under nonsurgical conditions, this suggests that the cortisol-associated networks we inferred from STARNET do operate also in unstressed conditions.

The tissues with the greatest number of trans-genes identified were the liver and both subcutaneous and visceral abdominal fat, all tissues known to play a role in glucocorticoid biology. In the liver, glucocorticoids have extensive effects on glucose and fatty acid metabolism (31, 32), while in adipose tissue, glucocorticoids regulate lipogenesis and lipid turnover (33, 34). Skeletal muscle is also a major target of glucocorticoids, where they modulate protein and glucose metabolism (47). A lack of available data for identifying tissue-specific GR targets in other tissues means that potential GR targets may have been missed in tissues outside of the liver and adipose.

We identified a subset of GR-responsive genes in the liver, subcutaneous fat, and visceral adipose fat. However, we did not observe a statistical enrichment of GR-regulated genes in any of these trans-gene sets. This does not negate the identification of GR targets that are associated with plasma cortisol, but it may imply that there are some effects of cortisol-linked genetic variation that are mediated by mechanisms other than directly by GR either through secondary regulation by GR-regulated genes or through the alternative mineralocorticoid receptor. Indeed, some of the genes with higher levels of evidence for GR regulation also demonstrated regulation of transcription networks, e.g., CPEB2, IRF2, and RNF13. This supports our strategy of setting a relatively lenient FDR threshold and then filtering to identify cortisol-associated trans-genes with prior evidence of GR regulation.

It should be noted that different FDR thresholds were used for the trans-gene discovery and for the network reconstruction. Initially, we selected a more lenient threshold of 15% for the identification of trans-genes, considering that trans-eQTLs tend to exhibit weaker associations compared to their cis counterparts (47). We then decided to restrict our list of trans-associations by implementing a biological rather than a statistical threshold, limiting the number of trans-genes to those with evidence of GR regulation. However, given that there was no biological threshold implemented with network reconstruction, a more stringent FDR threshold was appropriate. The 10% FDR in this context implies that 1 in 10 edges of a given network is a potential false positive. However, given the strength of the replication within independent datasets, this suggests that these networks are considerably robust.

We identified causal gene networks in the liver, subcutaneous fat, and visceral abdominal fat where cortisol-associated trans-genes act as regulators of subnetworks within overarching tissue-specific networks. Pairwise causal relationships were established between network regulators and downstream targets using cis-eQTLs as genetic instruments. This approach has the benefit of generating directed relationships between a regulator and target while accounting for any unobserved confounding. However, a drawback of this approach is that we are limited by only being able to examine GR-regulated trans-genes with valid cis-eQTLs. This means that there could be valid cortisol-responsive networks regulated by GR trans-genes that we were unable to predict due to lack of a corresponding instrument.

IRF2 stands out as a network regulator of particular interest. There is strong evidence of GR regulation, where IRF2 has been identified as a GR target from published dexamethasone-treated adipocyte ChIP-seq experiments (23) and as a putative GR target within ENCODE. It is robustly associated with its corresponding cis-eQTL instrument, and there is an enrichment of IRF2 targets within our predicted IRF2-regulated causal network. Additionally, we show evidence of regulation by glucocorticoids within the targets of IRF2, potentially suggesting evidence of a feed-forward loop motif (48). Interestingly, the genotype for rs8022616, the cortisol-associated SNP linked to IRF2 expression in subcutaneous fat, is associated with a decrease in IRF2 expression. Previous evidence suggests that interferon signaling is inhibited by glucocorticoids (49, 50).

Although we have determined the direction of causality between the regulator and target genes, we do not know if the expression of the target gene is upregulated or downregulated in response to modulation of the regulator. This could be investigated through functional experiments within a relevant cell line, whereby the differential gene expression of target genes is measured in response to perturbation of the network regulator. To take this one step further, the results of a cell line experiment could be used to determine the dynamics of the putative cortisol networks using systems biology approaches for modelling gene expression (51).

In conclusion, we have linked genetic variation for plasma cortisol to changes in gene expression across the genome, beyond that which has been previously described at the SERPINA6/SERPINA1 locus (8) and extending to adipose tissue as well as the liver. Furthermore, we have shown that a subset of these trans-genes is driven by the GR and in turn drives transcriptional networks across different tissues. These networks have been found to be robust and their network targets appear co-expressed within independent gene expression datasets of the same tissue. Further study of these networks and their downstream targets could be used to enhance our mechanistic understanding of the pathways linking cortisol with complex diseases as described in observational studies.

Data availability statement

All code used in the analyses presented in this study are available at the following repository: Data from the Stockholm Tartu Atherosclerosis Reverse Networks Engineering Task study (STARNET) are available through a database of Genotypes and Phenotypes (dbGaP) application (accession no. phs001203.v2.p1). Gene expression data from The Stockholm Atherosclerosis Gene Expression study (STAGE) and the Metabolic Syndrome in Man study (METSIM) are available publicly at GEO (accession no. GSE70353 and GSE40231, respectively). The summary statistics from the CORNET GWAMA are available at Edinburgh DataShare:

Ethics statement

The studies involving human participants were reviewed and approved by ethical approvals: Tartu, Dnr 154/7 and 188/M-12, Mount Sinai, IRB-20-03781. The patients/participants provided their written informed consent to participate in this study.

Author contributions

SB, TM, and BW contributed to the conception and design of this research. SB conducted all formal analyses and visualizations and wrote the article, supervised by TM, BW, and RA. LW and TM developed and supported the use of and interpretation of outputs from the software Findr. AC contributed to data analysis and interpretation for the CORNET consortium. RM conducted the experiments and contributed to data analysis of dexamethasone-treated mice. AR and JB provided access to and contributed to interpretation of data from the STARNET cohort. All authors reviewed the article and approved the submitted version.


This work has benefited from UK research and Innovation (UKRI) funding through a Medical Research Council (MRC) PhD studentship (project reference 1938124). Funding has also been provided by the Wellcome Trust (project number 107049/Z/15/Z) and the Norwegian Research Council (NFR) (project number 312045).

Conflict of interest

Authors JB and AR was employed by the company Clinical Gene Networks AB.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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Supplementary material

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1. Walker BR. Glucocorticoids and cardiovascular disease. Eur J Endocrinol (2007) 157(5):545–59. doi: 10.1530/EJE-07-0455

CrossRef Full Text | Google Scholar

2. Raff H, Carroll Ty. Cushing’s syndrome: from physiological principles to diagnosis and clinical care. J Physiol (2015) 593(3):493–506. doi: 10.1113/jphysiol.2014.282871

CrossRef Full Text | Google Scholar

3. Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing’s syndrome. Lancet (2006) 367(9522):1605–17. doi: 10.1016/S0140-6736(06)68699-6

CrossRef Full Text | Google Scholar

4. Whitworth JA, Brown MA, Kelly JJ, Williamson PM. Mechanisms of cortisol-induced hypertension in humans. Steroids Aldosterone Hypertension (1995) 60(1):76–80. doi: 10.1016/0039-128X(94)00033-9

CrossRef Full Text | Google Scholar

5. Chiodini I, Adda G, Scillitani A, Coletti F, Morelli V, Lembo SD, et al. Cortisol Secretion in Patients With Type 2 Diabetes: Relationship with chronic complications. Diabetes Care (2007) 30.1:83–8. doi: 10.2337/dc06-1267

CrossRef Full Text | Google Scholar

6. Bartels M, Geus, de Eco JC, Kirschbaum C, Sluyter F, Boomsma DI. Heritability of daytime cortisol levels in children. Behav Genet (2003) 33.4:421–433. doi: 10.1023/A:1025321609994

CrossRef Full Text | Google Scholar

7. Bolton JL, Hayward C, Direk N, Lewis JG, Hammond GL, Hill LA, et al. Genome wide association identifies common variants at the SERPINA6/SERPINA1 locus influencing plasma cortisol and corticosteroid binding globulin. PloS Genet (2014) 10.7:e1004474. doi: 10.1371/journal.pgen.1004474

CrossRef Full Text | Google Scholar

8. Crawford AA, Bankier S, Altmaier E, Barnes CLK, Clark DW, Ermel R, et al. Variation in the SERPINA6/SERPINA1 locus alters morning plasma cortisol, hepatic corticosteroid binding globulin expression, gene expression in peripheral tissues, and risk of cardiovascular disease. J Hum Genet (2021), 1–12. doi: 10.1038/s10038-020-00895-6

CrossRef Full Text | Google Scholar

9. Hammond GL. Molecular properties of corticosteroid binding globulin and the sex-steroid binding proteins*. Endocrine Rev (1990) 11.1:65–79. doi: 10.1210/edrv-11-1-65

CrossRef Full Text | Google Scholar

10. Perogamvros I, Ray DW, Trainer PJ. Regulation of cortisol bioavailability—effects on hormone measurement and action. Nat Rev Endocrinol (2012) 8.12:717–27. doi: 10.1038/nrendo.2012.134

CrossRef Full Text | Google Scholar

11. Pemberton PA, Stein PE, Pepys MB, Potter JM, Carrell RW. Hormone binding globulins undergo serpin conformational change in inflammation. Nature (1988) 336:6196. doi: 10.1038/336257a0

CrossRef Full Text | Google Scholar

12. Chan WL, Carrell RW, Zhou A, Read RJ. How changes in affinity of corticosteroid-binding globulin modulate free cortisol concentration. J Clin Endocrinol Metab (2013) 98.8:3315–22. doi: 10.1210/jc.2012-4280

CrossRef Full Text | Google Scholar

13. Nenke MA, Holmes M, Rankin W, Lewis JG, Torpy DJ. Corticosteroid binding globulin cleavage is paradoxically reduced in alpha-1 antitrypsin deficiency: Implications for cortisol homeostasis. Clinica Chimica Acta (2016) 452:27–31. doi: 10.1016/j.cca.2015.10.028

CrossRef Full Text | Google Scholar

14. Lewis JG, Bagley CJ, Elder PA, Bachmann AW, Torpy DJ. Plasma free cortisol fraction reflects levels of functioning corticosteroid-binding globulin. Clinica Chimica Acta (2005) 359.1:189–94. doi: 10.1016/j.cccn.2005.03.044

CrossRef Full Text | Google Scholar

15. Oakley RH, Cidlowski JA. The biology of the glucocorticoid receptor: new signaling mechanisms in health and disease. J Allergy Clin Immunol (2013) 132.5:1033–44. doi: 10.1016/j.jaci.2013.09.007

CrossRef Full Text | Google Scholar

16. Torpy DJ, Bachmann AW, Grice JE, Fitzgerald SP, Phillips PJ, Whitworth JA, et al. Familial corticosteroid-binding globulin deficiency due to a novel null mutation: association with fatigue and relative hypotension. J Clin Endocrinol Metab (2001) 86.8:3692–700. doi: 10.1210/jcem.86.8.7724

CrossRef Full Text | Google Scholar

17. Buss C, Schuelter U, Hesse J, Moser D, Phillips DI, Hellhammer D, et al. Haploinsufficiency of the SERPINA6 gene is associated with severe muscle fatigue: A de novo mutation in corticosteroid-binding globulin deficiency. J Neural Transm (2007) 114.5:563–9. doi: 10.1007/s00702-006-0620-5

CrossRef Full Text | Google Scholar

18. Simard M, Hill LA, Lewis JG, Hammond GL. Naturally occurring mutations of human corticosteroid-binding globulin. J Clin Endocrinol Metab (2015) 100.1:E129–39. doi: 10.1210/jc.2014-3130

CrossRef Full Text | Google Scholar

19. Franzén O, Ermel R, Cohain A, Akers NK, Narzo AD, Talukdar HA, et al. Cardiometabolic risk loci share downstream cis- and trans-gene regulation across tissues and diseases. Science (2016) 353.6301:827–30. doi: 10.1126/science.aad6970

CrossRef Full Text | Google Scholar

20. Talukdar HA, Foroughi Asl H, Jain RK, Ermel R, Ruusalepp A, Franzén O, et al. Cross-tissue regulatory gene networks in coronary artery disease. Cell Syst (2016) 2.3:196–208. doi: 10.1016/j.cels.2016.02.002

CrossRef Full Text | Google Scholar

21. Laakso M, Kuusisto J, Stančáková A, Kuulasmaa T, Pajukanta P, Lusis AJ, et al. The Metabolic Syndrome in Men study: a resource for studies of metabolic and cardiovascular diseases. J Lipid Res (2017) 58.3:481–93. doi: 10.1194/jlr.O072629

CrossRef Full Text | Google Scholar

22. Wang L, Michoel T. Efficient and accurate causal inference with hidden confounders from genome-transcriptome variation data. PloS Comput Biol (2017) 13.8:e1005703. doi: 10.1371/journal.pcbi.1005703

CrossRef Full Text | Google Scholar

23. Yu C-Y, Mayba O, Lee JV, Tran J, Harris C, Speed TP, et al. Genome-wide analysis of glucocorticoid receptor binding regions in adipocytes reveal gene network involved in triglyceride homeostasis. PloS One (2010) 5.12:e15188. doi: 10.1371/journal.pone.0015188

CrossRef Full Text | Google Scholar

24. Bell RMB, Villalobos E, Nixon M, Miguelez-Crespo A, Murphy L, Fawkes A, et al. Carbonyl reductase 1 amplifies glucocorticoid action in adipose tissue and impairs glucose tolerance in lean mice. Mol Metab (2021) 48:101225. doi: 10.1016/j.molmet.2021.101225

CrossRef Full Text | Google Scholar

25. Djebali S, Davis CA, Merkel A, Dobin A, Lassmann T, Mortazavi A, et al. Landscape of transcription in human cells. Nature (2012) 489.7414:101–108. doi: 10.1038/nature11233

CrossRef Full Text | Google Scholar

26. Matys V, Fricke E, Geffers R, Gößling E, Haubrock M, Hehl R, et al. TRANSFAC ® : transcriptional regulation, from patterns to profiles. Nucleic Acids Res (2003) 31.1:374–8. doi: 10.1093/nar/gkg108

CrossRef Full Text | Google Scholar

27. Lachmann A, Xu H, Krishnan J, Berger SI, Mazloom AR, and Ma’ayan A ChEA: transcription factor regulation inferred from integrating genome wide ChIP-X experiments. Bioinformatics (2010) 26.19:2438–44. doi: 10.1093/bioinformatics/btq466

CrossRef Full Text | Google Scholar

28. Virtanen P, Gommers R, Oliphant TE, Haberland M, Reddy T, Cournapeau D, et al. SciPy 1.0: fundamental algorithms for scientific computing in Python. Nat Methods (2020) 17.3:261–72. doi: 10.1038/s41592-019-0686-2

CrossRef Full Text | Google Scholar

29. Waskom ML. seaborn: statistical data visualization. J Open Source Softw (2021) 6.60:3021. doi: 10.21105/joss.03021

CrossRef Full Text | Google Scholar

30. Pruim RJ, Welch RP, Sanna S, Teslovich TM, Chines PS, Gliedt TP, et al. LocusZoom: regional visualization of genome-wide association scan results. Bioinformatics (2010) 26.18:2336–7. doi: 10.1093/bioinformatics/btq419

CrossRef Full Text | Google Scholar

31. Rahimi L, Rajpal A, Ismail-Beigi F. Glucocorticoid-induced fatty liver disease. Diab Metab Syndr Obesity: Targets Ther (2020) 13:1133–45. doi: 10.2147/DMSO.S247379

CrossRef Full Text | Google Scholar

32. Præstholm SM, Correia CM, Grøntved L. Multifaceted control of GR signaling and its impact on hepatic transcriptional networks and metabolism. English. Front Endocrinol (2020) 11. doi: 10.3389/fendo.2020.572981

CrossRef Full Text | Google Scholar

33. Pavlatou MG, Vickers KC, Varma S, Malek R, Sampson M, Remaley AT, et al. Circulating cortisol-associated signature of glucocorticoid-related gene expression in subcutaneous fat of obese subjects. Obesity (2013) 21.5:960–7. doi: 10.1002/oby.20073

CrossRef Full Text | Google Scholar

34. Lee RA, Harris CA, Wang J-C. Glucocorticoid receptor and adipocyte biology. Nucl receptor Res (2018) 5. doi: 10.32527/2018/101373

CrossRef Full Text | Google Scholar

35. DeLigio JT, Lin G, Chalfant CE, Park MA. Splice variants of cytosolic polyadenylation element–binding protein 2 (CPEB2) differentially regulate pathways linked to cancer metastasis. J Biol Chem (2017) 292.43:17909–18. doi: 10.1074/jbc.M117.810127

CrossRef Full Text | Google Scholar

36. Etzerodt A, Moestrup S. CD163 and inflammation: biological, diagnostic, and therapeutic aspects. Antioxid Redox Signaling (2013) 18.17:2352–63. doi: 10.1089/ars.2012.4834

CrossRef Full Text | Google Scholar

37. Gao G, Xie A, Huang S.-C, Zhou A, Zhang J, Herman AM, et al. The role of RBM25/LUC7L3 in abnormal cardiac sodium channel splicing regulation in human heart failure. Circulation (2011) 124.10:1124–31. doi: 10.1161/CIRCULATIONAHA.111.044495

CrossRef Full Text | Google Scholar

38. Li Y, Ito M, Sun S, Chida T, Nakashima K, Suzuki T, et al. LUC7L3/CROP inhibits replication of hepatitis B virus via suppressing enhancer II/basal core promoter activity. Sci Rep (2016) 6.1:36741. doi: 10.1038/srep36741

CrossRef Full Text | Google Scholar

39. Arshad M, Ye Z, Gu X, Wong CK, Liu Y, Li D, et al. RNF13, a RING Finger Protein, Mediates Endoplasmic Reticulum Stress induced Apoptosis through the Inositol-requiring Enzyme (IRE1α)/c-Jun NH2-terminal Kinase Pathway. J Biol Chem (2013) 288.12:8726–36. doi: 10.1074/jbc.M112.368829

CrossRef Full Text | Google Scholar

40. Harada H, Kitagawa M, Tanaka N, Yamamoto H, Harada K, Ishihara M, et al. Anti-oncogenic and oncogenic potentials of interferon regulatory factors-1 and -2. Science (1993) 259.5097:971–4. doi: 10.1126/science.8438157

CrossRef Full Text | Google Scholar

41. Chapin WJ, Lenkala D, Mai Y, Mao Y, White SR, Huang RS, et al. Peripheral blood IRF1 expression as a marker for glucocorticoid sensitivity. Pharmacogenetics Genomics (2015) 25.3:126–33. doi: 10.1097/FPC.0000000000000116

CrossRef Full Text | Google Scholar

42. Zhang H, Reilly MP. LIPA variants in genome-wide association studies of coronary artery diseases. Arteriosclerosis Thrombosis Vasc Biol (2017) 37.6:1015–7. doi: 10.1161/ATVBAHA.117.309344

CrossRef Full Text | Google Scholar

43. Shang M-M, Talukdar Husain A, Hofmann Jennifer J, Niaudet Colin Asl Hassan Foroughi, Jain Rajeev K, et al. Lim domain binding 2. Arteriosclerosis Thrombosis Vasc Biol (2014) 34.9:2068–77. doi: 10.1161/ATVBAHA.113.302709

CrossRef Full Text | Google Scholar

44. Bujalska IJ, Quinkler M, Tomlinson JW, Montague CT, Smith DM, and Stewart PM Expression profiling of 11beta-hydroxysteroid dehydrogenase type-1 and glucocorticoid target genes in subcutaneous and omental human preadipocytes. J Mol Endocrinol (2006) 37.2:327–40. doi: 10.1677/jme.1.02048

CrossRef Full Text | Google Scholar

45. Lightman SL, Birnie MT, Conway-Campbell BL. Dynamics of ACTH and cortisol secretion and implications for disease. Endocrine Rev (2020) 41.3:470–90. doi: 10.1210/endrev/bnaa002

CrossRef Full Text | Google Scholar

46. Finnerty CC, Mabvuure NT, Ali A, Kozar RA, Herndon DN. The surgically induced stress response. JPEN. J parenteral enteral Nutr (2013) 37.50:21S–9S. doi: 10.1177/0148607113496117

CrossRef Full Text | Google Scholar

47. Pierce BL, Tong L, Chen LS, Rahaman R, Argos M, Jasmine F, et al. Mediation analysis demonstrates that trans-eQTLs are often explained by cis-mediation: A genome-wide analysis among 1,800 South Asians. PloS Genet (2014) 10.12:e1004818. doi: 10.1371/journal.pgen.1004818

CrossRef Full Text | Google Scholar

48. Mangan S, Alon U. Structure and function of the feed-forward loop network motif. Proc Natl Acad Sci (2003) 100.21:11980–5. doi: 10.1073/pnas.2133841100

CrossRef Full Text | Google Scholar

49. Hu X, Li W-P, Meng C, Ivashkiv LB. Inhibition of IFN-γ Signaling by glucocorticoids. J Immunol (2003) 170.9:4833–9. doi: 10.4049/jimmunol.170.9.4833

CrossRef Full Text | Google Scholar

50. Flammer JR, Dobrovolna J, Kennedy MA, Chinenov Y, Glass CK, Ivashkiv LB, et al. The type I interferon signaling pathway is a target for glucocorticoid inhibition. Mol Cell Biol (2010) 30.19:4564–74. doi: 10.1128/MCB.00146-10

CrossRef Full Text | Google Scholar

51. Elowitz MB, Levine AJ, Siggia ED, Swain PS. Stochastic gene expression in a single cell. Science (2002) 297.5584:1183–6. doi: 10.1126/science.1070919

CrossRef Full Text | Google Scholar

Keywords: cortisol, corticosteroid-binding globulin, gene networks, systems genetics, causal inference

Citation: Bankier S, Wang L, Crawford A, Morgan RA, Ruusalepp A, Andrew R, Björkegren JLM, Walker BR and Michoel T (2023) Plasma cortisol-linked gene networks in hepatic and adipose tissues implicate corticosteroid-binding globulin in modulating tissue glucocorticoid action and cardiovascular risk. Front. Endocrinol. 14:1186252. doi: 10.3389/fendo.2023.1186252

Received: 15 March 2023; Accepted: 14 July 2023;
Published: 06 September 2023.

Edited by:

Jeff M. P. Holly, University of Bristol, United Kingdom

Reviewed by:

Eric Bonnet, Commissariat à l’Energie Atomique et aux Energies Alternatives (CEA), France
Vanessa Vermeirssen, Ghent University, Belgium

Copyright © 2023 Bankier, Wang, Crawford, Morgan, Ruusalepp, Andrew, Björkegren, Walker and Michoel. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Sean Bankier,

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.