Abstract
Acute Respiratory Distress Syndrome (ARDS) is a severe and heterogeneous critical illness characterized by systemic inflammation, lung injury, and profound hypoxemia. To investigate the temporal evolution of molecular features underlying ARDS heterogeneity, we applied advanced proteomics and redox proteomics to matched plasma and bronchoalveolar lavage (BAL) fluid samples collected longitudinally from 16 intensive care unit (ICU) ARDS patients during hospitalization. Exploratory, data-driven hierarchical clustering (Ward method) identified three distinct molecular patterns across patients represented as Groups A, B, and C. This framework was associated with illness severity at study enrollment (Group A profiling patients with more severe illness at enrollment), demonstrated temporal stability across sampling timepoints, and revealed molecular features associated with clinical improvement during hospitalization. Key pathways distinguishing the molecular patterns and consistent with prior findings included the production and detoxification of reactive oxygen species (ROS), Liver X receptor–Retinoid X receptor (LXR/RXR) activation and 24-dehydrocholesterol reductase (DHCR24) signaling, interleukin-12 (IL-12) signaling and production in macrophages, and neutrophil degranulation. Although plasma proteomic profiles were generally consistent with findings in BAL fluid, BAL fluid data were more mechanistically informative and enabled clearer and more consistent interrogation of ARDS molecular heterogeneity. The results highlight the potential value of lung–focused, temporal studies to improve patient stratification and guide future therapeutic strategies. However, the modest cohort size and exploratory nature of this study necessitate cautious interpretation of pathway-level inferences. Future longitudinal studies in larger, independent ARDS cohorts will be required to validate these molecular groups and assess their clinical relevance.
Data availability
Proteomic and redox proteomic data generated from this study and used for analyses have been made publicly available. The mass spectrometry data have been deposited to the ProteomeXchange Consortium via the PRIDE partner repository with the dataset identifier PXD060437 and 10.6019/PXD060437.
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Acknowledgements
We would like to acknowledge the Wake Forest Baptist Comprehensive Cancer Center (NIH/NCI P30 CA12197) support for the Proteomics and Metabolomics Shared Resource. We are also grateful for the Wake Forest University School of Medicine support for the Critical Illness, Injury and Research Recovery Research Center and the Center for Redox Biology and Medicine.
Funding
We would like to acknowledge the support provided by the R21/R33 GM144947 grant (CMF and DCF) from the National Institute of General Medical Sciences and by the Proteomics and Metabolomics Shared Resource of the Wake Forest University School of Medicine and Wake Forest Baptist Comprehensive Cancer Center (NIH/NCI P30 CA12197). We are also grateful for the Wake Forest University School of Medicine support for the Critical Illness, Injury and Research Recovery Research Center and the Center for Redox Biology and Medicine. DCF receives funding from NIH, Quantum Leap Healthcare Collaborative for projects unrelated to this work and reports payments as consultant by Novartis and InflaRx, unrelated to this work.
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DCF, KG, and CMF conceptualized and designed the study. DCF, PEM and KG oversaw patient selection and biospecimen collection. TF, KS, HW, and JL analyzed the biospecimens. TF, KS, and SS analyzed the data and drafted the manuscript. DCF, TF, AWT, KS, SS, KG and CMF edited the manuscript.
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Forshaw, T.E., Shukla, K., Wu, H. et al. A proteomics and redox proteomics approach to understanding ARDS heterogeneity. Sci Rep (2026). https://doi.org/10.1038/s41598-026-35606-2
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DOI: https://doi.org/10.1038/s41598-026-35606-2
