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Archive for the ‘Nutrition’ Category

Protein Malnutrition

Reporter and Curator: Dr. Sudipta Saha, Ph.D.

A large part of  the world’s population is undernourished by the standards of Western Europe and North America. Scientists and nonscientists alike recognize as one of the major challenges of our time the problem of how to ensure that the production and distribution of food keep pace with the increasing number of mouths to be fed. In the world as a whole the most widespread and serious dietary deficiency is that of protein. This fact emerges clearly from the reports of the expert committees of WHO and FAO (World Health Organization, 1951, 1953). Nevertheless, many protein chemists, even those associated with medical research, may not realize the extent and severity of protein malnutrition, because it occurs chiefly in the technically underdeveloped countries far from where they work.

Dietary histories and response to treatment point to deficiency of total protein as the primary cause of the clinical syndrome kwashiorkor. The level of calorie intake has an important influence on the pattern of the disease. Deficiency of one or more specific amino acids, or amino acid imbalances in the diet, may perhaps be responsible for some of the symptoms and signs, particularly those whose incidence varies from one part of the world to another. All these variations on a theme are covered by the general term protein malnutrition. The onset is often precipitated by the added burden of diarrhea, infection, and parasitic infestation. The nutritional state influences the resistance to infection, and conversely the presence of an infection affects the state of nutrition. A further contributory factor may be the psychological upheaval in the child when the next baby in the family is born. At the root of all these causes lie poverty, ignorance, and disruption of the family life.

The planning of preventive measures cannot be effective unless it is based on some knowledge of the magnitude of the problem to be tackled. At a very rough estimate, in some countries perhaps 10% of the children suffer from severe protein malnutrition at some age between birth and 4 years. The marginal deficiency states must be much more common, Clinical signs and biochemical changes are of little value in diagnosing the early case; a deficit in body weight still seems to be the best criterion. Prevention ideally would be by greater production and consumption of animal protein, and by the increased use of skim milk and of surplus fish at present often wasted. However, animal protein is likely to remain scarce and expensive. Plant sources are being investigated with a view to encouraging not only domestic production, but also the production on an industrial scale of cheap foodstuffs rich in protein. A preventive program that is nutritionally sound may fail if account is not taken of local food habits, traditions, and customs. Protein requirements are affected by the quality of protein, the intake of calories, and by the state of the body (growth, the presence of disease, etc.). The maintenance requirement and the amount required for growth in children can be estimated, but the requirement for health is still unknown. For the time being, the allowances of protein recommended for people in the world as a whole are based empirically on the known physiological requirement with an arbitrarily added wide margin of safety.

The absorption of nitrogen is remarkably efficient even in severely malnourished infants. In general the nitrogen of plant proteins is less well absorbed than that of milk. When a baby receives a diet in which the protein is derived entirely from vegetabIe sources, incomplete absorption of nitrogen may play a significant part in the production of protein malnutrition. The malnourished baby who responds to treatment is able to retain and utilize nitrogen very efficiently; there is no evidence of any impairment in the mechanisms of protein synthesis. It is possible, however, that these mechanisms may be irreversibly damaged in babies who die, and that this may be the cause of death. The level of calorie intake has an important influence on the efficiency of utilization of nitrogen. An adequate calorie intake promotes conservation of nitrogen in the body as a whole when supplies of protein are short, but this protective effect may not be exerted equally in all organs. In this way the level of calorie intake may modify the pattern of protein depletion. A greater than normal calorie intake is needed for the restoration of depleted protein stores.

The discussion of protein metabolism in protein malnutrition has been purposely limited to a narrow field-to studies made on man, and to the few animal experiments that have a direct bearing on those studies. For technical reasons most of the work discussed relates to plasma proteins. There is a conflict of evidence between results obtained in man and animals about the effect of protein depletion or a low protein diet on the rate of catabolism of plasma albumin. It is of great importance to settle this point. A priori there seems no reason why the rate of protein catabolism should be affected by nutritional state. Preliminary studies with radioactive methionine in infants suggest, as working hypotheses, that in protein malnutrition there may be an increase in the reutilization of amino acids liberated by tissue catabolism, and an apparent concentration of protein synthesis in the more essential organs at the expense of the less essential. There is some experimental support for both these ideas, but further work is badly needed. The concept of protein stores or reserve protein is based entirely on dynamic and not on chemical considerations. It is suggested that the essential difference between a “labile” and a “fixed” protein is a difference in turnover rate. An attempt is made to show that the changes produced by protein depletion in the protein content of organs such as liver and muscle are a necessary consequence of the metabolic characteristics of proteins in those organs. There may be no need to invoke the help of homeostatic or compensatory regulations to explain the changes found in protein depletion.

Aging and growth are processes during which some metabolic adjustments must take place. It is believed that it may be better to regard the changes which are found in protein malnutrition in a similar light: as evidence of an alteration in functional pattern, rather than of damage or disease. Protein malnutrition in man has two aspects-a practical and a theoretical one. From the practical point of view it is an extremely common disease with a high mortality, and there is every reason to believe that it will become more common unless urgent preventive measures are taken. Theoretically it raises many questions that are of interest in relation to other branches of medicine and biochemistry. It is believed that the two aspects are linked, and that progress towards prevention is still impeded by our lack of basic knowledge as well as by our failure to apply what is already known. In protein malnutrition there is no sharp line between health and disease. The simple concept of specific deficiency diseases that grew from the discovery of vitamins is not applicable. We have to go back instead to the ideas of an earlier era, when nutrition was regarded as a branch of physiology, concerned with the functions, fate, and metabolic interrelationships of the major nutrients.

It is a characteristic of protein metabolism that nitrogen balance can be maintained at many different levels of protein intake. These different steady states are achieved by adjustments of the amount and distribution of proteins in the body as a whole, in organs, and in cells. It is believed that these changes in amount and distribution of proteins must result in alterations of metabolic pattern, with a gradation of change from an optimum, which cannot be defined, to a state of irreversible breakdown incompatible with life. In the intermediate stages function is modified and efficiency perhaps impaired. It seems possible that variations in diet, and particularly in the amount and quality of the protein, may underlie many of the differences in incidence and symptomatology of disease which are gradually being uncovered in different parts of the world.

Source References:

http://www.sciencedirect.com/science/article/pii/S0065323308603095#

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Benefits of Functional Foods in Nutrient Imbalance of Vulnerable Populations

Reporter and Curator: Dr. Sudipta Saha, Ph.D.

There are clear distinctions between a food and a drug. Nutraceuticals, however, occupy a place between the two. Nutraceuticals are naturally derived phytochemicals with potential health benefits and without the characteristics of being essential nutrients. Foods that contain these non-essential substances with potential health benefits may qualify as “functional foods.” As defined by the Food and Nutrition Board of the National Academy of Sciences, the term functional food refers to foods that provide health benefits beyond basic nutrition. Examples of these are

  • psyllium seeds (soluble fiber),
  • soy foods (isoflavones),
  • cranberry juice (proanthocyanidins),
  • purple grape juice (resveratrol),
  • tomatoes (lycopene), and
  • green tea (catechins).

The bioactive components of functional foods:

  • flavonols,
  • monomeric and polymeric flavan-3-ols,
  • highly coloured anthocyanins, and
  • phenolic acids

may be increased in or added to traditional foods. An example is a genetically modified tomato high in lycopene, which has potent antioxidant capabilities.

The risk of nutrient imbalance is highest in vulnerable populations unable to access essential or conditionally essential nutrients. To a large extent, the

  • very young and the
  • frail elderly

are the select groups who might benefit most from alleviating this risk. The lack of adequate nutrition may be due to seasonal and unexpected losses of agricultural produce; however, poverty is a factor on a global scale as a result of growing economic disparities. The question then becomes what role functional foods offer to improve recognized population nutritional deficiencies. The range of work being done on functional foods is impressive, from

  • modified oils that contain heart-healthy ω-3 fatty acids to
  • cassava plants developed with an increased protein content to help counter malnutrition in developing nations.

However, the nutraceutical industry has responded to and relies on the untested expectations of the healthiest members of the world’s population rather than its more vulnerable ones. Due largely to economic causes, those in need are less likely to receive the benefits of nutraceuticals from whole foods or from manufactured foods or supplements. This is particularly striking where the source is locally available and extracted for commerce but is unaffordable or unavailable to the native population.

The rapid advances in biotechnology and functional foods confront us with a need to address the benefits of these with regard to improving health and managing or decreasing disease risks. Conventional dietary recommendations have focused on the consumption of fruits, vegetables, legumes, and whole grains, a decreased sugar intake, and an emphasis on plant oils, recommendations that have unproved benefits for the prevention of chronic diseases and that have complexities involving individual, environmental, and genetic influences.

Although the potential benefits of phytochemicals could have an impact on health status for vulnerable populations, the recommendations focused on plant foods do not address the primary concerns of the undernutrition associated with a poor quality of protein intake. Taken individually, plant sources do not provide a balanced amino acid profile necessary for protein synthesis, being deficient in lysine and/or methionine. Animal sources of protein, specifically meat and fish, also provide essential fatty acids not found in plant sources of protein and that may be otherwise limited. In addition, plants may contain antinutritional factors (wheat, cassava roots, cabbages, soy beans), and plant-based diets may be deficient in important essential nutrients.

Programs must focus on the sustainable production and local processing of indigenous products that can be used by needy populations to improve their nutritional intake and enhance economic stability. In addition, dietary recommendations must not exclude important sources of nutrition for more vulnerable populations by focusing primarily on plant-based sources of food, decreasing saturated fat, and de-emphasizing the importance of high-value biologic protein. The global economic crisis has touched the lives of 80% of the population in most developing countries with a threat to the development of a generation of children (approximately 250 million) who are most vulnerable in the first 2 years of life. An investment in nutrition in this circumstance has a high value, and the use of complementary food supplements to increase a meal’s nutrient content is warranted.

A recent proposal has concluded there are health benefits for foods and food constituents put together in a synergic diet pattern, suggesting that the interrelation between constituents within whole foods is significant, and has recommended dietary variety and the selection of nutrient-rich foods. Providing vulnerable populations with an adequate supply of whole foods should take precedence over the recommendation of food products in supplying not only essential macro- and micronutrients and energy but also phytochemicals whose value to the human diet is still to be determined.

Source References:

http://www.sciencedirect.com/science/article/pii/S0899900711003133

 

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How Might Sleep Apnea Lead to Serious Health Concerns like Cardiac and Cancer?

Author: Larry H Bernstein, MD, FCAP

3.3.16

3.3.16   How Might Sleep Apnea Lead to Serious Health Concerns like Cardiac and Cancer?, Volume 2 (Volume Two: Latest in Genomics Methodologies for Therapeutics: Gene Editing, NGS and BioInformatics, Simulations and the Genome Ontology), Part 2: CRISPR for Gene Editing and DNA Repair

UPDATED on 7/23/2019

Israel-led research team develops AI-based model to detect sleep apnea | The Times of Israel

https://www.timesofisrael.com/israel-led-research-team-develops-ai-based-model-to-detect-sleep-apnea/?utm_source=dlvr.it

What is the link between sleep apnea and cardiovascular disease and is the treatment of obstructive sleep apnea (OSA) by continuous positive airway pressure in patients (CPAP) with heart failure to improve left ventricular systolic function sufficient?  There are statistics incicating the benefit of CPAP and improvement of LVSF in those patients on CPAP with CHF.  But that observation does not get at why the patients benefit, or whether the OSA is sufficient.  Don’t expect a randomized clinical trial of any design to be brought to bear on the subject, considering the ethical issues involved.  We’ll return to that in a moment.
In a recent study researchers in Spain followed thousands of patients at sleep clinics and found that those with the most severe forms of sleep apnea had a 65 percent greater risk of developing cancer of any kind. The second study, of about 1,500 government workers in Wisconsin, showed that those with the most disordered sleep had five times the rate of dying from cancer as people without the sleep disorder (apnea not specified). Both research teams only looked at cancer diagnoses and outcomes in general.  If I lump the two studies, assuming that all patients with the most disordered sleep had OSA and were on CPAP, what does this tell us?  The heart and lung function together as a cardiopulmonary oxygenation unit!  A problem disrupting oxygenation, such as autonomically controlled sleep disruption or, oronasal obstruction (ASSOCIATED WITH SNORING), would be expected to have an effect on alertness during the day, predisposition to CHF from strain on the CP circulation as well as ventilatory impairment and peripheral oxygenation.  It appears that an association with ANY cancer, unspecified, is a long reach.
In both studies the researchers ruled out the possibility that the usual risk factors for cancer, like
  1. age
  2. smoking
  3. alcohol use
  4. physical activity
  5. weight
The association between cancer and disordered breathing at night remained
  • even after they adjusted for confounding variables.
This led to the conclusion that cancer might be linked to (intermittent) lack of oxygen supply interrupting aerobic cell activity over long periods of time.  The conclusion is drawn that from two associations
  • the research on positive outcome from CPAP in OSA and
  • a possible link between breathing and cardiac and cancer clearly
demonstrates the importance of regular breathing exercises (other wise known as ‘Pranayama’ in India) as part of our every day life.
This answers the first observation I posed. That is, the use of CPAP, while enormously important, is not sufficient.  Regular breathing exercises would seem to be helpful, although not a standard part of current treatment. This would be especially important if the movement of the abdominal muscles and diaphragm were synchronized with the expansion of the nthorax for maximum air flow.  This observation is familiar from working with a certified exercise physiologist.   The other part of this is an optimum time for walking and carrying out basic muscle and flexibility exercises several times a week, which has been shown repeatedly by studies on health benefits.
It is not my place to raise some questions about the way the studies were carried out.  The patients who have sleep apnea would be expected to have an increased body mass index (BMI), and while not sarcopenic, more likely to have excess body fat, abdominal distribution in males, and hip distribution in females, amd more importantly, unseen fat in the abdominal peritoneum.  This is related to type 2 diabetes with a metabolic syndrome, a separate indicator of CVD risk.   The metabolic syndrome involves TNF-alpha (once also known as cachexin), IL-1, IL-6, C-reactive protein, and in the case of fat signaling, adipokines, as well as insulin resistance and, as a result, some counter-regulatory secretion of glucocorticosteroids.  This metabolic picture would result in the following:
  1. impaired glucose utilization
  2. some excess and uncompensated gluconeogenesis
  3. the impaired lactate reentry at the end of glycolysis
  4. an effect on allosteric PFK
Features 1-4 look like what Warburg called a Pasteur Effect, not at the clellular level, but in the whole individual.   While obesity and type 2 diabetes are occuring in the young and adolescent population, the consequences might not be seen until years later.  The consequences could be in a middle aged person falling asleep at a meeting, or a series of automabile accidents related to falling asleep at the wheel.
At a time that clinical laboratory measurements are so accurate, and
  • the associations between type 2 diabetes,
  • measurement of wt/ht^2,
  • arm strength,
  • skin fold thickness,

are common measures of fitness, they don’t appear to have any place in these studies. If that is the case, then how is it possible to make sense of a relationship between SEVERITY of sleep disturbance and health outcome.

English: The Cycle of Obstructive Sleep Apnea ...

English: The Cycle of Obstructive Sleep Apnea – OSA (Photo credit: Wikipedia)

English: The graph shows the correlation betwe...

English: The graph shows the correlation between body mass index (BMI) and percent body fat (%BF) for men in NCHS’ NHANES III 1994 data. The body fat percent shown uses the method from Romero-Corral et al. to convert NHANES BIA to %BF (June 2008). “Accuracy of body mass index in diagnosing obesity in the adult general population”. International Journal of Obesity 32 (6) : 959–956. DOI:10.1038/ijo.2008.11. PMID 18283284. (Photo credit: Wikipedia)

English: Body mass index, BMI, body size, body...

English: Body mass index, BMI, body size, body weight, mortality Italiano: indice di massa corporea, IMC, altezza corporea, peso corporeo, mortalità (Photo credit: Wikipedia)

Italiano: biometria, epidemiologia, rischio, p...

Italiano: biometria, epidemiologia, rischio, peso corporeo umano, mortalità, indice di massa corporea, IMC, body mass index, BMI, prospective studies collaboration (Photo credit: Wikipedia)

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Accurate Identification and Treatment of Emergent Cardiac Events

Accurate Identification and Treatment of Emergent Cardiac Events

Author: Larry H Bernstein, MD, FCAP
In the immediately preceding article, I discussed the difficulties in predicting long-term safety for developing drugs, and the cost of failure in early identification.

It is not the same scale of issue as for the patient emergently presenting to the ED. Despite enormous efforts to reduce the development of and the complications of acute ischemia related cardiac events, the accurate diagnosis of the patient presenting to the emergency room is still, as always, reliant on clinical history, physical examination, effective use of the laboratory, and increasingly helpful imaging technology. The main issue that we have a consensus agreement that PLAQUE RUPTURE is not the only basis for a cardiac ischemic event. The introduction of  high sensitivity troponin tests has made it no less difficult after throwing out the receiver-operator characteristic curve (ROC) and assuming that any amount of cardiac troponin released from the heart is pathognomonic of an acute ischemic event.  This has resulted in a consensus agreement that

  • ctn measurement at a coefficient of variant (CV) measurement in excess of 2 Std dev of the upper limit of normal is a “red flag”
  • signaling AMI? or other cardiomyopathic disorder

This is the catch.  The ROC curve established AMI in ctn(s) that were accurate for NSTEMI – (and probably not needed with STEMI or new Q-wave, not previously seen) –

  1. ST-depression
  2. T-wave inversion
    • in the presence of other findings
    • suspicious for AMI

Wouldn’t it be nice if it was like seeing a robin on your lawn after a harsh winter?  Life isn’t like that.  When acute illness hits the patient may well present with ambiguous findings.   We are accustomed to relying on

  1. clinical history
  2. family history
  3. co-morbidities, eg., diabetes, obesity, limited activity?, diet?
    1. stroke and/or peripheral vascular disease
    2. hypertension and/or renal vascular disease
    3. aortic atherosclerosis or valvular heart disease
      • these are evidence, and they make up syndromic classes
  4. Electrocardiogram – 12 lead EKG (as above)
  5. Laboratory tests
    1. isoenzyme MB of creatine kinase (CK)… which declines after 12-18 hours
    2. isoenzyme-1 of LD if the time of appearance is > day-1 after initial symptoms (no longer used)
    3. cardiac troponin cTnI or cTnT
      • genome testing
      • advanced analysis of EKG

This may result in more consults for cardiologists, but it lays the ground for better evaluation of the patient, in the long run.  When you look at the amount of information that has to be presented to the physician, there is serious need for improvement in the electronic medical record to benefit the patient and the caregivers.  Recently, we have a publication on a new test that has been evaluated, closely related to the C-reactive protein (CRP), a test that has generated much discussion over the effect of treatment for patients who have elevated CRP in the absence of increased LDL cholesterol, diabetes, or obvious atherosclerotic comorbidities.  The serum pentraxin 3 test is related to cell mediated immunity, and an evaluation has been published in the Journal of Investigative Medicine.

Journal of Investigative Medicine Feb 2013; 61 (2): 278–285.
http://dx.doi.org/10.231/JIM.0b013e31827c2971

Serum Pentraxin 3 Levels Are Associated With the Complexity and Severity of Coronary Artery Disease in Patients With Stable Angina Pectoris
Karakas, Mehmet Fatih MD*; Buyukkaya, Eyup MD*; Kurt, Mustafa MD*; et al.
From the Departments of Cardiology and,Clinical Biochemistry, Mustafa Kemal University, Tayfur Ata Sokmen Medical School, Hatay, Turkey.
Reprints: Mehmet Fatih Karakas, MD, Antakya 31005, Turkey. E-mail: mfkarakas@hotmail.com.

Abstract
Background: Atherosclerosis is a complex inflammatory process. Although pentraxin 3 (PTX-3), a newly identified inflammatory marker, was associated with adverse outcomes in stable angina pectoris,

  • an association between PTX-3 and the complexity of coronary artery disease (CAD) has not been reported.

The aim of the present study is to assess

  • the association between the level of PTX-3 and
  • the complexity and severity of CAD assessed with
  • SYNTAX and Gensini scores in patients with stable angina pectoris.

Methods: The study population is 2 groups:

  • 161 patients with anginal symptoms and evidence of ischemia
    • who underwent coronary angiography and
  • 50 age- and sex- matched control subjects without evidence of ischemia .

Patients were grouped into 3 groups according to the complexity and severity of coronary lesions

  • assessed by the SYNTAX score (30 patients with a SYNTAX score of 0 were excluded).

Serum PTX-3 and high-sensitivity C-reactive protein (hs-CRP) levels were measured in both groups.

Results: The PTX-3 levels demonstrated

  • an increase from low to high SYNTAX groups (r = 0.72, P < 0.001).

Whereas the low SYNTAX group had statistically significantly higher PTX-3 levels when compared with the control group (0.50 ± 0.01 vs 0.24 ± 0.01 ng/mL, P < 0.001),

  • the hs-CRP levels were not different (0.81 ± 0.42 vs 0.86 ± 0.53 mg/dL, P = 0.96).
  • but  the intermediate SYNTAX group had higher hs-CRP levels compared with the low SYNTAX group (1.3 ± 0.66 vs 0.86 ± 0.53 mg/dL, P = 0.002).

Serum PTX-3 levels and hs-CRP levels were both correlated with the SYNTAX scores and Gensini scores (for SYNTAX: r = 0.87 [P < 0.001] and r = 0.36 [P = 0.01]; for Gensini: r = 0.75 [P < 0.001] and r = 0.27 [P = 0.002], respectively), and

  • according to the results of univariate and multivariate analyses, for “intermediate and high” SYNTAX scores, age, diabetes mellitus, low-density lipoprotein cholesterol, hs-CRP, and PTX-3
  • were found to be independent predictors, whereas
  • for the presence of “high” SYNTAX score only PTX-3 was found to be an independent predictor.
  • The receiver operating characteristic curve analysis further revealed that the PTX-3 level was
    • a strong indicator of high SYNTAX score with an area under the curve of 0.91 (95% confidence interval, 0.86–0.96).

Conclusions: Pentraxin 3, a novel inflammatory marker, was more tightly associated with the complexity and severity of CAD than hs-CRP and

    • it was found to be an independent predictor for high SYNTAX score.

The association between atherosclerosis and inflammation has been more understood during recent years. Currently, atherosclerosis is considered as a complex inflammatory process in which

    • leukocytes and inflammatory markers are involved.1

Several inflammatory markers

  1.  high-sensitivity C-reactive protein (hs-CRP),
  2. fibrinogen, and
  3. complement C3…. are associated with cardiovascular events.1–5

Pentraxin 3 (PTX-3), that resembles CRP both in structure and function,1 is produced both by

  • hematopoietic cells such as macrophages, dendritic cells, neutrophils, and by
  • nonhematopoietic cells such as fibroblasts and vascular endothelial cells.2

Plasma PTX-3 levels may be elevated in patients with

  1. vasculitis,6
  2. acute myocardial infarction,7,8 and
  3. systemic inflammation or sepsis,9
  4. psoriasis,
  5. unstable angina pectoris, and
  6. heart failure.10–13

Dubin et al14 reported that PTX-3 levels are associated with with adverse outcomes in stable angina pectoris (SAP). Despite reports about the association of PTX-3 and coronary artery disease (CAD),

an association between the level of PTX-3 and the complexity and severity of CAD is not established.15,16 Thus, the aim of this study was

  • to assess the association between the level of PTX-3 and the complexity and severity of CAD assessed with SYNTAX and Gensini scores in SAP patients.

MATERIALS AND METHODS

Of 211 patients were prospectively recruited,  161 SAP patients with evidence of ischemia (positive treadmill or myocardial perfusion scan) underwent coronary angiography for suspected CAD, and 50 age- and sex- matched outpatient subjects with a negative treadmill or myocardial perfusion scan test were taken as the control group. Patients were excluded if they had

  •  acute coronary syndrome
  • history of previous myocardial infarction;
  • coronary artery bypass grafting or percutaneous coronary intervention;
  • secondary hypertension (HT);
  • renal failure;
  • hepatic failure;
  • chronic obstructive lung disease and/or
  • manifest heart disease, such as
    • cardiac failure (left ventricular ejection fraction <50%),
    • atrial fibrillation, and
    • moderate to severe cardiac valve disease; and
    • SYNTAX score of zero

Similarly, patients were excluded with

  • infection,
  • acute stress, or chronic systemic inflammatory disease and
  • those who had been receiving medications affecting the number of leukocytes .

Thirty patients were excluded from the study because the coronary angiograms revealed normal coronary arteries (SYNTAX score of 0). All the participants included in the study were informed about the study, and they voluntarily consented to participate. The Serum PTX-3 level was measured on blood samples collected after 12-hour fast just prior to coronary angiography and kept at −80°C until the assays were performed. PTX3 was measured by enzyme immunoassay (EIA) using quantitative kit (human PTX-3/TSG-14 immunoassay, DPTX30; R&D Systems, Inc, Minneapolis, MN). The intra-assay and interassay coefficients of variation ranged from 3.8% to 4.4% and 4.1% to 6.1%, respectively (minimum detectable concentration, 0.025 ng/mL). High-sensitivity CRP was measured in serum by EIA (Immage hs-CRP EIA Kit; Beckman Coulter Inc, Brea, CA). Transthoracic echocardiography was performed, and biplane Simpson’s ejection fraction (%) was calculated before coronary angiography. Hypertension was defined as having at least 2 blood pressure measurements greater than 140/90 mm Hg or using antihypertensive drugs, whereas diabetes mellitus (DM) was defined as having at least 2 fasting blood sugar measurements greater than 126 mg/dL or using antidiabetic drugs. Smoking was categorized into current smokers and nonsmokers. Nonsmokers included ex-smokers who had quit smoking for at least 6 months before the study. Body mass index (BMI) values were calculated based on the height and weight of each patient. Medications used before the coronary angiography were noted. The study was approved by the local ethics committee.
SYNTAX and Gensini Scores
To grade the complexity of CAD, the SYNTAX score was used. Each coronary lesion with a stenosis diameter of 50% or greater in vessels of 1.5 mm or greater was scored. Parameters used in the SYNTAX scoring are shown in Table 1. The latest online updated version (2.11) was used in the calculation of the SYNTAX scores (www.syntaxscore.com).17 The SYNTAX score was classified as follows:

  1. low SYNTAX score (≤22),
  2. intermediate SYNTAX score (23–32)
  3. high SYNTAX score (≥33).

Table 1   http://images.journals.lww.com/jinvestigativemed/LargeThumb.00042871-201302000-00007.TT1.jpeg

The severity of CAD was determined by the Gensini score, which

  • measures the extent of coronary stenosis according to degree and location.18

In the Gensini scoring system,

  • larger segments are more heavily weighted ranging from 0.5 to 5.0
    • left main coronary artery × 5;
    • proximal segment of the left anterior descending coronary artery [LAD] × 2.5;
    • proximal segment of the circumflex artery × 2.5;
    • midsegment of the LAD × 1.5;
    • right coronary artery distal segment of the LAD,
    • posterolateral artery, and obtuse marginal artery × 1;
    • and others × 0.5.

The narrowing of the coronary artery lumen is rated

  1. 2 for 0% to 25% stenosis,
  2. 4 for 26% to 50%,
  3. 8 for 51% to 75%,
  4. 16 for 76% to 90%,
  5. 32 for 91% to 99%,
  6. 64 for 100%.

The Gensini index is the sum of the total weights for each segment. All angiographic variables of the SYNTAX and Gensini score were computed by

  • 2 experienced cardiologists who were blinded to the procedural data and clinical outcomes.

The final decision was reached by consensus when a conflict occurred.The number of diseased vessels with

  • greater than 50% luminal stenosis was scored from 1 to 3 (namely, 1-, 2-, or 3-vessel disease), and
  • a lesion greater than 50% in the left main coronary artery was regarded as a 2-vessel disease.

Statistical Analyses

Statistical analyses were conducted with SPSS 17 (SPSS Inc, Chicago, IL) software package program.
Continuous variables were expressed as mean ± SD or median ± interquartile range values, whereas categorical variables were presented as percentages.
The differences between normally distributed numeric variables were evaluated by Student t test or 1-way analysis of variance, whereas

  • non–normally distributed variables were analyzed by Mann-Whitney U test or Kruskal-Wallis variance analysis as appropriate.

χ2 Test was used for the comparison of categorical variables. Pearson test was used for correlation analysis.
To determine the independent predictors of “intermediate and high” SYNTAX scores and only “high” SYNTAX scores,

  • 2 different sets of univariate and multivariate analyses were performed
    • (in the first model SYNTAX cutoff was 22, whereas
    • in the second model SYNTAX cutoff was 33).

The standardized parameters that were found to have a significance (P < 0.10) in the univariate analysis were evaluated by stepwise logistic regression analysis.
Ninety-five percent confidence interval (CI) and odds ratio (OR) per SD increase were presented together. Interobserver and intraobserver variability for SYNTAX scores

  • was done by Bland-Altman analysis.

An exploratory evaluation of additional cut points was performed using the receiver operating characteristic (ROC) curve analysis.
All the P values were 2-sided, and a P < 0.05 was considered as statistically significant.
RESULTS
Baseline Characteristics
In total, 181 patients (50.2 ± 6.5 years, 52.5% were composed of males) were included in the study. Baseline clinical, angiographic, and laboratory characteristics of the patients
relative to SYNTAX score groups are shown in Table 2. Age, sex, HT, DM, BMI, and medication were not different between the groups. Baseline clinical and laboratory characteristics
of patients according to PTX-3 quartiles are shown in Table 3. The Bland-Altman analysis revealed that the degrees of intraobserver and interobserver variability for SYNTAX score
and Gensini score readings were 5% and 6% for SYNTAX and 8% and 9% for Gensini,
respectively.
Table 2   http://images.journals.lww.com/jinvestigativemed/Original.00042871-201302000-00007.TT2.jpeg
Table 3   http://images.journals.lww.com/jinvestigativemed/Original.00042871-201302000-00007.TT3.jpeg

The PTX-3 levels demonstrated an increase from the low SYNTAX group to the high SYNTAX group (r = 0.87, P < 0.001).
The low SYNTAX group had statistically significantly higher PTX-3 levels when compared with the control group (0.50 ± 0.01 vs 0.24 ± 0.01 ng/mL, P < 0.001); similarly,
the PTX-3 levels were higher in the high SYNTAX group than in both

  • the intermediate SYNTAX group (0.84 ± 0.08 vs 0.55 ± 0.01 ng/mL, P < 0.001) and
  • the low SYNTAX group (0.84 ± 0.08 vs 0.50 ± 0.01 ng/mL, P < 0.001).
  • there was no difference in levels of PTX-3 between the low and the intermediate SYNTAX group (0.50 ± 0.01 vs 0.55 ± 0.01 ng/mL, P = 0.09).

On the other hand, there was no difference in levels of hs-CRP between the control and the low SYNTAX group (0.81 ± 0.42 vs 0.86 ± 0.53 mg/dL, P = 0.96).
The intermediate SYNTAX group had statistically significantly higher hs-CRP levels

  • compared with the low SYNTAX group (1.3 ± 0.66 vs 0.86 ± 0.53 mg/dL, P = 0.002);
  • the hs-CRP levels were not different between the high SYNTAX group
    • and the intermediate SYNTAX group. (1.3 ± 0.66 vs 1.3 ± 0.43 mg/dL, P = 0.99).

Univariate correlation analysis revealed a positive correlation between serum PTX-3 levels and hs-CRP levels with

  • the SYNTAX and Gensini scores
    • for SYNTAX: r = 0.87 [P < 0.001] and r = 0.36 [P = 0.01];
    • for Gensini: r = 0.75 [P < 0.001] and r = 0.27 [P = 0.002],  (Fig. 1).

In addition to that, the Gensini and SYNTAX scores are found to be well correlated with each other (r = 0.80, P < 0.001).
When the SYNTAX score was taken as continuous variable, multivariate linear regression analysis revealed that

  • the SYNTAX score was correlated with PTX-3 and hs-CRP (for PTX-3: β = 0.84 [P < 0.001]; hs-CRP: β =0.08 [P = 0.032]).

Figure 1   http://images.journals.lww.com/jinvestigativemed/Original.00042871-201302000-00007.FF1.jpeg

For determining the predictors of intermediate and high SYNTAX scores and only-high SYNTAX scores,

  • 2 different sets of univariate and multivariate analyses were performed among the patients who underwent coronary angiography.

For predicting the intermediate and high SYNTAX scores, the SYNTAX score was dichotomized into

  • high (score ≥22) and
  • low (<22) groups,

whereas for predicting the only-high SYNTAX scores, the SYNTAX score was dichotomized into

  • 2 groups with a score of 33 or greater and a score of less than 33.

In the first multivariate analysis (where SYNTAX cutoff was 22), the parameters showing significance in the univariate analysis

  • age,
  • sex,
  • HT,
  • DM,
  • low-density lipoprotein cholesterol [LDL-C],
  • hs-CRP,
  • PTX-3

were evaluated by multivariate analysis to determine the

  • independent predictors of intermediate and high SYNTAX scores.

In the univariate analysis, higher values of

  • age (OR, 1.5 [95% CI, 1.1–2.0]; P = 0.01),
  • LDL-C (OR, 1.3 [95% CI, 0.98–1.8]; P = 0.068),
  • hs-CRP (OR, 2.6 [95% CI, 1.8–3.8]; P < 0.001), and
  • PTX-3 (OR, 13.6 [95% CI, 6.4–28.9]; P < 0.001)
    • were associated with higher SYNTAX scores,
  • HT (OR, 0.44 [95% CI, 0.24–0.80]; P = 0.008) and
  • DM (OR, 0.48 [95% CI, 0.25–0.91]; P = 0.02)
    • were associated with lower SYNTAX scores.

In the multivariate analysis – age, DM, LDL-C, hs-CRP, and PTX-3 – were found to be

  • independent predictors of “intermediate to high” SYNTAX score (Table 4).

Increased

  • age (OR, 2.5 [95% CI, 1.3–4.8]; P = 0.007),
  • LDL-C (OR, 2.8 [95% CI, 1.5–5.2]; P = 0.001),
  • hs-CRP (OR, 3.3 [95% CI, 1.8–6.1]; P < 0.001), and
  • PTX-3 (OR, 35.4 [95% CI, 10.1–123.6]; P < 0.001)
    • were associated with increased SYNTAX scores,

whereas DM (OR, 0.08 [95% CI, 0.02–0.33]; P < 0.001) was associated with lower SYNTAX score (Table 4).

In the second univariate and multivariate analyses (where SYNTAX cutoff was 33),

  • the parameters that showed significance in the univariate analysis were age, LDL-C, glucose, hs-CRP, and PTX-3.
  • In the univariate analysis, increased
    • age (OR, 1.5 [95% CI, 1.0–2.3]; P = 0.05),
    • LDL-C (OR, 1.5 [95% CI, 0.97–2.2]; P = 0.07),
    • hs-CRP (OR, 1.4 [95% CI, 0.97–2.1]; P = 0.072), and
    • PTX-3 (OR, 18.5 [95% CI, 6.6–51.8]; P < 0.001)
      • were found to be associated with increased SYNTAX scores.

When these parameters were evaluated with multivariate analysis, only PTX-3 (OR, 18.4 [95% CI, 6.2–54.2]; P < 0.001)

    • was found to be an independent predictor for high SYNTAX score (Table 4).

Table 4   http://images.journals.lww.com/jinvestigativemed/Original.00042871-201302000-00007.TT4.jpeg

The ROC curve analysis further revealed that the PTX-3 level was a strong indicator of high SYNTAX score with

  • an area under the curve (AUC) of 0.91 (95% CI, 0.86–0.96) (Fig. 2).

The optimal cutoff of PTX-3 for the high SYNTAX score was 0.75 ng/mL.
Sensitivity, specificity, positive predictive value, and negative predictive value to identify high SYNTAX score for the PTX-3 level

  • were 90%, 84%, 97%, and 60%, respectively.
  • the ROC curve analysis of PTX-3 for intermediate-high SYNTAX score revealed that the AUC value was 0.82 (95% CI, 0.75–0.89).

The optimal threshold of PTX-3 level that

  • maximized the combined specificity and sensitivity to predict
    • intermediate to high SYNTAX score was 0.73 ng/mL.

For the cutoff value of 0.73 ng/mL, sensitivity, specificity, positive predictive value, and negative predictive value

  • to identify intermediate-high SYNTAX score were 56%, 98%, 97%, and 56%, respectively.

Figure 2   http://images.journals.lww.com/jinvestigativemed/Original.00042871-201302000-00007.FF2.jpeg

In the ROC analysis of hs-CRP for high SYNTAX scores, the AUC value was found to be 0.68 (95% CI, 0.59–0.77; P < 0.001).
The optimal threshold of hs-CRP that maximized the combined specificity and sensitivity to predict for high SYNTAX scores was 0.89 mg/dL.
Similarly, the ROC analysis of hs-CRP for the intermediate-high SYNTAX scores revealed an AUC of 0.74 (95% CI, 0.65–0.83; P = 0.001).
The cutoff value of hs-CRP to predict the intermediate-high SYNTAX scores with a maximized sensitivity and specificity was 0.66 mg/dL.
DISCUSSION
In this particular study, we investigated the relationship between the serum PTX-3 level and the severity of CAD

  • assessed by SYNTAX and Gensini scores in patients with SAP.

The PTX-3, was significantly higher than control group in the patients with CAD, and the serum PTX-3 levels

  • were associated with the SYNTAX and Gensini scores.

When compared with the hs-CRP, the PTX-3 was found to be more tightly associated with the complexity and severity of CAD in the patients with SAP.
Pentraxin 3, an acute-phase reactant that is functionally and structurally similar to CRP,1 is produced both by different kinds of cells such as

  • macrophages, dendritic cells, neutrophils, fibroblasts, and vascular endothelial cells.2
  • Pentraxin 3 is released following the inflammatory stimuli19; therefore, it may reflect the local inflammatory status in tissues.20

Serum PTX-3 levels were shown to be elevated in patients with

  • vasculitis,6 acute myocardial infarction,7,8 and systemic inflammation or sepsis,9 psoriasis, unstable angina pectoris, and heart failure.10–13

Higher PTX3 levels were reported to be associated with worse cardiovascular outcomes

  1. after acute coronary syndromes,8,21
  2. in the elderly people without known cardiovascular disease22 and
  3. associated with overall mortality in patients with stable coronary disease,
  4. independent of systemic inflammation.14

There are 2 reports investigating the association of PTX-3 level and the atherosclerotic burden.15,16 In one of these reports,

  • Knoflach et al.15 took B-mode ultrasonography as the atherosclerosis index.

They did not provide any information about coronary anatomy, and in the other report, Soeki et al.16 evaluated 40 patients who

  • underwent coronary angiography and measured their Gensini scores.

However, in none of the studies were the SYNTAX score and Gensini score used together to assess the degree of coronary atherosclerotic burden.
To our knowledge, this is the first report that showed the association of PTX-3 levels with the complexity and severity of CAD assessed by

  • SYNTAX and Gensini scores in patients with stable coronary disease.

Chronic low-grade inflammation has been thought to play a major role in the pathogenesis of atherosclerosis.23,24 Previous studies have reported that

  • levels of inflammatory markers such as hs-CRP, interleukin 6, and so on were increased in atherosclerosis.25

In the present study, both the SYNTAX and the Gensini scores were found to be correlated with serum PTX-3 and hs-CRP levels,

  • which in turn might reflect the degree of inflammation.

The SYNTAX score is an important tool in the classification of complex CAD26 and can give predictive information about short- and long-term outcomes

  • in patients with stable CAD who undergo percutaneous coronary intervention.27–30

Although the SYNTAX score is currently used for assessing the angiographic complexity of CAD rather than the severity of coronary atherosclerotic burden,

  • because more complex lesions tend to have more atherosclerotic burden,
  • the SYNTAX scores may also reflect the severity of coronary atherosclerotic burden.

The Gensini score, a well-known and widely used scoring system to evaluate the severity of CAD,18 was measured and

  • found to be well correlated with the SYNTAX score,
    • which supports the idea that angiographically more complex lesions tend to have more atherosclerotic burden.

When compared with the hs-CRP,

  • the PTX-3 seems to be more tightly associated with coronary disease burden (r = 0.36 vs r = 0.87).

We found out that the serum PTX-3 levels were higher than those in the control group, even in the low SYNTAX group.
On the other side, the serum hs-CRP levels were not different in the control and the low SYNTAX groups.
It was reported that the leukocytes mainly found in the coronary artery lumen are the neutrophils.31
It is also known that PTX-3 is stored in specific granules of neutrophils and released in response to inflammatory signals.32
The reason why serum PTX-3 levels seem more tightly associated with the coronary disease burden

  • when compared with serum hs-CRP levels may be the association of the
  • on-site presence of neutrophils and local inflammatory signal–triggered release of  PTX-3.

On the other hand, some human studies revealed that PTX-3 was produced more in areas of atherosclerosis and may contribute to its pathogenesis.31
Some other studies suggested that PTX-3 may be part of a protective mechanism in

  • vascular repair via inhibiting fibroblast growth factor 2 or some other growth factors responsible for smooth muscle proliferation.33,34

But still, the exact role of PTX-3 in the pathophysiology of atherosclerosis seems to be obscure for the time being. It is well established that atherosclerosis
has an inflammatory background in most of the cases. In addition to that, high blood CRP level is known as an indicator of future cardiovascular disease risk
even in healthy individuals.35 According to the results of univariate and multivariate analyses, for intermediate and high SYNTAX scores,

  1. age, DM, LDL-C, hs-CRP, and PTX-3 were found to be independent predictors, whereas for the presence of
  2. high SYNTAX score, only PTX-3 was found to be an independent predictor.

Because of the tighter association with atherosclerotic burden and the on-site vascular presence,

    • PTX-3 may be a promising candidate marker for vascular inflammation and future cardiovascular events.

LIMITATIONS
The major limitation of the current study is the number of patients included. It would be better to include more patients to increase the statistical power.

Besides, the SYNTAX and Gensini scores give us an idea about the complexity and severity of coronary atherosclerosis; however,
with coronary angiography alone, it is not possible to understand the extent of coronary plaque. In addition to that, the coronary anatomy of the
control group was not known, which was another limitation. Our selected population was free of other confounders of systemic inflammation, and
we did not have data about inflammatory markers other than hs-CRP, such as interleukin 6, tumor necrosis factor α, and so on, which may be accepted
as a limitation. Another limitation of the current study is that because there was no long-term follow-up of the patients, it did not provide any prognostic
data in terms of future cardiovascular events.
CONCLUSIONS
Pentraxin 3, a novel inflammatory marker, is associated with the complexity and severity of the CAD assessed by the SYNTAX and the Gensini scores in patients with SAP and seems to be more tightly associated with coronary atherosclerotic burden than hs-CRP.

REFERENCES

1. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005; 352: 1685–1695.
2. Brown DW, Giles WH, Croft JB. White blood cell count: an independent predictor of coronary heart disease mortality among a national cohort. J Clin Epidemiol. 2001; 54: 316–322.
3. Kannel WB, Anderson K, Wilson PW. White blood cell count and cardiovascular disease. Insights from the Framingham Study. JAMA. 1992; 267: 1253–1256.
4. Muscari A, Bozzoli C, Puddu GM, et al.. Association of serum C3 levels with the risk of myocardial infarction. Am J Med. 1995; 98: 357–364.
5. Ridker PM, Cushman M, Stampfer MJ, et al.. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med. 1997; 336: 973–979.
6. Fazzini F, Peri G, Doni A, et al.. PTX3 in small-vessel vasculitides: an independent indicator of disease activity produced at sites of inflammation. Arthritis Rheum. 2001; 44: 2841–2850.
7. Peri G, Introna M, Corradi D, et al.. PTX3, A prototypical long pentraxin, is an early indicator of acute myocardial infarction in humans. Circulation. 2000; 102: 636–641.
8. Latini R, Maggioni AP, Peri G, et al.. Prognostic significance of the long pentraxin PTX3 in acute myocardial infarction. Circulation. 2004; 110: 2349–2354.
9. Muller B, Peri G, Doni A, et al.. Circulating levels of the long pentraxin PTX3 correlate with severity of infection in critically ill patients. Crit Care Med. 2001; 29: 1404–1407.
10. Bevelacqua V, Libra M, Mazzarino MC, et al.. Long pentraxin 3: a marker of inflammation in untreated psoriatic patients. Int J Mol Med. 2006; 18: 415–423.
11. Inoue K, Sugiyama A, Reid PC, et al.. Establishment of a high sensitivity plasma assay for human pentraxin3 as a marker for unstable angina pectoris. Arterioscler Thromb Vasc Biol. 2007; 27: 161–167.
12. Suzuki S, Takeishi Y, Niizeki T, et al.. Pentraxin 3, a new marker for vascular inflammation, predicts adverse clinical outcomes in patients with heart failure. Am Heart J. 2008; 155: 75–81.
13. Matsubara J, Sugiyama S, Nozaki T, et al.. Pentraxin 3 is a new inflammatory marker correlated with left ventricular diastolic dysfunction and heart failure with normal ejection fraction. J Am Coll Cardiol. 2011; 57: 861–869.
14. Dubin R, Li Y, Ix JH, et al.. Associations of pentraxin-3 with cardiovascular events, incident heart failure, and mortality among persons with coronary heart disease: data from the Heart and Soul Study. Am Heart J. 2012; 163: 274–279.
16. Soeki T, Niki T, Kusunose K, et al.. Elevated concentrations of pentraxin 3 are associated with coronary plaque vulnerability. J Cardiol. 2011; 58: 151–157.
17. SYNTAX working group. SYNTAX score calculator. Available at http://www.syntaxscore.com. Accessed May 20, 2012.
18. Gensini GG. A more meaningful scoring system for determining the severity of coronary heart disease. Am J Cardiol. 1983; 51: 606.
20. Mantovani A, Garlanda C, Bottazzi B, et al.. The long pentraxin PTX3 in vascular pathology. Vascul Pharmacol. 2006; 45: 326–330.
21. Matsui S, Ishii J, Kitagawa F, et al.. Pentraxin 3 in unstable angina and non-ST-segment elevation myocardial infarction. Atherosclerosis. 2010; 210: 220–225.
22. Jenny NS, Arnold AM, Kuller LH, et al.. Associations of pentraxin 3 with cardiovascular disease and all-cause death: the Cardiovascular Health Study. Arterioscler Thromb Vasc Biol. 2009; 29: 594–599.
26. Serruys PW, Morice MC, Kappetein AP, et al.. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009; 360: 961–972.
27. van Gaal WJ, Ponnuthurai FA, Selvanayagam J, et al.. The SYNTAX score predicts peri-procedural myocardial necrosis during percutaneous coronary intervention. Int J Cardiol. 2009; 135: 60–65.
28. Lemesle G, Bonello L, de Labriolle A, et al.. Prognostic value of the SYNTAX score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease. Catheter Cardiovasc Interv. 2009; 73: 612–617.
29. Capodanno D, Di Salvo ME, Cincotta G, et al.. Usefulness of the SYNTAX score for predicting clinical outcome after percutaneous coronary intervention of unprotected left main coronary artery disease. Circ Cardiovasc Interv. 2009; 2: 302–308.
30. Kim YH, Park DW, Kim WJ, et al.. Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv. 2010; 3: 612–623.
32. Jaillon S, Peri G, Delneste Y, et al.. The humoral pattern recognition receptor PTX3 is stored in neutrophil granules and localizes in extracellular traps. J Exp Med. 2007; 204: 793–804.
33. Inforzato A, Baldock C, Jowitt TA, et al.. The angiogenic inhibitor long pentraxin PTX3 forms an asymmetric octamer with two binding sites for FGF2. J Biol Chem. 2010; 285: 17681–17692.
34. Camozzi M, Zacchigna S, Rusnati M, et al.. Pentraxin 3 inhibits fibroblast growth factor 2–dependent activation of smooth muscle cells in vitro and neointima formation in vivo. Arterioscler Thromb Vasc Biol. 2005; 25: 1837–1842.
35. Koenig W, Sund M, Frohlich M, et al.. C-Reactive protein, a sensitive marker of inflammation, predicts future risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Augsburg Cohort Study, 1984 to 1992. Circulation. 1999; 99: 237–242.
Keywords:  pentraxin 3; coronary artery disease; SYNTAX score; hs-CRP; inflammation

This is not the only recent finding that adds to the ability to evaluate these patients.  An as yet unpublished paper, expected to be published soon reports on

QRS fragmentation as a Prognostic test in Acute Coronary Syndrome,  and this reviewer expects the work to have a high impact.  The authors state that
QRS complex fragmentation is a promising bed-side test for assessment of prognosis in those patients.  Presence of fragmented QRS in surface ECG during ACS

  • represents myocardial scar or fibrosis and reflect severity of coronary lesions and a correlation between fQRS and depression of Lv function is established.

There are still other indicators that need to be considered, such as the mean arterial blood pressure.

There has been review and revisions of the guidelines for treatment of UA/NSTEMI within the last year, with differences being resolved among the Europeans and US.

Guidelines Updated for Unstable Angina/Non-ST Elevation Myocardial Infarction
According to the current study by Jneid and colleagues, new evidence is available on the management of unstable angina. This report replaces the 2007 American College of Cardiology Foundation/American Heart Association (ACC/AHA) Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (UA/NSTEMI) that were updated by the 2011 guidelines.

This guideline was reviewed by

  • 2 official reviewers each nominated by the ACCF and the AHA, as well as
  • 1 or 2 reviewers each from the American College of Emergency Physicians; the Society for Cardiovascular Angiography and Interventions; and the Society of Thoracic Surgeons; and
  • 29 individual content reviewers, including members of the ACCF Interventional Scientific Council.

The recommendations in this focused update are considered current

  • until they are superseded in another focused update or the full-text guideline is revised, and are official policy of both the ACCF and the AHA.

STUDY SYNOPSIS AND PERSPECTIVE
American cardiology societies have caught up with the European Society of Cardiology by

  • issuing their second update to the UA/NSTEMI guidelines in 18 months,
  • with the 2012 focused update replacing the 2011 guidelines [1].

The new recommendations include ticagrelor (Brilinta) as one of the options for antiplatelet therapy alongside prasugrel (Effient) and clopidogrel, bringing them in line with European.
The European guidance, however, gave precedence to the new antiplatelets over clopidogrel, whereas the American update “places ticagrelor on an equal footing with the other two antiplatelets available–
this is the main reason for the update,” lead author Dr Hani Jneid (Baylor College of Medicine, Houston, TX), told heartwire . “Doctors now have a choice for second-line therapy after aspirin, depending on

  • the patient’s clinical scenario,
  • physician preference, and cost,”
    • now that clopidogrel is available generically.

The US decision to recommend

  • first prasugrel–in its 2011 update to the UA/NSTEMI guidelines–and
  • now ticagrelor as equivalent antiplatelet therapy choices to clopidogrel after aspirin
    • puts it somewhat at odds with the Europeans,
    • who reserve clopidogrel use for those who cannot take the newer agents.

The reason for the Americans differing stance is that because while they are faster acting and more potent–

  • the cost-effectiveness of the new agents is not known.
  • it isn’t clear how the efficacy observed in pivotal clinical trials of these agents is going to translate into real-world benefit,
  • and issues such as bleeding with prasugrel and compliance with a twice-daily drug such as ticagrelor remain concerns.

Bulk of 2012 Update on How to Use Ticagrelor
The 2012 ACCF/AHA focused update for the management of UA/NSTEMI stresses that

  • all patients at medium/high risk should receive dual antiplatelet therapy on admission,
  • with aspirin being first-line, indefinite therapy.

The bulk of the update centers on how to use ticagrelor which–

  • like prasugrel or clopidogrel–
  • can be added to aspirin for up to 12 months (or longer, at the discretion of the treating clinician).

Jneid notes it’s important to remember that prasugrel can only be used in the cath lab

  • in patients undergoing percutaneous coronary intervention (PCI),
  • whereas ticagrelor, like clopidogrel, can be used in medically managed or PCI patients.

And he emphasizes that, in line with the FDA’s black-box warning on ticagrelor,

The 81-mg aspirin dose is also considered a reasonable option in preference to a higher maintenance dose of 325 mg in

  • any acute coronary syndrome (ACS) patient following PCI, he adds, as
  • this strategy is believed to result in equal efficacy and lower bleeding risk.

With regard to how long antiplatelet therapy should be stopped before planned cardiac surgery, the recommendation is

  • five days for ticagrelor–the same as that advised for clopidogrel.
  • and seven days prior to surgery for prasugrel.

Jneid also highlights other important recommendations from the 2011 focused update carried over to 2012:

It is “reasonable” to proceed with cardiac catheterization and revascularization within

  • 12–24 hours of admission in initially stable, very high-risk patients with ACS.

An invasive strategy is “reasonable” in patients with

  • mild and moderate chronic kidney disease.

In those with diabetes hospitalized with ACS, insulin use should target glucose levels <180 mg/dL,

  • a less-intensive reduction than previously recommended.

Platelet function or genotype testing for clopidogrel resistance are both considered “reasonable”

  • if clinicians think the results will alter management,
  • but Jneid acknowledged that “there is not much evidence to support these assays” .

Committee Encourages Participation in Registries
Jneid observes that unstable angina and NSTEMI are “very common” conditions that carry a high risk of death and recurrent heart attacks,

  • which is why “the AHA and ACCF constantly update their guidelines so that physicians can provide patients with
  • the most appropriate, aggressive therapy with the goal of improving health and survival.”

To this end, he notes that the writing panel encourages

  • clinicians and hospitals to participate in quality-of-care registries designed
  • to track and measure outcomes, complications, and
  • adherence to evidence-based medicines.

Conflicts of interest for the writing committee are listed in the paper.

References

Jneid H, Anderson JL, Wright SR, et al. 2012 ACCF/AHA focused update on the guideline for the management of patients with unstable angina/non-ST elevation myocardial infarction (Updating the 2007 guideline and replacing the 2011 focused update): A report of the ACCF/AHA.
Circulation 2012;      Available at: http://circ.ahajournals.org/  http://dx.doi.org/10.1161/CIR0b013e3182566fleo
source   http://www.medscape.org

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Liver Endoplasmic Reticulum Stress and Hepatosteatosis

Larry H Bernstein, MD, FCAP

 

1. Absence of adipose triglyceride lipase protects from hepatic endoplasmic reticulum stress in mice.

Fuchs CD, Claudel T, Kumari P, Haemmerle G, et al.
LabExpMol Hepatology, Medical Univ of Graz, Austria.
Hepatology. 2012 Jul;56(1):270-80.   http://dx.doi.org/10.1002/hep.25601. Epub 2012 May 29.

Nonalcoholic fatty liver disease (NAFLD) is characterized by

  • triglyceride (TG) accumulation and
  • endoplasmic reticulum (ER) stress.

Fatty acids (FAs) may trigger ER stress, therefore,

  •  the absence of adipose triglyceride lipase (ATGL/PNPLA2)-
    • the main enzyme for intracellular lipolysis,
  • releasing FAs, and
  • closest homolog to adiponutrin (PNPLA3)

recently implicated in the pathogenesis of NAFLD-

  • could protect against hepatic ER stress.

Wild-type (WT) and ATGL knockout (KO) mice

  •  were challenged with tunicamycin (TM) to induce ER stress.

Markers of hepatic

  •  lipid metabolism,
  • ER stress, and
  • inflammation were explored
    • for gene expression by
    •  serum biochemistry,
    • hepatic TG and FA profiles,
    • liver histology,
    • cell-culture experiments were performed in Hepa1.6 cells
  • after the knockdown of ATGL before FA and TM treatment.

TM increased hepatic TG accumulation in ATGL KO, but not in WT mice. Lipogenesis and β-oxidation
were repressed at the gene-expression level
(sterol regulatory element-binding transcription factor 1c,
fatty acid synthase, acetyl coenzyme A carboxylase 2, and carnitine palmitoyltransferase 1 alpha) in
both WT and ATGL KO mice. Genes for very-low-density lipoprotein (VLDL) synthesis (microsomal
triglyceride transfer protein and apolipoprotein B)

  •  were down-regulated by TM in WT
  • and even more in ATGL KO mice,
  • which displayed strongly reduced serum VLDL cholesterol levels.

ER stress markers were induced exclusively in TM-treated WT, but not ATGL KO, mice:

  •  glucose-regulated protein,
  • C/EBP homolog protein,
  • spliced X-box-binding protein,
  • endoplasmic-reticulum-localized DnaJ homolog 4, and
  • inflammatory markers Tnfα and iNos.

Total hepatic FA profiling revealed a higher palmitic acid/oleic acid (PA/OA) ratio in WT mice.
Phosphoinositide-3-kinase inhibitor-

  • known to be involved in FA-derived ER stress and
  • blocked by OA-
  • was increased in TM-treated WT mice only.

In line with this, in vitro OA protected hepatocytes from TM-induced ER stress. Lack of ATGL may protect from
hepatic ER stress through alterations in FA composition. ATGL could constitute a new therapeutic strategy
to target ER stress in NAFLD.
PMID: 22271167 Diabetes Obes Metab. 2010 Oct;12 Suppl 2:83-92.
http://dx.doi.org/10.1111/j.1463-1326.2010.01275.x.

2. Hepatic steatosis: a role for de novo lipogenesis and the transcription factor SREBP-1c.
Ferré P, Foufelle F. INSERM, and Université Pierre et Marie Curie-Paris, Paris, France.    PMID: 21029304

Excessive availability of plasma fatty acids and lipid synthesis from glucose (lipogenesis) are important determinants of steatosis.
Lipogenesis is an insulin- and glucose-dependent process that is under the control of specific transcription factors,

Insulin induces the maturation of SREBP-1c in the endoplasmic reticulum (ER).

  • SREBP-1c in turn activates glycolytic gene expression,
    • allowing glucose metabolism, and
    • lipogenic genes in conjunction with ChREBP.

Lipogenesis activation in the liver of obese markedly insulin-resistant steatotic rodents is then paradoxical.
It appears the activation of SREBP-1c and thus of lipogenesis is

  •  secondary in the steatotic liver to an ER stress.

The ER stress activates the

  •  cleavage of SREBP-1c independent of insulin,
  • explaining the paradoxical stimulation of lipogenesis
  • in an insulin-resistant liver.

Inhibition of the ER stress in obese rodents

  •  decreases SREBP-1c activation and lipogenesis and
  • improves markedly hepatic steatosis and insulin sensitivity.
  • ER is thus worth considering as a potential therapeutic target for steatosis and metabolic syndrome.

3. SREBP-1c transcription factor and lipid homeostasis: clinical perspective
Ferré P, Foufelle F
Inserm, Centre de Recherches Biomédicales des Cordeliers, Paris, France.
Horm Res. 2007;68(2):72-82. Epub 2007 Mar 5. PMID:17344645

Insulin has long-term effects on glucose and lipid metabolism through its control on the expression of specific genes.
In insulin sensitive tissues and particularly in the liver,

  •  the transcription factor sterol regulatory element binding protein-1c (SREBP-1c) transduces the insulin signal, which is
  • synthetized as a precursor in the membranes of the endoplasmic reticulum
  • which requires post-translational modification to yield its transcriptionally active nuclear form.

Insulin activates the transcription and the proteolytic maturation of SREBP-1c, which induces the

  •  expression of a family of genes
  • involved in glucose utilization and fatty acid synthesis and
  • can be considered as a thrifty gene.

Since a high lipid availability is

  •  deleterious for insulin sensitivity and secretion,
  • a role for SREBP-1c in dyslipidaemia and type 2 diabetes
  • has been considered in genetic studies.

SREBP-1c could also participate in

  •  hepatic steatosis observed in humans
  • related to alcohol consumption and
  • hyperhomocysteinemia
  • concomitant with a ER-stress and
  • insulin-independent SREBP-1c activation.

4. Hepatic steatosis: a role for de novo lipogenesis and the transcription factor SREBP-1c
Ferré P, Foufelle F
INSERM, Centre de Recherches des Cordeliers and Université Pierre et Marie Curie-Paris, Paris, France.
Diabetes Obes Metab. 2010 Oct;12 Suppl 2:83-92. PMID: 21029304
http://dx.doiorg/10.1111/j.1463-1326.2010.01275.x.

Lipogenesis in liver steatosis is

  •  an insulin- and glucose-dependent process
  • under the control of specific transcription factors,
  • sterol regulatory element binding protein 1c (SREBP-1c),
  • activated by insulin and carbohydrate response element binding protein (ChREBP)

Insulin induces the maturation of SREBP-1c in the endoplasmic reticulum (ER).
SREBP-1c in turn activates glycolytic gene expression, allowing –

  •  glucose metabolism in conjunction with ChREBP.

activation of SREBP-1c and lipogenesis is secondary in the steatotic liver to ER stress, which

  •  activates the cleavage of SREBP-1c independent of insulin,
  • explaining the stimulation of lipogenesis in an insulin-resistant liver.
  • Inhibition of the ER stress in obese rodents decreases SREBP-1c activation and improves
  • hepatic steatosis and insulin sensitivity.

ER is thus a new partner in steatosis and metabolic syndrome

5. Pharmacologic ER stress induces non-alcoholic steatohepatitis in an animal model
Jin-Sook Leea, Ze Zhenga, R Mendeza, Seung-Wook Hac, et al.
Wayne State University SOM, Detroit, MI
Toxicology Letters 20 May 2012; 211(1):29–38      http://dx.doi.org/10.1016/j.toxlet.2012.02.017

Endoplasmic reticulum (ER) stress refers to a condition of

  •  accumulation of unfolded or misfolded proteins in the ER lumen, which is known to
  • activate an intracellular stress signaling termed
  • Unfolded Protein Response (UPR).

A number of pharmacologic reagents or pathophysiologic stimuli

  •  can induce ER stress and activation of the UPR signaling,
  • leading to alteration of cell physiology that is
  • associated with the initiation and progression of a variety of diseases.

Non-alcoholic steatohepatitis (NASH), characterized by hepatic steatosis and inflammation, has been considered the
precursor or the hepatic manifestation of metabolic disease. In this study, we delineated the

  • toxic effect and molecular basis
  • by which pharmacologic ER stress,
  • induced by a bacterial nucleoside antibiotic tunicamycin (TM),
  • promotes NASH in an animal model.

Mice of C57BL/6J strain background were challenged with pharmacologic ER stress by intraperitoneal injection of TM. Upon TM injection,

  •  mice exhibited a quick NASH state characterized by
  • hepatic steatosis and inflammation.

TM-treated mice exhibited an increase in –

  •  hepatic triglycerides (TG) and a –
  • decrease in plasma lipids, including
  • plasma TG,
  • plasma cholesterol,
  • high-density lipoprotein (HDL), and
  • low-density lipoprotein (LDL),

In response to TM challenge,

  •  cleavage of sterol responsive binding protein (SREBP)-1a and SREBP-1c,
  •  the key trans-activators for lipid and sterol biosynthesis,
  • was dramatically increased in the liver.

Consistent with the hepatic steatosis phenotype, expression of

  •  some key regulators and enzymes in de novo lipogenesis and lipid droplet formation was up-regulated,
  • while expression of those involved in lipolysis and fatty acid oxidation was down-regulated
  • in the liver of mice challenged with TM.

TM treatment also increased phosphorylation of NF-κB inhibitors (IκB),

  •  leading to the activation of NF-κB-mediated inflammatory pathway in the liver.

Our study not only confirmed that pharmacologic ER stress is a strong “hit” that triggers NASH, but also demonstrated

  •  crucial molecular links between ER stress,
  • lipid metabolism, and
  • inflammation in the liver in vivo.

Highlights
► Pharmacologic ER stress induced by tunicamycin (TM) induces a quick NASH state in vivo.
► TM leads to dramatic increase in cleavage of sterol regulatory element-binding protein in the liver.
► TM up-regulates lipogenic genes, but down-regulates the genes in lipolysis and FA oxidation.
► TM activates NF-κB and expression of genes encoding pro-inflammatory cytokines in the liver.
Abbreviations
ER, endoplasmic reticulum; TM, tunicamycin; NASH, non-alcoholic steatohepatitis; NAFLD,
non-alcoholic fatty liver disease; TG, triglycerides; SREBP, sterol responsive binding protein;
NF-κB, activation of nuclear factor-kappa B; IκB, NF-κB inhibitor
Keywords: ER stress; Non-alcoholic steatohepatitis; Tunicamycin; Lipid metabolism; Hepatic inflammation
Figures and tables from this article:

Fig. 1. TM challenge alters lipid profiles and causes hepatic steatosis in mice. (A) Quantitative real-time RT-PCR analysis of liver mRNA isolated from mice challenged with TM or vehicle control. Total liver mRNA was isolated at 8 h or 30 h after injection with vehicle or TM (2 μg/g body weight) for real-time RT-PCR analysis. Expression values were normalized to β-actin mRNA levels. Fold changes of mRNA are shown by comparing to one of the control mice. Each bar denotes the mean ± SEM (n = 4 mice per group); **P < 0.01. Edem1, ER degradation enhancing, mannosidase alpha-like 1. (B) Oil-red O staining of lipid droplets in the livers of the mice challenged with TM or vehicle control (magnification: 200×). (C) Levels of TG in the liver tissues of the mice challenged with TM or vehicle control. (D) Levels of plasma lipids in the mice challenged with TM or vehicle control. TG, triglycerides; TC, total plasma cholesterol; HDL, high-density lipoproteins; VLDL/LDL, very low and low density lipoproteins. For C and D, each bar denotes mean ± SEM (n = 4 mice per group); *P < 0.05; **P < 0.01.

 Fhttp://ars.els-cdn.com/content/image/1-s2.0-S0378427412000732-gr1.jpgigure options

Fig. 2. TM challenge leads to a quick NASH state in mice. (A) Histological examination of liver tissue sections of the mice challenged with TM (2 μg/g body weight) or vehicle control. Upper panel, hematoxylin–eosin (H&E) staining of liver tissue sections; the lower panel, Sirius staining of collagen deposition of liver tissue sections (magnification: 200×). (B) Histological scoring for NASH activities in the livers of the mice treated with TM or vehicle control. The grade scores were calculated based on the scores of steatosis, hepatocyte ballooning, lobular and portal inflammation, and Mallory bodies. The stage scores were based on the liver fibrosis. Number of mice examined is given in parentheses. Mean ± SEM values are shown. P-values were calculated by Mann–Whitney U-test.

 http://ars.els-cdn.com/content/image/1-s2.0-S0378427412000732-gr2.jpg

Fig. 3. TM challenge significantly increases levels of cleaved/activated forms of SREBP1a and SREBP1c in the liver. Western blot analysis of protein levels of SREBP1a (A) and SREBP1c (B) in the liver tissues from the mice challenged with TM (2 μg/g body weight) or vehicle control. Levels of GAPDH were included as internal controls. For A and B, the values below the gels represent the ratios of mature/cleaved SREBP signal intensities to that of SREBP precursors. The graph beside the images showed the ratios of mature/cleaved SREBP to precursor SREBP in the liver of mice challenged with TM or vehicle. The protein signal intensities shown by Western blot analysis were quantified by NIH imageJ software. Each bar represents the mean ± SEM (n = 3 mice per group); **P < 0.01. SREBP-p, SREBP precursor; SREBP-m, mature/cleaved SREBP.

 http://ars.els-cdn.com/content/image/1-s2.0-S0378427412000732-gr3.jpg

Fig. 4. TM challenge up-regulates expression of genes involved in lipogenesis but down-regulates expression of genes involved in lipolysis and FA oxidation. Quantitative real-time RT-PCR analysis of liver mRNAs isolated from the mice challenged with TM (2 μg/g body weight) or vehicle control, which encode regulators or enzymes in: (A) de novo lipogenesis: PGC1α, PGC1β, DGAT1 and DGAT2; (B) lipid droplet production: ADRP, FIT2, and FSP27; (C) lipolysis: ApoC2, Acox1, and LSR; and (D) FA oxidation: PPARα. Expression values were normalized to β-actin mRNA levels. Fold changes of mRNA are shown by comparing to one of the control mice. Each bar denotes the mean ± SEM (n = 4 mice per group); **P < 0.01. (E and F) Isotope tracing analysis of hepatic de novo lipogenesis. Huh7 cells were incubated with [1-14C] acetic acid for 6 h (E) or 12 h (F) in the presence or absence of TM (20 μg/ml). The rates of de novo lipogenesis were quantified by determining the amounts of [1-14C]-labeled acetic acid incorporated into total cellular lipids after normalization to cell numbers.

 http://ars.els-cdn.com/content/image/1-s2.0-S0378427412000732-gr4.jpg

Fig. 5. TM activates the inflammatory pathway through NF-κB, but not JNK, in the liver. Western blot analysis of phosphorylated Iκ-B, total Iκ-B, phosphorylated JNK, and total JNK in the liver tissues from the mice challenged with TM (2 μg/g body weight) or vehicle control. Levels of GAPDH were included as internal controls. The values below the gels represent the ratios of phosphorylated protein signal intensities to that of total proteins.

 http://ars.els-cdn.com/content/image/1-s2.0-S0378427412000732-gr5.jpg

Fig. 6. TM induces expression of pro-inflammatory cytokines and acute-phase responsive proteins in the liver. Quantitative real-time RT-PCR analyses of liver mRNAs isolated from the mice challenged with TM (2 μg/g body weight) or vehicle control, which encode: (A) pro-inflammatory cytokine TNFα and IL6; and (B) acute-phase protein SAP and SAA3. Expression values were normalized to β-actin mRNA levels. Fold changes of mRNA are shown by comparing to one of the control mice. (C–E) ELISA analyses of serum levels of TNFα, IL6, and SAP in the mice challenged with TM or vehicle control for 8 h ELISA. Each bar denotes the mean ± SEM (n = 4 mice per group); *P < 0.05, **P < 0.01.

http://ars.els-cdn.com/content/image/1-s2.0-S0378427412000732-gr6.jpg

Corresponding author at: Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, 540 E. Canfield Avenue, Detroit, MI 48201, USA. Tel.: +1 313 577 2669; fax: +1 313 577 5218.

The SREBP regulatory pathway. Brown MS, Goldst...

The SREBP regulatory pathway. Brown MS, Goldstein JL (1997). “The SREBP pathway: regulation of cholesterol metabolism by proteolysis of a membrane-bound transcription factor”. Cell 89 (3) : 331–340. doi:10.1016/S0092-8674(00)80213-5. PMID 9150132. (Photo credit: Wikipedia)

English: Structure of the SREBF1 protein. Base...

English: Structure of the SREBF1 protein. Based on PyMOL rendering of PDB 1am9. (Photo credit: Wikipedia)

The SREBP regulatory pathway

The SREBP regulatory pathway (Photo credit: Wikipedia)

English: Diagram of rough endoplasmic reticulu...

English: Diagram of rough endoplasmic reticulum by Ruth Lawson, Otago Polytechnic. (Photo credit: Wikipedia)

Micrograph demonstrating marked (macrovesicula...

Micrograph demonstrating marked (macrovesicular) steatosis in non-alcoholic fatty liver disease. Masson’s trichrome stain. (Photo credit: Wikipedia)

 

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BARI 2D Trial Outcomes

Reporter: Larry H Bernstein, MD, FCAP
Results from the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) Trial
GR. Dagenais, MD; Jiang Lu, MS; David P. Faxon, MD; Peter Bogaty, MD, et. Al.

Prognostic Impact of the Presence and Absence of Angina on Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Stable Coronary Artery Disease : 

 

Results from the BARI 2D Trial…Bypass Angioplasty Revascularization Investigation 2 Diabetes

Objectives

The purpose of this analysis was

  1. to assess in patients with type 2 diabetes and stable coronary artery disease (CAD)
  2. whether the risk of all-cause mortality and cardiovascular events
  3. varied according to the presence or absence of angina and angina equivalent symptoms.

Background  Data on the prognostic value of symptoms in these patients are limited.

Methods

Post-hoc analysis was performed in 2,364 patients with type 2 diabetes and documented CAD enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial to determine

  1. the occurrence of death and composite of death,
  2. myocardial infarction, and
  3. stroke

during a 5-year follow-up according to cardiac symptoms at baseline.

Results

There were 1,434 patients with angina (A), 506 with angina equivalents (E), and 424 with neither of these (N).
The cumulative death rates (total 316) were

  • 12% in A,
  • 14% in E, and
  • 10% in N (p = 0.3), and

cardiovascular composite rates (total 548) were

  • 24% in A,
  • 24% in E, and
  • 21% in N (p = 0.5).

Compared with N, the hazard ratios adjusted for confounders were not different for death in

  • A (1.11; 99% CI: 0.81 to 1.53) and
  • E (1.17; 99% CI: 0.81 to 1.68) or

for cardiovascular events in

  • A (1.17; 99% CI: 0.92 to 1.50) and
  • E (1.11; 99% CI: 0.84 to 1.48).

Conclusions

Whatever their symptom status,

    • patients with type 2 diabetes and stable CAD were at similar risk of cardiovascular events and death.

These findings suggest that these patients

      • may be similarly managed in terms of risk stratification and preventive therapies.

(Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; NCT00006305)

Key Words
  • angina;
  • coronary artery disease;
  • silent ischemia;
  • type 2 diabetes

Abbreviations and Acronyms

  • BMI, body mass index;
  • CABG, coronary artery bypass graft surgery;
  • CAD, coronary artery disease;
  • CVD,cardiovascular disease;
  • HbA1c, glycosylated hemoglobin;
  • MI, myocardial infarction;
  • PCI, percutaneous coronary intervention
Prognostic Impact of the Presence and Absence of Angina on Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Stable Coronary Artery Disease
http://www.ncbi.nlm.nih.gov/pubmed/23410541

J Am Coll Cardiol. 2013 Feb 19;61(7):702-11.   http://dx. doi.org/ 10.1016/j.jacc.2012.11.036.

http://www.j.JACC.org/Prognostic Impact of the Presence and Absence of Angina on Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Stable Coronary Artery Disease

Prognostic Impact of the Presence and Absence of Angina on Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes and Stable Coronary Artery Disease: Results from the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) Trial.
Dagenais GR, Lu J, Faxon DP, Bogaty P, Adler D, Fuentes F, Escobedo J, Krishnaswami A, Slater J, Frye RL; BARI 2D Study Group.        PMID: 23410541 [PubMed – in process]
Source: Quebec Heart and Lung University Institute, Quebec City, Quebec, Canada. Electronic address: gilles.dagenais@criucpq.ulaval.ca.

Diabetes Mellitus

Diabetes Mellitus (Photo credit: anaxolotl)

Micrograph of an artery that supplies the hear...

Micrograph of an artery that supplies the heart with significant atherosclerosis and marked luminal narrowing. Tissue has been stained using Masson’s trichrome. (Photo credit: Wikipedia)

Bildbeschreibung: Deutsch: Koronarangiografie ...

Bildbeschreibung: Deutsch: Koronarangiografie und PTCA bei akutem Hinterwandinfarkt (li.: RCA verschlossen, re.: RCA erfolgreich dilatiert) Quelle: Deutsch: Scan von 2 Videoprints einer selbst durchgeführten Prozedur Fotograf/Zeichner: selbst gescannt / own work Datum: ca. 1999 (hochgeladen 03. Oktober 2005) andere Versionen: (Photo credit: Wikipedia)

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Curator: Aviva Lev-Ari, PhD. RN

UPDATED on 11/2/2013

 

Medscape Update on Calcium and Cardiovascular Risk

Curator and Reporter: Larry H. Bernstein, MD, FCAP

http://pharmaceuticalintelligence.com/2013/10/11/new-data-dispute-calcium-cardiovascular-risk-in-both-sexes/

Minerals and Cardiovascular Risk

Modern diet contains high sodium to potassium ratio, low omega-3-polyunsaturated acid. (PUFAs) increased omega-6-polyunstaureted, saturated fat and Trans fatty acids these have lead to higher incidence of cardiovascular disease, diabetes mellitus and hyperlipidemia.
Nutrient
Paleolithic diet
Modern diet
More than 10,000 mEq/day (256 Grm)
150mEq/day (6gram)
Less than 50 mmol/day 1.2 Grm
175 mmol/day (4Gram)
Na/K ratio
Less than 0.13 /day
More than 0.67/day
Fiber
More than 100gram/day
Less than 9 gram/day
Protein
37%
20%
Carbohydrate
41%
40-50%
Fat
22%
30-40%
Poly saturated to saturated ratio
1.4
0.4
Sodium
Increased intake of sodium is associated with hypertension and reduction of salt intake is associated with decrease in BP by 4-6/2-3mmhg in salt sensitive patients. Daily allowance of sodium is not more than 500mg/day.
Cardiovascular events are more common in salt sensitive patients than salt resistance patients, independent of BP reduction. Reduction of BP by salt restriction has benefit apart from BP reduction.
A balance of sodium with other nutrients is important not only for reduction of BP but also for reduction cardiovascular events.
 
Potassium
Increased intake of potassium is associated with BP reduction. Recommended daily intake of potassium is 650mEq/day with Na/k ratio of 5:1.
Supplements of 120 mEq/day of potassium reduce BP by 4.4/2.5mmhg in hypertensive patients.
Higher Na/K ratio reduces not only BP but also cardiovascular events.
 
Magnesium
Intake of 500mg/day to 1000mg/day reduces BP by 5.6/2.8mmhg. Reducing intracellular sodium and calcium and increasing intracellular magnesium and potassium improves BP response.
Insulin sensitivity, LVH and dyslipidemia can be improved with magnesium supplementation.
Oral magnesium acts like natural calcium channel blocker, increases nitric oxide, and improves endothelial dysfunction, and induces vasodilatation.
 
Calcium
Studies show link between calcium and hypertension. But trials supplementing calcium do not show benefit. Below we present results of a recent study on Calcium supplementation citing >1400 mg/day been associated with increased cardiovascular risk and mortality.
 
Zinc
Low serum zinc levels are associated with hypertension.

Authors of the BMJ of 2/13/2013 article reported, below offer the following Possible Explanations and Implications

Calcium levels in serum are under tight homeostatic control, and calcium intake is not normally correlated with calcium serum levels.

  • Diets that are low or very high in calcium can, however, override normal homeostatic control causing changes in blood levels of calcium or calciotropic hormones.52
  • Calcium enriched meals can reduce calcitriol, the active vitamin D metabolite, by inhibition of 1α hydroxylase53and also increase serum levels of fibroblast growth factor 23.54
  • Higher levels of circulating fibroblast growth factor 23 are associated with an increased risk of cardiovascular events and all cause mortality.55 56 57 In addition,
  • fibroblast growth factor 23 downregulates calcitriol levels.58
  • Vitamin D suppression leads to an upregulation of the renin-angiotensin-aldosterone system and hypertension, higher levels of proinflammatory cytokines involved in the pathogenesis of atherosclerosis:

–  increased carotid artery intima medial thickness,

–  decreased endothelial function,

–  hypertrophy of cardiac and vascular muscle cells, and a

–  possible increase in serum triglycerides.59 Finally,

  • high serum calcium levels can increase the risk of cardiovascular mortality60 by induction of a hypercoagulable state.61

Vascular calcification and plaque rupture

There are two types of vascular calcification,  intimal calcification of atherosclerosis and medial calcification. Both are associated with increased incidence of ischemic heart disease. Plaque rupture is manly restricted to intimal plaques fibrous cap calcification. Calcification of this fibrous cap is associated with increased incidence of ischemic heart disease. Below discussion is about controversy associated with fibrous cap calcification.

Whether intimal calcification stabilizes the plaque or makes it prone for rupture is a matter debate. Calcified and fibrotic lesions are more hypo-cellular, they are stiffer than cellular lesions, and further more biomechanical data suggest calcification reduces the “stresses” in a plaque does not cause rupture.  Plaques with heavily calcified are 5 times stiffer that non-calcified lesions.
Calcium crystal have shown to aggravate inflammation
Above observation are contradictory to each other. If calcium induces inflammation than plaque should get destabilize?
Under mechanical stress produced by balloon angioplasty, calcified plaque is more likely to rupture than non-calcified plaque, and the rupture occurs along the interface between the calcium deposit and soft tissue. So this suggest that plaque rupture may occur at these week points
Conclusion
It has been stated that when entire plaque is calcified it protects against rupture unlike focal calcification
The ratio of surface area to volume in calcium deposits may determine whether they are harmful or protective

Lipoprotein a (Lp(a)) genetic variant doubles the causal risk of Aortic valvular calcification.

In the last 15 to 20 years our understanding of aortic valve calcification has changed from just simple degenerative disease to disease secondary to an active process involving endothelial dysfunction, lipid accumulation, an inflammatory infiltrate. With this understanding many potential therapeutic approach have been considered. Statins showed promise in prevention of calcification in retrospective trials but prospective trials did not show benfit. Rennin angiotensin inhibitors have given discordant results in retrospective trials and no randomized control trial is there to prove their efficacy.

Aortic Valvular Calcification

new potential therapeutic  target for prevention aortic valve calcification i.e. Lp(a).Article published in NEJM Feb 7 2013 from Johns Hopkins, Harvard University, McGill University, the University of Iceland and the National Institutes of Health says, there is variant of Lp(a) which is associated with aortic valve calcification. In this publication genomewide association was evaluated for 6942 participants of aortic valvular calcification and 3795 participants of mitral valve calcification, detected by CT scanning.

Previous studies showed association of Lp(a) with calcification of aortic valve. Causal or just marker of calcification was not confirmed, present study shows causal relationship of Lp(a) and aortic valve calcification.
From this causal relationship one may think of targeting Lp(a) for preventing aortic valve calcification. Niacin reduces Lp(a) levels. Although  HPS-2 THRIVE trial (with niacin/laropiprant) which was done for coronary artery disease did not show clinical benfit, still one may keep hope for prevention of aortic valve calcification. Time may tell about us this in future.

Types of Vascular Calcification

  • Artery Medial Calcification (AMC) – Concentric Vessel – Stiffening
  • Atherosclerotic Intimal Calcification (AIC)

Long term calcium intake and rates of all cause and cardiovascular mortality: community based prospective longitudinal cohort study

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f228 (Published 13 February 2013)

Cite this as: BMJ 2013;346:f228

  1. Karl Michaëlsson, professor1,
  2. Håkan Melhus, professor2,
  3. Eva Warensjö Lemming, researcher1,
  4. Alicja Wolk, professor3,
  5. Liisa Byberg, associate professor1

Author Affiliations

  1. 1Department of Surgical Sciences, Section of Orthopedics, Uppsala University, SE-751 85 Uppsala, Sweden

  2. 2Department of Medical Sciences, Section of Clinical Pharmacology, Uppsala University, Uppsala, Sweden

  3. 3Division of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  1. Correspondence to: K Michaëlsson karl.michaelsson@surgsci.uu.se
  • Accepted 28 December 2012

Abstract

Objective To investigate the association between long term intake of dietary and supplemental calcium and death from all causes and cardiovascular disease.

Design Prospective longitudinal cohort study.

Setting Swedish mammography cohort, a population based cohort established in 1987-90.

Participants 61 433 women (born between 1914 and 1948) followed-up for a median of 19 years.

Main outcome measures Primary outcome measures, identified from registry data, were time to death from all causes (n=11 944) and cause specific cardiovascular disease (n=3862), ischaemic heart disease (n=1932), and stroke (n=1100). Diet was assessed by food frequency questionnaires at baseline and in 1997 for 38 984 women, and intakes of calcium were estimated. Total calcium intake was the sum of dietary and supplemental calcium.

Results The risk patterns with dietary calcium intake were non-linear, with higher rates concentrated around the highest intakes (≥1400 mg/day). Compared with intakes between 600 and 1000 mg/day, intakes above 1400 mg/day were associated with higher death rates from all causes (hazard ratio 1.40, 95% confidence interval 1.17 to 1.67), cardiovascular disease (1 49, 1.09 to 2.02), and ischaemic heart disease (2.14, 1.48 to 3.09) but not from stroke (0.73, 0.33 to 1.65). After sensitivity analysis including marginal structural models, the higher death rate with low dietary calcium intake (<600 mg/day) or with low and high total calcium intake was no longer apparent. Use of calcium tablets (6% users; 500 mg calcium per tablet) was not on average associated with all cause or cause specific mortality but among calcium tablet users with a dietary calcium intake above 1400 mg/day the hazard ratio for all cause mortality was 2.57 (95% confidence interval 1.19 to 5.55).

Conclusion High intakes of calcium in women are associated with higher death rates from all causes and cardiovascular disease but not from stroke.

Introduction

Calcium is one of the most abundant minerals in the human body and plays a pivotal role in human physiology. The serum levels of calcium are strictly regulated and an insufficient calcium intake is met by a more efficient intestinal absorption and renal conservation of calcium. Calcium is also mobilised from the skeleton, which can lead to bone loss1 and subsequent risk of fractures. Consequently, to prevent fractures in elderly people previous and existing guidelines2 recommend avoidance of low calcium intake. Fractures are common, especially in women, and are associated with high disability, healthcare costs, and mortality.3 Insufficient calcium intakes might also lead to secondary hyperparathyroidism, which is associated with higher mortality.1 4 5 Supplemental use of calcium has become common, and more than 60% of middle aged and older women in the United States are regular users of calcium supplements.6 7 Worryingly, three recent reanalyses of randomised trials in women have indicated a higher risk of both ischemic heart disease and stroke with calcium supplements,8 9 10 a pattern not observed in a reanalysis of another randomised trial.11 Few cohort studies in women have examined the association between dietary and supplemental intake of calcium with risk of cardiovascular incidence and mortality; instead,12 13 14 15 16 the focus has been on the incidence of stroke, with both contrary and inconsistent findings.12 13 14 16

We hypothesised that long term intake of low or high calcium increases the risk of cardiovascular mortality. We investigated associations between long term dietary and supplemental intake of calcium with all cause mortality as well as with cardiovascular mortality in a large population based prospective study of Swedish women.

Methods

The Swedish mammography cohort

The Swedish mammography cohort was established in 1987-90. All women (n=90 303) residing in two Swedish counties (Uppsala and Västmanland) and born between 1914 and 1948 received a mailed invitation to a routine mammography screening. Enclosed with this invitation was a questionnaire covering diet (food frequency questionnaire) and lifestyle, which was completed by 74% of the women. In 1997, a second, expanded questionnaire was distributed to those who were still living in the study area (response rate 70%). The study sample with exclusions has been described previously.17 18 In all, 61 433 women with baseline data (1987-90) and 38 984 with data from 1997 were available for analysis in the present study (fig 1⇓).

Fig 1 Study samples in Swedish mammography cohort

Outcomes

Follow-up was through the Swedish cause of death registry. Complete linkage with the register is rendered by the personal identity number provided to all Swedish residents. Since 1952 the National Board of Health and Welfare has collected information on the causes of death for all Swedish residents in the cause of death registry. We used the underlying cause of death in the registry to define the outcomes of death from all causes, cardiovascular disease (international classification of diseases, ninth and 10th revisions; ICD-9 codes 390-459 or ICD-10 codes I00-I99), ischaemic heart disease (ICD-9 codes 410-414 or ICD-10 codes I20-I25), and stroke (ICD-9 codes 430-436 or ICD-10 codes I60-I64).

Dietary assessment

The food frequency questionnaires have been described previously.17 19 20 The participants reported their average frequency of consumption of up to 96 foods and beverages during the past year. For most food items, eight categories for frequency of consumption were provided, ranging from never to three or more times daily. For some commonly consumed foods such as milk, sour milk/yogurt, and cheese, participants could fill in the exact number of servings they consumed daily or weekly. We estimated nutrient intakes by multiplying the consumption frequency of each food item by the nutrient content of age specific portion sizes. Nutrient data were obtained from the Swedish National Food Administration database.21 We adjusted nutrient intakes for total energy intake (7.1 MJ or 1700 kcal, mean in the study population) using the residual method.22 To better account for changes in diet during follow-up and to better represent long term dietary intake we treated calcium intake as cumulative average intake.23 In the second questionnaire the lifetime use of dietary supplements and multivitamins was reported. In Sweden one calcium dose contains 500 mg if from calcium supplements and 120 mg if from multivitamins. Total calcium intake included supplemental calcium from any source. Even if supplement use was absent in the first food frequency questionnaire (baseline questionnaire), the frequency of calcium containing supplement use (with or without vitamin D) within the cohort during the first years of follow-up was low (6%),24 and this proportion was similar across the whole range of dietary calcium intake. Calcium intake in the 1997 food frequency questionnaire correlated well with estimates from 14 repeated 24 hour recalls over one year (r=0.77).25 Furthermore, a second validation of calcium intake was carried out with four seven day food records every third month in 104 of the women (r=0.72). Bland-Altman plots revealed only small systematic errors related to intake level between the methods, and the average difference with 95% confidence interval between the 1997 food frequency questionnaire and seven day food record was 56.4 mg/day (95% confidence interval −4.4 to 108.4 mg/day)—that is, as previously reported,25 a tendency of higher estimates for calcium intake with the food frequency method. Similar estimates were achieved for the baseline questionnaire.24

Comorbidity and other additional information

Lifestyle information was obtained from the questionnaires. This information included the use of postmenopausal oestrogen therapy and menopausal status, parity, weight and height, smoking habits, and leisure time physical activity during the past year, with five predefined levels ranging from one hour weekly to more than five hours weekly. Physical activity, collected in the 1997 questionnaire, is valid compared with activity records and accelerometer data.26 We divided educational level into four categories: up to 9 years, 10-12 years, more than 12 years, and other (such as vocational). Diagnosis codes were collated from the national patient registry (ICD codes 8, 9, and 10) to calculate Charlson comorbidity scores.27 28 The Charlson comorbidity index predicts the 10 year mortality for a patient who may have a range of comorbid conditions (up to 22 diseases). Each condition is assigned a score of 1 to 6 depending on the risk of dying associated with this condition.

Statistical analysis

For each participant, follow-up time was accrued from baseline (1987-90) until the first date of death, date of leaving the study regions, or the end of the study period (31 December 2008), whichever occurred first. In secondary analyses we considered time to incidence of cardiovascular disease, ischaemic heart disease, and stroke. To improve the validity of our exposure estimate, we used a calibrated calcium intake obtained by usage of linear regression coefficients between food records (FR) and the food frequency questionnaire (FFQ): (RiFR=αFR+ βFR* FFQi, (R reported calcium in the food records, i in the individual)).29 Using Cox proportional hazards regression we estimated age adjusted and multivariable adjusted hazard ratios and their 95% confidence intervals for prespecified categories of calcium intake: <600, 600-999, 1000-1399, and ≥1400 mg/day. To facilitate comparisons of the estimates we used the same category cut-offs in the analysis of dietary and total calcium intake. We estimated the risk with use of calcium containing supplements from the date of the second questionnaire survey (from 1 January 1998). The proportional hazard assumptions in the Cox models were confirmed graphically by comparing Nelson-Aalen plots. Non-linear trends of risk were additionally analysed using restricted cubic-spline Cox regression. We used four “knots” placed at centiles 5, 35, 65, and 95 of the cumulative average calcium intake.30 The reference level was set to 800 mg of calcium, which corresponds to the recommended daily intake for Swedish women aged more than 50 years.31

To minimise potential bias we used the directed acyclical graph approach to identify a suitable multivariable model. The model included age, total energy and vitamin D intake, body mass index, height (all continuous), educational level (≤9, 10-12, >12 years, other), living alone (yes or no), use of supplements containing calcium (yes or no), a healthy dietary pattern (fifths), physical activity (five categories), smoking status (never, former, current), and score on the Charlson comorbidity index (continuous, 1-16).27 28 A healthy dietary pattern was defined by using a validated method.3233 Briefly, we used factor analysis to derive the dietary pattern empirically. Factor analysis reduces dietary data to a few composite factors (one being a healthy dietary pattern) that describe the eating pattern in the population. Other potential covariates (such as menopausal status; hormone replacement therapy; intakes of total fat, retinol, alcohol, potassium, phosphorous, and protein; nulliparity; and previous fracture of any type) in the multivariable models only marginally changed the relations and were therefore not included in the models. We treated covariates as cumulative averages.28 The Markov chain Monte Carlo multiple imputation method was used to impute covariates not assessed in the baseline questionnaire in 1987-90 (for example, smoking habits and physical activity). Restriction to non-missing data did not alter our interpretation of the results (data not shown). Moreover, in an attempt to examine whether calcium supplement use modified the association between dietary calcium intake and mortality, we performed stratified analysis by calcium supplement use (no use, use of any type of calcium containing supplements, and specific use of calcium tablets). Additionally, we estimated the synergy index between dietary calcium intake and calcium tablet use.34 We performed sensitivity analysis, limiting the analysis to baseline data using ordinary Cox’s regression without time updated information. In an attempt to validate the robustness of the Cox’s regression model using information updated over time, we used marginal structural modelling.35 The categorical exposure in the marginal structural models was treated as described previously.36 We calculated an additional inverse probability weight for having time varying data, and we gave a weight of zero to those without time varying data.

In addition to ultraviolet radiation and genes, vitamin D intake is a determinant of vitamin D status,37 38 39 and vitamin D insufficiency is related to cardiovascular disease mortality and incidence.40 We therefore investigated effect measure modification between dietary calcium and vitamin D intake by including a product interaction term in the multivariable models and performing likelihood ratio tests of its contribution in nested models. We further calculated the relative excess risk that is due to interaction.34 When analysing cause specific mortality, we considered the potential competing risk problem from other causes of mortality41 and cumulative incidence curves.42 The subhazard ratios were similar to the hazard ratios from the ordinary Cox regression, suggesting no major effect of competing risks, which is also the conclusion drawn after analysis of cumulative incidence curves (data not shown).

The statistical analyses were performed with STATA 11 and SAS, version 9.2.

Results

Table 1⇓ lists the characteristics of the study participants by categories of calcium intake. The average total cumulative calcium intake in the lowest category was 572 mg/day and in the highest was 2137 mg/day. With increasing categories of energy standardised calcium intake, the reported intake for most other nutrients also increased, although alcohol intake tended to decrease. There were small differences in calcium supplement use, comorbidity, educational level, smoking status, and physical activity level between categories of calcium intake.

Vitamin D intake did not significantly modify the associations between calcium intake and the rate of deaths from all causes, cardiovascular disease, or ischaemic heart disease (results not shown).

Discussion

In this study of women in the Swedish mammography cohort, a high calcium intake (>1400 mg/day) was associated with an increased rate of mortality, including death from cardiovascular disease. The increase was moderate with a high dietary calcium intake without supplement use, but the combination of a high dietary calcium intake and calcium tablet use resulted in a more pronounced increase in mortality. For most women with lower intakes we observed only modest differences in risk.

Strengths and weaknesses of the study

Strengths of our study include the population based prospective design, study size, and repeated measurements of calcium intake, as well as a large number of potential covariates. Date and cause of death were traced through national healthcare registries and deterministic record linkage, permitting complete ascertainment of the outcomes. The accuracy of classification of causes of death in the cause of death registry and diagnoses in the national patient registry are high.43 Furthermore, we adjusted for several important covariates (for example, smoking, socioeconomic status, physical activity, nutrients other than calcium, educational level, and comorbidity), but residual confounding remains a possible limitation. The lower age adjusted rates of death from all causes and cardiovascular disease among women with a high total calcium intake were largely explained by their use of dietary supplements (table 2), a variable considered in the multivariable models. Other health related covariates, including a healthy diet and level of physical activity contributed to a lesser degree. People who use dietary supplements have, on average, a healthier lifestyle and a lower risk factor profile for cardiovascular disease44 and not considering this might distort the risk estimates. Moreover, the low proportion of women who took prescription calcium tablets (6%), containing a four times higher dose of calcium than in regular multivitamin dietary supplements, made it difficult to detect modestly strong associations with calcium tablet use specifically. Dietary assessment methods are prone to several limitations, affecting both the precision and accuracy of the measurement. In larger studies, a food frequency questionnaire is used to assess the habitual intake of diet, and a recent review concluded that it was a valid method for assessing dietary mineral intake, particularly for calcium.45 The food frequency questionnaire may, to some extent, overestimate calcium intake,25 which was also indicated by our validation. A further limitation in our study is the use of age standardised portion sizes and not actual individual portion sizes. By use of our calibrated analysis of calcium intake, we none the less tried to avoid some misclassification of study participants. By using repeated measurements on dietary intake we increased the accuracy of the measurement but may also have introduced bias using time dependent Cox regression models. Indeed, after using only baseline data and also after performing the marginal structural model analyses, we no longer observed an increased mortality for women with low calcium intakes or a high total calcium intake. Without being causally linked to death, a low calcium intake could therefore be viewed as a marker of frailty or a less healthy behaviour associated with a higher mortality. There are, however, also theoretical drawbacks of our causal inference model. It is sensitive to correct model specifications and indeed renders estimates with lower precision than ordinary Cox’s regression.46 47 It is worth emphasising that traditionally obtained estimates, such as those from Cox’s regression, would not generally agree with estimates from marginal structural models even when there is no confounding.48 Irrespective of analytical approach, the observational study design precludes conclusions about causality, and cautious interpretations of the results are therefore recommended. The results for women with a high calcium intake are, however, compatible with results from previous randomised studies,8 9 10 and by fitting the marginal structural model we obtained similar risk estimates although with wider confidence intervals. Our results might also not apply to people of different ethnic origins or to men.

Strengths and weaknesses in relation to other studies

Calcium intake in adulthood and all cause mortality in women has not been previously investigated. In an analysis including 387 deaths within the Iowa Women’s Health Study cohort15 a total calcium intake below 700 mg/day but not above 1400 mg/day was associated with higher mortality from ischaemic heart disease. Furthermore, a recent reanalysis of the same cohort showed that use of calcium supplements was inversely related to the total and cardiovascular mortality rate, although the benefit was lost at the highest doses of dietary calcium intake.49In contrast, use of calcium supplements in a Finnish cohort increased the risk of cardiovascular disease.50 Intriguingly, three reanalyses of randomised trials have consistently shown a higher rate of both myocardial infarction and stroke by 25% to 30% and by 15% to 20%, respectively, with calcium supplementation.8 9 10These results were not confirmed in a reanalysis of another randomised trial using a broad composite endpoint of different cardiovascular events.11 Interestingly, the higher risk of cardiovascular events with calcium supplements in a meta-analysis8was only observed in women with a dietary calcium intake higher than 800 mg/day and not in women with lower intake levels.

The results from the few prospective cohort studies that have examined the relation between calcium intake and incidence of cardiovascular disease in women are contradictory or not conclusive. In the Nurses’ Health Study cohort there was a higher risk of stroke in women with a calcium intake below 600 mg/day.12 Similarly, in a Japanese setting with a comparably low average calcium intake, women with an intake below about 500 mg/day had a higher rate of stroke but not of coronary heart disease.13 14 None the less, calcium intake was not related to stroke incidence in a previous analysis in our cohort,16 concordant with the results of the present investigation. We have recently shown that calcium intakes above 700 mg/day do not further reduce the risk of fracture and osteoporosis.18

Vitamin D enhances, directly or indirectly, renal conservation and intestinal absorption of calcium.51 Our results suggest that vitamin D intake did not modify the association of calcium intake and mortality rate. In comparison with exposure to ultraviolet radiation and genetic constitution, vitamin D intake contributes only modestly to vitamin D status,37 38 39 which is determined by serum calcidiol levels, a metabolite not measured in the present investigation.

Possible explanations and implications

Calcium levels in serum are under tight homeostatic control, and calcium intake is not normally correlated with calcium serum levels. Diets that are low or very high in calcium can, however, override normal homeostatic control causing changes in blood levels of calcium or calciotropic hormones.52 Calcium enriched meals can reduce calcitriol, the active vitamin D metabolite, by inhibition of 1α hydroxylase53and also increase serum levels of fibroblast growth factor 23.54 Higher levels of circulating fibroblast growth factor 23 are associated with an increased risk of cardiovascular events and all cause mortality.55 56 57 In addition, fibroblast growth factor 23 downregulates calcitriol levels.58 Vitamin D suppression leads to an upregulation of the renin-angiotensin-aldosterone system and hypertension, higher levels of proinflammatory cytokines involved in the pathogenesis of atherosclerosis, increased carotid artery intima medial thickness, decreased endothelial function, hypertrophy of cardiac and vascular muscle cells, and a possible increase in serum triglycerides.59 Finally, high serum calcium levels can increase the risk of cardiovascular mortality60 by induction of a hypercoagulable state.61

Our present data together with previous observations suggest that for the prevention of fractures in elderly people18 and simultaneous avoidance of possible serious adverse events related to a high calcium intake (such as higher risk of hip fracture,18 62 cardiovascular disease,63 renal stones,64 and, as observed in the current study, mortality) emphasis should be placed on people with a low intake of calcium rather than increasing the intake of those already consuming satisfactory amounts.

Conclusion

When looking at the totality of our data, high calcium intakes were associated with higher rates of death from all causes and cardiovascular disease. Mortality was not increased between 600 and 1400 mg/day of total calcium intake, the most customary levels of intake in this setting. The suggestion of an increased risk of mortality by a low calcium intake in our study seemed to be biased by time varying confounding factors.

What is already known on this topic

  • A low calcium intake is associated with higher fracture rates in elderly people and a higher risk of stroke and fatal ischaemic heart disease
  • Meta-analyses of some randomised studies have, however, shown a higher risk of incident ischaemic heart disease and stroke with calcium supplement use
  • In observational studies, use of calcium supplements has been associated with both lower overall and cardiovascular mortality rate, as well as higher incidence of cardiovascular disease

What this study adds

  • In this Swedish cohort study of women, high intakes of calcium (>1400 mg/day) were associated with higher mortality
  • The increase was moderate with a high dietary calcium intake without supplement use, but more pronounced with a high dietary calcium intake with calcium tablet use
  • For most women with lower calcium intakes only modest differences in risk were observed

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    Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, Burckhardt P, Li R, Spiegelman D, et al. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr2007;86:1780-90.
  63. ↵
    Reid IR, Bolland MJ, Sambrook PN, Grey A. Calcium supplementation: balancing the cardiovascular risks. Maturitas2011;69:289-95.
  64. ↵
    Jackson RD, LaCroix AZ, Gass M, Wallace RB, Robbins J, Lewis CE, et al. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med2006;354:669-83.

Other related articles published on this Open Access Online Scientific Journal include the following: 

Calcium dependent NOS induction by sex hormones: Estrogen

http://pharmaceuticalintelligence.com/2012/10/03/calcium-dependent-nos-induction-by-sex-hormones/

Assessing Cardiovascular Disease with Biomarkers

http://pharmaceuticalintelligence.com/2012/12/25/assessing-cardiovascular-disease-with-biomarkers/

 

What is the role of plasma viscosity in hemostasis and vascular disease risk?

http://pharmaceuticalintelligence.com/2012/11/28/what-is-the-role-of-plasma-viscosity-in-hemostasis-and-vascular-disease-risk/

Mitochondrial dynamics and cardiovascular diseases

http://pharmaceuticalintelligence.com/2012/11/14/mitochondrial-dynamics-and-cardiovascular-diseases/

Peroxisome proliferator-activated receptor (PPAR-gamma) Receptors Activation: PPARγ transrepression for Angiogenesis in Cardiovascular Disease and PPARγ transactivation for Treatment of Diabetes

http://pharmaceuticalintelligence.com/2012/11/13/peroxisome-proliferator-activated-receptor-ppar-gamma-receptors-activation-pparγ-transrepression-for-angiogenesis-in-cardiovascular-disease-and-pparγ-transactivation-for-treatment-of-dia/

Nitric Oxide, Platelets, Endothelium and Hemostasis

http://pharmaceuticalintelligence.com/2012/11/08/nitric-oxide-platelets-endothelium-and-hemostasis/

Cardiovascular Risk Inflammatory Marker: Risk Assessment for Coronary Heart Disease and Ischemic Stroke – Atherosclerosis.

http://pharmaceuticalintelligence.com/2012/10/30/cardiovascular-risk-inflammatory-marker-risk-assessment-for-coronary-heart-disease-and-ischemic-stroke-atherosclerosis/

Endothelial Function and Cardiovascular Disease

http://pharmaceuticalintelligence.com/2012/10/25/endothelial-function-and-cardiovascular-disease/

NO Nutritional remedies for hypertension and atherosclerosis. It’s 12 am: do you know where your electrons are?

http://pharmaceuticalintelligence.com/2012/10/07/no-nutritional-remedies-for-hypertension-and-atherosclerosis-its-12-am-do-you-know-where-your-electrons-are/

Too Much Vitamin D Can Be as Unhealthy as Too Little

http://pharmaceuticalintelligence.com/2012/05/30/too-much-vitamin-d-can-be-as-unhealthy-as-too-little/

Linus Pauling: On Lipoprotein(a) Patents and On Vitamin C

http://pharmaceuticalintelligence.com/2013/01/18/linus-pauling-on-lipoproteina-patents-and-on-vitamin-c/

Special Considerations in Blood Lipoproteins, Viscosity, Assessment and Treatment

http://pharmaceuticalintelligence.com/2012/11/28/special-considerations-in-blood-lipoproteins-viscosity-assessment-and-treatment/

Artherogenesis: Predictor of CVD – the Smaller and Denser LDL Particles

Artherogenesis: Predictor of CVD – the Smaller and Denser LDL Particles

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Ubiquitin-Proteosome pathway, Autophagy, the Mitochondrion, Proteolysis and Cell Apoptosis: Part III

Curator: Larry H Bernstein, MD, FCAP

 

Introduction

This chapter is a major bridge between the chromosome and metabolism by elucidating the major regulatory role of the nuclear chromatin through interactions between the nucleus, the mitochondrion, the lysosome (phagosome), and the ribosome.  The function is an evolutionary wonder of our adaptive living world because it has ancient roots that have been passed on for millenia.  There are changes directed through this mechanism that have been carried forward and that have been modified from the age of oceanic single cell and small plantlike organism, to fish and to the lizards, dinosaurs, and birds that crawled and later hopped, and finally flew on this earth.  The genome carried the code for the construction of the “plant or animal life”.   The living creatures have had to adapt to desert, rainforest, oceanic, and moderate terrains.  In order to adapt, there were code sequence changes that enabled the adoption of the new conditions.  It is not the intention here to go into the soil conditions, essential trace elements (Cu, Cd, Se, Mn), and other key elements (C, O, N, S) that play a behind the scenes role by way of weak and strong binding, affecting the folding and affected by mutations in a code switch.  It is essential to understand that the ubiquination process is of paramount importance in underlying enzymatic reactions guiding the cells processes, such as,

  1. cell signaling
  2. cell division
  3. reaction to oxidative stress
  4. embryogenesis
  5. proliferation
  6. cell migrations
  7. differentiation
  8. cell death
  9. proteolytic destruction
  10. DNA damage and repair

Ubiquitin is related to what has been known as Coenzyme Q10.  It acts through ubiquitin-ligase.  Ligases, kinases, pyridine and pyrimidines, and purines, nucleotides and nucleosides, all are integrated within the nucleus or between the cell surface or ribosomal, lysosomal, and mitochondrial structures.  This is what we eventually call LIFE!
It is in this sense that Ubiquitin supports the unexpected paradigm: No to whole genome, yes to cell level genomics.

Discovery of Ubiquitin-mediated Protein Degradation

The work reviewed follows a seminal contribution by two Israeli and an American molecular biologists who shared the Nobel Prize in Chemistry in 2004.

The Royal Swedish Academy of Sciences awarded the Nobel Prize in Chemistry for 2004 “for the discovery of ubiquitin-mediated protein degradation” jointly to Aaron Ciechanover Technion – Israel Institute of Technology, Haifa, Israel, Avram Hershko Technion – Israel Institute of Technology, Haifa, Israel and Irwin Rose – University of California, Irvine, USA.

Aaron Ciechanover, born 1947 (57 years) in Haifa, Israel (Israeli citizen) received a Doctor’s degree in medicine in 1975 at Hebrew University of Jerusalem, and in biology in 1982 at the Technion (Israel Institute of Technology), Haifa. He is a Distinguished Professor at the Center for Cancer and Vascular Biology, and the Rappaport Faculty of Medicine and Research Institute at the Technion, Haifa, Israel.

Avram Hershko, born 1937 (67 years) in Karcag, Hungary (Israeli citizen) earned the Doctor’s degree in medicine in 1969 at the Hadassah and the Hebrew University Medical School, Jerusalem.  He is a Distinguished Professor at the Rappaport Family Institute for Research in Medical Sciences at the Technion (Israel Institute of Technology), Haifa, Israel.

http://www.youtube.com/watch?v=lGJvsmG3mhw&list=PL8814C902ACB98559&feature=p

Irwin Rose, born 1926 (78 years) in New York, USA (American citizen) achieved a Doctor’s degree in 1952 at the University of Chicago, USA. Specialist at the Department of Physiology and Biophysics, College of Medicine, University of California, Irvine, USA.

Proteins labelled for destruction

Proteins build up all living things: plants, animals and therefore us humans. In the past few decades biochemistry has come a long way towards explaining how the cell produces all its various proteins. But as to the breaking down of proteins, not so many researchers were interested. Aaron Ciechanover, Avram Hershko and Irwin Rose went against the stream and at the beginning of the 1980s discovered one of the cell’s most important cyclical processes, regulated protein degradation. For this, they are being rewarded with the 2004 Nobel Prize in Chemistry.

The label consists of a molecule called ubiquitin. This fastens to the protein to be destroyed, accompanies it to the proteasome where it is recognised as the key in a lock, and signals that a protein is on the way for disassembly. Shortly before the protein is squeezed into the proteasome, its ubiquitin label is disconnected for re-use.

nature10774-f5.2      nature10774-f3.2   ubiquitin structures  Rn1  Rn2

Aaron Ciechanover, Avram Hershko and Irwin Rose have brought us to realise that the cell functions as a highly-efficient checking station where proteins are built up and broken down at a furious rate. The degradation is not indiscriminate but takes place through a process that is controlled in detail so that the proteins to be broken down at any given moment are given a molecular label, a ‘kiss of death’, to be dramatic. The labelled proteins are then fed into the cells’ “waste disposers”, the so called proteasomes, where they are chopped into small pieces and destroyed.

Thanks to the work of the three Laureates it is now possible to understand at  molecular level how the cell controls a number of central processes by breaking down certain proteins and not others. Examples of processes governed by ubiquitin-mediated protein degradation are cell division, DNA repair, quality control of newly-produced proteins, and important parts of the immune defence. When the degradation does not work correctly, we fall ill. Cervical cancer and cystic fibrosis are two examples. Knowledge of ubiquitin-mediated protein degradation offers an opportunity to develop drugs against these diseases and others.

Aaron Ciechanover and Ronen Ben-Saadon. N-terminal ubiquitination: more protein substrates join in. TRENDS in Cell Biology 2004; 14 (3):103-106.

The ubiquitin–proteasome system (UPS) is involved in selective targeting of innumerable cellular proteins through a complex pathway that plays important roles in a broad array of processes. An important step in the proteolytic cascade is specific recognition of the substrate by one of many ubiquitin ligases, E3s, which is followed by generation of the polyubiquitin degradation signal. For most substrates, it is believed that the first ubiquitin moiety is conjugated, through its C-terminal Gly76 residue, to an 1-NH2 group of an internal Lys residue. Recent findings indicate that, for several proteins, the first ubiquitin moiety is fused linearly to the a-NH2 group of the N-terminal residue.

The ubiquitin–proteasome system (UPS). Ubiquitin is first activated to a high-energy intermediate by E1. It is then transferred to a member of the E2 family of enzymes. From E2 it can be transferred directly to the substrate (S, red) that is bound specifically to a member of the ubiquitin ligase family of proteins, E3

(a). This occurs when the E3 belongs to the RING finger family of ligases. In the case of a HECT-domain-containing ligase

(b), the activated ubiquitin is transferred first to the E3 before it is conjugated to the E3-bound substrate.  Additional ubiquitin moieties are added successively to the previously conjugated moiety to generate a polyubiquitin chain.

The polyubiquitinated substrate binds to the 26S proteasome complex (comprising 19S and 20S sub-complexes): the substrate is degraded to short peptides, and free and reusable ubiquitin is released through the activity of de-ubiquitinating enzymes (DUBs).

Ubiquitination on an internal lysine and on the N-terminal residue of the target substrate.

(a) The first ubiquitin moiety is conjugated, through its C-terminal Gly76 residue, to the 1-NH2 group of an internal lysine residue of the target substrate (Kn).

(b) The first ubiquitin moiety is conjugated to a free a-NH2 group of the N-terminal residue, X.

In both cases, successive addition of activated ubiquitin moieties to internal Lys48 on the previously conjugated ubiquitin moiety leads to the synthesis of a  polyubiquitin chain that serves as the degradation signal for the 26S proteasome

Ubiquitination Today

Signaling-mediated Control of Ubiquitin Ligases in Endocytosis

Simona Polo   Polo BMC Biology 2012, 10:25   http://www.biomedcentral.com/1741-7007/10/25

Ubiquitin-dependent regulation of endocytosis plays an important part in the control of signal transduction, and therefore relates to regulation of ubiquitination in the endocytic pathway.

Signal transduction from transmembrane cell surface receptors to nuclear transcription factors is regulated at multiple levels. The covalent attachment of one, or often more, ubiquitin moieties has emerged as the principal mechanism for termination of signaling, by

  • targeting the receptor for endocytosis and,
  • degradation in the lysosome.

This device controls a vast array of mammalian signaling receptors, such as

  • receptor tyrosine kinases,
  • G-protein coupled receptors (GPCRs),
  • growth hormone receptors,
  • the major histocompatibility complex I,
  • NOTCH,
  • various channels and transporters, and cytokine and interferon receptors [3].

Receptors that are internalized after activation are directed

  • first into the endosomes of the endocytic pathway, and then
  • into multivesicular bodies (MVBs),

which undergo a process of maturation that ends with fusion with the lysosome and delivery of the contents for degradation. Ubiquitination of the receptor provides the crucial signal for entering this pathway.

Following Ariadne’s thread: A New Perspective on RBR Ubiquitin Ligases

Dawn M Wenzel and Rachel E Klevit

Wenzel and Klevit BMC Biology 2012, 10:24  http://www.biomedcentral.com/1741-7007/10/24

Ubiquitin signaling pathways rely on E3 ligases for effecting the final transfer of ubiquitin from E2 ubiquitin conjugating enzymes to a protein target. Here we re-evaluate the hybrid RING/HECT mechanism used by the E3 family RING-between-RINGs (RBRs) to transfer ubiquitin to substrates. We place RBRs into the context of current knowledge of HECT and RING E3s. Although not as abundant as the other types of E3s (there are only slightly more than a dozen RBR E3s in the human genome), RBRs are conserved in all eukaryotes and play important roles in biology. Re-evaluation of RBR ligases as RING/HECT E3s provokes new questions and challenges the field.

On the basis of their mechanism and structure, E3 ligases have historically been classified into two families, the HECT- and RING/UBOX-type ligases. Recently we determined that Ariadne, the defining member of a subclass of RING-containing E3 ligases known as RING-between-RINGs (RBRs), blurs the line between RING and HECT-type E3s.

Eukaryotic E3 ubiquitin ligases are generally identified by the presence of either a HECT or a RING domain. The features of each type of domain are well defined and are readily predictable by primary sequence analysis. RINGs are characterized by a regular spacing of conserved cysteines and histidines which bind two Zn2+ ions that stabilize the overall structure of this domain, allowing for recognition and activation of E2 Ub-conjugating enzymes [2]. HECT domains are identified on the basis of their similarity to the founding member of the family, E6AP. In contrast to RING domains, which can occur at any position within a given protein, all known HECT domains are found at the carboxy-terminal end of their respective proteins.

There are two general mechanisms by which the ultimate substrate-ubiquitin isopeptide adduct is formed. An essential difference between the two mechanisms is

  • the location of activated ubiquitin at the final transfer step.

In reactions involving RING/UBOX-type ligases,

  • the ubiquitin is attached to an E2 to form an E2~Ub thioester conjugate, and the
  • E3 binds both substrate and the E2~Ub simultaneously
  • to promote the aminolysis reaction in which ubiquitin is transferred to a lysine on a substrate.

Ubiquitin ligases and beyond

Ivan Dikic and Miranda Robertson

Dikic and Robertson BMC Biology 2012, 10:22  http://www.biomedcentral.com/1741-7007/10/22

It was already clear in 2004 that the number of ubiquitinating and deubiquitinating enzymes was very large, and that ubiquitin tags can be attached to proteins either as monomers or as poly-ubiquitin chains. But it had only recently been discovered that there are at least seven different kinds of poly-ubiquitin chains, and how the diversity of poly-ubiquitin signals is generated and interpreted in cells was still to be explored.  In a series of articles the first three of which are published this month, we review what is now known about some of the central issues in research on ubiquitination, revisiting the questions of

  • how ubiquitin signals are conjugated to and removed from specific targets, and
  • how they are recognized and contribute to the regulation of central processes in cells.

Where are we now?

Ubiquitin is a protein of 76 amino acids attached to a lysine in its target proteins either as a monomer or as a poly-ubiquitin chain. Each monomer is linked through its carboxy-terminal glycine to (usually) a lysine in the preceding ubiquitin in the chain. Three enzymes, known generically as E1, E2 and E3, act in series to catalyze ubiquitination. The E1 is the ubiquitin-activating enzyme, to which ubiquitin becomes attached in an ATP-dependent reaction through a reactive thioester bond.

Ubiquitin is a small, compact protein characterized by a b-grasp fold.

Ubiquitin is a compact protein with a b-grasp fold. The seven lysines that can be linked to the terminal glycine of another ubiquitin molecule to form poly-ubiquitin chains are colored red. The green shading indicates the hydrophobic patch through which ubiquitin interacts with specific ubiquitin-binding proteins. Image created by Masato Akatsu, Frankfurt University.

Three enzymes act in sequence to ubiquitinate targets. The E1 enzyme is the activating enzyme, to which ubiquitin is attached in an ATP-dependent reaction by a thioester bond. The E2 enzyme is the conjugating enzyme, to which the ubiquitin is transferred from the E1. The E3 is the ubiquitin ligase, which directly or indirectly catalyzes the transfer of the ubiquitin to the target protein (the substrate), with the formation of an isopeptide bond.

HECT and RING ligases act by different mechanisms. HECT E3 ligases

  • directly catalyze the attachment of ubiquitin to the substrate, whereas
  • in the case of RING ligases the ubiquitin is transferred from the E2 which, with the substrate, is bound to the E3.
  1. E2 is the ubiquitin-conjugating enzyme, to which the ubiquitin is transferred from the E1; and
  2. E3 is the ubiquitin ligase, which binds the target protein and directly or indirectly catalyzes its ligation to the ubiquitin.

The E3 therefore determines the substrate specificity of ubiquitination, and

  • the diversity of the cellular functions of ubiquitination is reflected in the existence of some hundreds of different mammalian E3s, compared with a few dozen E2s and two E1s.

The E2 conjugating enzymes have special significance in determining the type of ubiquitin chain assembled. There are seven lysines in ubiquitin, and poly-ubiquitin chains can be assembled through linkage to any of the seven: the distinct chains are known as K6, K11, K27, K29, K33, K48 and K63 chains, depending upon the lysine through which the monomers are linked. In most cases (the so-called RING E3 ligases are by far the most numerous) it is the

  • E2 that decides which type of chain is made.

This generalization, and the generalization that

  • ubiquitination involves linkage through a lysine

fell victim in 2006 to the discovery that ubiquitin chains can be formed through linkage between the carboxy-terminal glycine of one ubiquitin and the amino-terminal methionine of another, to form so-called

  • linear ubiquitin chains;

and in this case it is the E3 (a complex known as LUBAC) that determines the linkage. What we now know of the mechanism of linear ubiquitin chain assembly and the function of linear ubiquitin chains in immune signaling is discussed by Henning Walczak, Kazuhiro Iwai and Ivan Dikic [2] in one of the three inaugural reviews published this month.

A third generalization has succumbed to research described in the second article, from Dawn Wenzel and Rachel Klevit [3]. E3 ubiquitin ligases have until recently been classified as belonging to one of two structurally and functionally distinct families:

  • the HECT ligases, and
  • the RING/Ubox ligases.

The mechanisms of these ligases are lucidly outlined by Wenzel and Klevit and illustrated schematically in their Figure 1.  Briefly,

  • whereas in the case of the HECT ligases, the ubiquitin is transferred from the E2 to the E3, which then directly catalyzes its attachment to the substrate,
  • in the RING ligases, the ubiquitin is transferred from the E2 to the substrate bound by the E3 (Figure 3).
  • The RBR ligases, which are the topic of the article by Wenzel and Klevit, contain a RING domain that is structurally similar to that of other RING-type E3s, and
  • had been regarded as a subclass of RING ligases; but it transpires that
  • the RBR ligases behave more like the HECT family of E3s, and directly transfer the ubiquitin to the target protein.

The active enzyme in the LUBAC complex belongs to the RBR subclass of E3s, helping to explain its eccentric behaviour. These fresh insights however raise again outstanding issues of how the different domains of these ligases contribute to their catalytic action and the type of chain assembled by them, and show how astonishingly little is still known about some of the fundamental mechanisms of ubiquitination.

Beyond ligases

The world beyond the assembly of ubiquitin chains and the attachment of ubiquitin to cellular targets now encompasses all of cell biology. Ubiquitin chains of different linkages have distinct structural properties the principles of whose recognition by ubiquitin-binding proteins have yet to be fully explored. In particular, it is not known

  • how the ubiquitin-binding modules that recognize mono-ubiquitins and the different poly-ubiquitin chains achieve the specificity for different ubiquitin species, and
  • how this is translated into physiological responses.

Recent studies have provided initial data about the mechanisms of deconjugation and functions of deubiquitinating enzymes, but many questions on the specificity of deubiquitinating enzymes and their roles in cell-specific functions remain open.

In the third review published this month, Simona Polo reaches into the territory of cell biology and explores the contribution of ubiquitination to the regulation of cell signaling by endocytosis [4],

  • drawing parallels with the regulation at many levels of signaling pathways by phosphorylation.

The critical issue here is how ligand-induced signaling regulates the activity of the E3 ligases that ubiquitinate receptors to initiate endocytic sorting for subsequent receptor degradation in the lysosome. Another important contribution of ubiquitination to the regulation of endocytosis is the ubiquitination of endocytic adaptor molecules through a process called coupled mono-ubiquitination that can be either E3-dependent and E3-independent.

Dikic I and Robertson M: Ubiquitin ligases and beyond. BMC Biology 2012, 10:22. doi:10.1186/1741-7007-10-22

http://BMCbiology.com/Ubiquitin ligases and beyond/

Crystallographic Structure of Ubiquitin in Complex with Cadmium Ions

IA Qureshi, F Ferron, CC Seh, P Cheung and J Lescar*

BMC Research Notes 2009, 2:251 doi:10.1186/1756-0500-2-251
http://www.biomedcentral.com/1756-0500/2/251

Background: Ubiquitination

  • is catalyzed by a specific enzymatic cascade ultimately leading to
  • the conjugation of ubiquitin to lysine residues of the target protein that can be the ubiquitin molecule itself and
  • to the formation of poly-ubiquitin chains.

We present the crystal structure at 3.0 Å resolution of bovine ubiquitin crystallized in presence of cadmium ions. Two molecules of ubiquitin are present in the asymmetric unit.

  • this non-covalent dimeric arrangement brings Lys-6 and Lys-63 of each crystallographically-independent monomer
  • in close contact with the C-terminal ends of the other monomer.
  • Residues Leu-8, Ile-44 and Val-70 that form a hydrophobic patch at the surface of the Ub monomer are trapped at the dimer interface.

The structural basis for signalling by poly-Ub chains relies on a visualization of conformations of alternatively linked poly-Ub chains. This arrangement of ubiquitin could illustrate how linkages involving Lys-6 or Lys-63 of ubiquitin are produced in the cell. It also details how ubiquitin molecules can specifically chelate cadmium ions.

The Fission Yeast COP9/signalosome is involved in Cullin Modification by Ubiquitin-related Ned8p

C Zhou, V Seibert, R Geyer, E Rhee, S Lyapina, … and Dieter AWolf*    Dieter AWolf* – dwolf@hsph.harvard.edu

BMC Biochemistry (2001) 2:7     http://www.biomedcentral.com/1471-2091/2/7    http://BMC.com/The fission yeast COP9/signalosome is involved in cullin modification by ubiquitin-related Ned8p

Background: The function of the fission yeast cullins Pcu1p and Pcu4p requires modification by the ubiquitin-related peptide Ned8p. A recent report by Lyapina et al. shows that the COP9/signalosome (CSN), a multifunctional eight subunit complex, regulates Ned8p modification of Pcu1p. Disruption of caa1/csn1, results in accumulation of Pcu1p exclusively in the modified form. However, it remained unclear whether this reflects global control of all cullins by the entire CSN complex.
Results: multiple CSN subunits control Ned8p modification of Pcu3p, another fission yeast cullin, which, in complex with the RING domain protein Pip1p, forms a ubiquitin ligase that functions in cellular stress response. Pcu3p is modified by Ned8p on Lys 729 and accumulates exclusively in the neddylated form in cells lacking the CSN subunits 1, 3, 4, and 5. These CSN subunits co-elute with Pcu3p in gel filtration fractions corresponding to ∼ 550 kDa and specifically bind both native and Ned8p-modified Pcu3p in vivo. While CSN does not influence the subcellular localization of Pcu3p,

  • Pcu3p-associated in vitro ubiquitin ligase activity is stimulated in the absence of CSN.

A UPS Autophagy Review

This discussion is another in a series discussing

  • mitochondrial metabolism,
  • energetics and regulatory function, and dysfunction, and
  • the process leading to apoptosis and a larger effect on disease,
  • with a specific targeting of neurodegeneration.

Why neurological and muscle damage are more sensitive than other organs is not explained easily. Recall with regard to mitochondrial oxidation-reduction reactions and repair that there are organ specific differences in the rates of organelle mutation errors and in the rates of repair. Consider also the effect of

  • iron-binding in the function of the cell, and
  • Ca2+ binding in the creation of the mechanic work or signal transmission carried out by the neuromuscular system.

We target the  role of ubiquitin-proteosome, and interaction with

  • autophagy,
  • mitophagy, and
  • disease.

Ubiquitin-Proteosome Pathway

Three recent papers, describing three apparently independent biological processes, highlight the role of the ubiquitin-proteasome system as a major, however selective, proteolytic and regulatory pathway. Using specific inhibitors to the proteasome, Rock et al. (1994) demonstrate a role for this protease in the degradation of the major bulk of cellular proteins. They also showed that antigen processing requires the ubiquitin-activating enzyme, El. This indicates that antigen processing is both ubiquitin dependent and proteasome dependent. Furthermore, inhibitors to the proteasome prevent tumor necrosis factor a (TNFα)-induced activation of mature NFĸB and its entry into the nucleus. The two studies clearly demonstrate that the ubiquitin-proteasome system is involved not only in

  • complete destruction of its protein substrates, but also
  • in limited proteolysis and posttranslational processing in which
  • biologically active peptides or fragments are generated.

In addition, the unstable c-Jut but not the stable v-Jun, is multi-ubiquitinated and degraded. The escape of the oncogenic v-Jun from ubiquitin-dependent degradation suggests

  • a novel route to malignant transformation.

Experimental evidence implicates the ubiquitin system in the degradation of

  • mitotic cyclins,
  • oncoproteins,
  • the tumor suppressor protein p53,
  • several cell surface receptors,
  • transcriptional regulators, and
  • mutated and damaged proteins.

Some of the proteolytic processes occur throughout the cell cycle, whereas others are tightly programmed and occur following cell cycle-dependent posttranslational modifications of the components involved. Signaling and degradation of other proteins (cell surface receptors, for example) may occur only following structural changes or modification(s) in the target molecule that results from ligand binding. Cell cycle-and modification-dependent degradation, as well the ability of the system to destroy completely or only partially its protein substrates, reflects the complexity involved in regulated intracellular protein degradation.

Enzymes of the System

The reaction occurs in two distinct steps:

  • signaling of the protein by covalent attachment of multiple ubiquitin molecules and
  • degradation of the targeted protein with the release of free and reutilizable ubiquitin.

Conjugation of ubiquitin to proteins destined for degradation proceeds, in general, in a three-step mechanism.

  1. Initially, the C-terminal Gly of ubiquitin is activated by ATP to a high energy thiol ester intermediate in a reaction catalyzed by the ubiquitin-activating enzyme, El.
  2. Following activation, E2 (ubiquitin carrier protein or ubiquitin-conjugating enzyme [USC]) transfers ubiquitin from El to the substrate that is bound to a ubiquitin-protein ligase, E3.
  3. Here an isopeptide bond is formed between the activated C-terminal Gly of ubiquitin and an c-NH2 group of a Lys residue of the substrate.

As E3 enzymes specifically synthesized by processive transfer of ubiquitin moieties to Lys-48 of the previous (and already conjugated) ubiquitin molecule. In many cases, E2 transfers activated ubiquitin directly to the protein substrate. Thus, E2 enzymes also play an important role in substrate recognition, although, in most cases, this modification is of the monoubiquitin type.

The Ubiquitin-Mediated Proteolytic Pathway

(1) Activation of ubiquitin by El and E2.

(2) Binding of the protein substrate to E3.

(3) EP dependent but EM independent monoubiquitination.

(4) EP-dependent but EM independent polyubiquitination?

(5) Ed-dependent polyubiquitination.

(6) Degradation of ubiquitin-protein conjugate by the 26s protease.

(7) “Correction” function of C-terminal hydrolase(s).

(6) Release of ubiquitin from terminal proteolytic products by &terminal hydrolase(s).

It is essential for the system that ubiquitin recycles. This function is carried out by ubiquitin C-terminal hydrolases (isopeptidases). In protein degradation, hydrolase(s) is required

  • to release ubiquitin from isopeptide linkage with Lys residues of the protein substrate at the final stage of the proteolytic process.
  • A ubiquitin C-terminal hydrolytic activity is also required
  • to disassemble polyubiquitin chains linked to the protein substrate, following or during the degradative process.
  • A “proofreading” function has been proposed for hydrolases to release free protein from “incorrectly” ubiquitinated proteins.
  • Another possibility is that ubiquitin C-terminal hydrolases are required for trimming polyubitin chains.

Hydrolases are probably required for the processing of biosynthetic precursors of ubiquitin, since most ubiquitin genes are arranged either in linear polyubiquitin arrays or are fused to ribosomal proteins. Yet another hydrolase may be required for the removal of extra amino acid residues that are encoded by certain genes at the C-termini of some polyubiquitin molecules. Ubiquitin C-terminal hydrolases may have other functions as well. High energy El-ubiquitin and E2-ubiquitin thiol esters may react with intracellular nucleophiles (such as glutathione or polyamines). Such reactions may lead to rapid depletion of free ubiquitin unless such side products are rapidly cleaved.

Recognition of Substrates

Short-lived proteins contain a region enriched with Pro, Glu, Ser, and Thr (PEST region). However, it has not been shown that this region indeed serves as a consensus proteolysis targeting signal. An interesting problem involves the evolution of the N-end rule pathway and its physiological roles. Proteins that are derived from processing of polyproteins (Sindbis virus RNA polymerase, for example) may contain destabilizing N-termini and thus are proteolyzed via the N-end rule pathway.

Using a “synthetic lethal” screen, Ota and Varshavsky attempted to isolate a mutant that requires the N-end rule pathway for viability. They characterized an extragenic suppressor of the mutation and found that it encodes a protein with a strong correlation to protein phosphotyrosine phosphatase. The target protein or the connection between dephosphorylation of phosphotyrosine and the N-end rule pathway is still obscure. In an additional study, these researchers have shown that a missense mutation in SLNI, a member of a two-component signal transduction system in yeast, is lethal in the absence, but not in the presence, of the N-end rule pathway. Further studies are required to isolate the target protein and identify the signal transduction pathway.

Two studies shed light on the role of the ubiquitin system and the proteasome in the process. Michalek et al. (1993) have shown that a mutant cell that harbors a thermolabile El cannot present peptides derived from ovalbumin following inactivation of the enzyme. In contrast, presentation of a minigene-expressed antigene peptide or presentation of exogenous similar peptide was not perturbed at the nonpermissive temperature. The important conclusion of the researchers is that the processing of the protein to peptides requires the complete ubiquitin pathway. In a complementary study, Rock et al. (1994) showed that inhibitors that block the chymotryptic activity of the proteasome also block antigen presentation, most probably by inhibiting proteolysis of the antigen (ovalbumin). Thus, it appears that processing of MHC restricted class I antigens requires both ubiquitination and subsequent degradation by the proteasome. It is likely that the proteasome catalyzes processing of these antigens as part of the 26s protease complex.

Ciechanover A. The Ubiquitin-Proteasome Proteolytic Pathway. Cell 1994; 79:13-21.
http://Cell.com/ The Ubiquitin-Proteasome Proteolytic Pathway/

Autophagy, microphagy, macrophagy

Regulation of autophagy

The protein content of the cell is determined by the balance between protein synthesis and protein degradation. At constant intracellular protein concentration, i.e. at steady state, rates of protein synthesis and degradation are equal. Although turnover of protein results in energy dissipation, regulation at the level of protein degradation effectively controls protein levels. Intracellular proteins to be degraded in the lysosomes can get access to these organelles by the following processes:

  • macroautophagy,
  • microautophagy,
  • crinophagy and selective,
  • chaperonin mediated, direct uptake of proteins.

Overview of the involvement of signal transduction in the regulation of macroautophagic proteolysis by amino acids and cell swelling.

  1. Amino acids (AA) stimulate a protein kinase cascade via a plasma membrane receptor.
  2. Receptor activation results in activation of PtdIns 3-kinase (PI3K), possibly via a heterotrimeric Gái3 protein.
  3. followed by activation of PKC-æ, PKB/Akt, p70S6 kinase (p70S6k) and finally phosphorylation of ribosomal protein S6 (S6P).
  4. The GDP-bound form of Gái3 is required for autophagic sequestration, whereas the GTP-bound form is inhibitory.

The constitutively formed phosphatidylinositol 3-phosphate (PI3P) is also required for autophagic sequestration. Therefore, inhibition of PtdIns 3-kinase activity by

  • wortmannin (W),
  • LY294002 (LY) or
  • 3-methyladenine (3MA) prevents autophagic sequestration.

Activation of PKC-æ and PKB/Akt is

  • mediated by the 3,4- and 3,4,5-phosphate forms of phosphatidylinositol (PI3,4P2 and PI3,4,5P3)
  • that are produced upon activation of PtdIns 3-kinase.

As a result of this, the first step of the macroautophagic pathway is

  • inhibited by components of the cascade that are downstream of PtdIns 3-kinase.
  • inhibition of this downstream cascade by rapamycin (RAPA) accelerates autophagic sequestration.
  • cell swelling potentiates the effect of amino acids via a change in the receptor owing to membrane stretch.

Furthermore, the site of action of the different effectors of the cytoskeleton (okadaic acid, cytochalasin, nocodazole, vinblastin and colchicine) are indicated.

  • AVi,
  • initial autophagic vacuole;
  • AVd,
  • mature degradative autophagic vacuole,
  • ER, endoplasmic reticulum.

The rate of proteolysis , an important determinant of the intracellular protein content, and part of its degradation occurs in the lysosomes and is mediated by macroautophagy. In liver, macroautophagy is very active and almost completely accounts for starvation-induced proteolysis. Factors inhibiting this process include

  • amino acids,
  • cell swelling and
  • insulin.

In the mechanisms controlling macroautophagy, protein phosphorylation plays an important role. Activation of a signal transduction pathway, ultimately leading to phosphorylation of ribosomal protein S6, accompanies Inhibition of macroautophagy.

Components of this pathway may include

  • a heterotrimeric Gi3-protein,
  • phosphatidylinositol 3-kinase and
  • p70S6 kinase.

Selectivity of Autophagy

It has been assumed for a long time that macroautophagy is a non-selective process, in which macromolecules are randomly degraded in the same ratio as they occur in the cytoplasm . However, recent observations strongly suggest that this may not always be the case, and that macroautophagy can be selective. Lysosomal protein degradation can selectively occur via ubiquitin-dependent and -independent pathways. In the perfused liver, although autophagic breakdown of protein and RNA (mainly ribosomal RNA) is sensitive to inhibition by amino acids and insulin, glucagon accelerates proteolysis but has no effect on RNA degradation.

Another example of selective autophagy is the degradation of superfluous peroxisomes in hepatocytes from clofibrate-treated rats. When hepatocytes from these rats, in which the number of peroxisomes is greatly increased, are incubated in the absence of amino acids to ensure maximal flux through the macroautophagic pathway, peroxisomes are degraded at a relative rate that exceeds that of any other component in the liver cell. The accelerated degradation of peroxisomes was sensitive to inhibition by 3-methyladenine, a specific autophagic sequestration inhibitor. Interestingly, the accelerated removal of peroxisomes was prevented by long-chain but not short-chain fatty acids. Since long-chain fatty acids are substrates for peroxisomal â-oxidation, this indicates that these organelles are removed by autophagy when they are functionally redundant.  Our hypothesis is that acylation (palmitoylation?) of a peroxisomal membrane protein protects the peroxisome against autophagic sequestration.

Under normal conditions macroautophagy may be largely unselective and serves, for example, to produce amino acids for gluconeogenesis and the synthesis of essential proteins in starvation. When cell structures are functionally redundant or when they become damaged, the autophagic system is able to recognize this and is able to degrade the structure concerned. As yet, nothing is known about the recognition signals. A possibility is that ubiquitination of membrane proteins is required to mark the structure to be degraded for autophagic sequestration.

Ubiquitin may be involved in Macroautophagy

Ubiquitin not only contributes to extra-lysosomal proteolysis but is also involved in autophagic protein degradation. Thus, in fibroblasts ubiquitin–protein conjugates can be found in the lysosomes, as shown by immunohistochemistry and immunogold electron microscopy. Free ubiquitin can also be found inside lysosomes. Accumulations of ubiquitin–protein conjugates in filamentous, presumably lysosomal, structures are also found in a large number of neurodegenerative diseases. Mallory bodies in the liver of alcoholics also contain ubiquitin–protein conjugates.

This presence of ubiquitin–protein conjugates in filamentous inclusions in neurons and other cells can be caused by a defect in the extra-lysosomal ubiquitin-dependent proteolytic pathway. However, it is also possible that these filamentous inclusions represent an attempt of the cell to get rid of unwanted material (proteins, organelles) via autophagy. Direct evidence that ubiquitin may be involved in the control of macroautophagy came from experiments with CHO cells with a temperature-sensitive mutation in the ubiquitin-activating enzyme E1. Wild-type cells increased their rate of proteolysis in response to stress (amino acid depletion, increased temperature). This was prevented by the acidotropic agent ammonia or by the autophagic sequestration inhibitor 3-methyladenine, indicating that the accelerated proteolysis occurred by autophagy. In the mutant cells, there was no such increase in proteolysis in response to stress at the restrictive temperature.

Autophagy and Carcinogenesis

In cancer development, cell growth is mainly induced by inhibition of protein degradation, since differences in the rate of protein synthesis between tumorigenic cells and their normal counterparts are rather small. A striking example of how reduced autophagic proteolysis can contribute to cell growth can be found in the development of liver carcinogenesis. This decrease in autophagic flux results from a decrease in the rate of autophagic sequestration and is already detectable in the early preneoplastic stage. Autophagic flux is then hardly inhibitable by amino acids nor is it inducible by catabolic stimuli and declines in the more advanced stage of cancer development to a rate of less than 20% of that seen in normal hepatocytes. The fact that the addition of 3-methyladenine to hepatocytes from normal rats increased hepatocyte viability to the same level as observed for the tumour cells strongly suggests that the fall in autophagic proteolysis contributes to the rapid growth rate of these cells and gives them a selective advantage over the normal hepatocytes.

Underlying control mechanisms for autophagy are gradually being unraveled. It is perhaps not surprising that protein phosphorylation and signal transduction are key elements in these mechanisms. The discovery of an amino acid receptor in the plasma membrane of the hepatocyte with a signal transduction pathway coupled to it may have important repercussions, not only for the control of macroautophagy but also for the control of other pathways.

It remains to be seen whether the details of the mechanisms controlling the process in yeast are similar to those in mammalian cells. For example, it is not known whether amino acids are able to control the process as they do in mammalian cells.

Blommaart EFC, Luiken JJFP, Meijer AJ. Autophagic proteolysis: control and specificity. Histochemical Journal (1997); 29:365–385.
http://HistochemJ.com/ Autophagic proteolysis: control and specificity/

A Novel Type of Selective Autophagy

Eukaryotic cells use autophagy and the ubiquitin–proteasome system (UPS) as their major protein degradation pathways. Whereas the UPS is required for the rapid degradation of proteins when fast adaptation is needed, autophagy pathways selectively remove protein aggregates and damaged or excess organelles. However, little is known about the targets and mechanisms that provide specificity to this process. Here we show that mature ribosomes are rapidly degraded by autophagy upon nutrient starvation in Saccharomyces cerevisiae. Surprisingly, this degradation not only occurs by a nonselective mechanism, but also involves a novel type of selective autophagy, which we term ‘ribophagy’. A genetic screen revealed that selective degradation of ribosomes requires catalytic activity of the Ubp3p/Bre5p ubiquitin protease. Although Ubp3p and Bre5p cells strongly accumulate 60S ribosomal particles upon starvation, they are proficient in starvation sensing and in general trafficking and autophagy pathways. Moreover, ubiquitination of several ribosomal subunits and/or ribosome associated proteins was specifically enriched in Ubp3p cells, suggesting that the regulation of ribophagy by ubiquitination may be direct. Interestingly, Ubp3p cells are sensitive to rapamycin and nutrient starvation, implying that selective degradation of ribosomes is functionally important in vivo. Taken together, our results suggest a link between ubiquitination and the regulated degradation of mature ribosomes by autophagy.

Kraft C, Deplazes A, Sohrmann M,Peter M. Mature ribosomes are selectively degraded upon starvation by an autophagy pathway requiring the Ubp3p/Bre5p ubiquitin protease. Nature Cell Biology 2008; 10(5): 603-609. DOI: 10.1038/ncb1723.  www.nature.com/naturecellbiology
http://nature.com/naturecellbiol/ Mature ribosomes are selectively degraded upon starvation by an autophagy pathway requiring the Ubp3p/Bre5p ubiquitin protease/

Mitochondrial Damage and Repair, Mitophagy

Mitochondrial Failure and Protein Degradation

Progressive mitochondrial failure is tightly associated with the development of most age-related human diseases including neurodegenerative diseases, cancer, and type 2 diabetes. This tight connection results from the double-edged sword of mitochondrial respiration, which is responsible for generating both ATP and ROS, as well as from risks that are inherent to mitochondrial biogenesis. To prevent and treat these diseases, a precise understanding of the mechanisms that maintain functional mitochondria is necessary. Mitochondrial protein quality control is one of the mechanisms that protect mitochondrial integrity, and increasing evidence implicates the cytosolic ubiquitin/proteasome system (UPS) as part of this surveillance network. This review discusses our current understanding of UPS-dependent mitochondrial protein degradation, its roles in diseases progression, and insights into future studies.

While mitochondria have their own genome, about 99% of the roughly 1000 mitochondrial proteins are encoded in the nuclear genome. Most mitochondrial proteins are therefore

  • synthesized in the cytoplasm,
  • unfolded,
  • transported across one or both mitochondrial membranes,
  • then refolded and/or assembled into complexes (Tatsuta, 2009).

Failure of this complex series of events generates unfolded or misfolded proteins within mitochondria, often disrupting critical functions.

Mitochondrial oxidative phosphorylation generates usable cellular energy in the form of ATP, but also produces reactive oxygen species (ROS). ROS tend to react quickly, so their predominant sites of damage are mitochondrial macromolecules that are localized near the source of ROS production. Exposure to oxidative stress facilitates misfolding and aggregation of these mitochondrial proteins, leading to disassembly of protein complexes and eventual loss of mitochondrial integrity. The clearance of misfolded and aggregated proteins is constantly needed to maintain functional mitochondria. There are several systems promoting this turnover. Mitophagy, a selective mitochondrial autophagy, mediates a bulk removal of damaged mitochondria.

  • mitochondria intrinsically contain proteases in each of their compartments and these proteases recognize misfolded mitochondrial proteins and mediate their degradation.

Accumulating evidence shows that the ubiquitin proteasome system (UPS) plays an important role in mitochondrial protein degradation. At various cellular sites, the UPS is involved in protein degradation. With the help of ubiquitin E1–E2–E3 enzyme cascades, target proteins destined for destruction are marked by conjugation of K48-linked poly-ubiquitin chain. This poly-ubiquitinated protein is then targeted to the proteasome for degradation. Cells treated with proteasome inhibitors exhibit elevated levels of ubiquitinated mitochondrial proteins, suggesting the potentially important roles of the proteasome on mitochondrial protein degradation. Studies have also identified mitochondrial substrates of the UPS.

  1. Fzo1, an outer mitochondrial membrane (OMM) protein involved in mitochondrial fusion, is partially dependent on the proteasome for its degradation in yeast.
  2. The F box protein Mdm30 mediates ubiquitination of Fzo1 by Skp1-Cullin-F-boxMdm30 ligase, which leads to proteasomal degradation.

The UPS has also been implicated in mitochondrial protein degradation in higher organisms. In mammals,

  • the OMM proteins mitofusin 1 and 2 (Mfn1/2; the mammalian orthologs of Fzo1) and Mcl1 are polyubiquitinated and degraded by the proteasome.
  • VDAC1, Tom20 and Tom70 were also suggested as targets of proteasomal degradation as they are stabilized by proteasome inhibition.
  • inactivation of the proteasome also induces accumulation of intermembrane space (IMS) proteins and, consistent with this, the proteasome plays a role in degradation of the IMS protein, Endonuclease G.

Turnover of some inner mitochondrial membrane (IMM) proteins is also dependent upon the proteasome. Uncoupling proteins (UCPs) 2 and 3 exhibit an unusually short half-life compared with other IMM proteins, and Brand and colleagues showed that inactivation of the proteasome prevents their turnover in vivo and in a reconstituted in vitro system. Finally, mitochondrial matrix proteins can also be degraded by the proteasome.

Cdc48/p97 is involved in many cellular processes through its role in protein degradation and is targeted to different subcellular sites by adaptor proteins. For example, Cdc48/p97 is recruited to the endoplasmic reticulum with the help of two adaptor proteins, Npl4 and Ufd1. This implies the existence of specific adaptors that recruit Cdc48/p97 to mitochondria. Consistent with this notion, the authors recently identified a mitochondrial adaptor protein for Cdc48, which we named Vms1 (VCP/Cdc48-associated mitochondrial stress responsive 1). Vms1 interacts with Cdc48/p97 and Npl4, but not with Ufd1, which indicates that the Cdc48/p97–Npl4–Ufd1 complex functions in ER protein degradation while the Vms1–Cdc48/p97–Npl4 complex acts in mitochondria. In agreement with this notion, overexpression of Cdc48 or Npl4 rescues the Vms1 mutant phenotype while Ufd1 has no effect.

Normally, Vms1 is cytoplasmic. Vms1 recruits Cdc48 and Npl4 to mitochondria under mitochondrial stress. In agreement with the role of Cdc48/p97 in OMM protein degradation, under mitochondrial stress conditions loss of the Vms1 system results in accumulation of ubiquitin-conjugated proteins in purified mitochondria as well as stabilization of Fzo1. Accumulation of damaged and misfolded mitochondrial proteins disturbs the normal physiology of the mitochondria, leading to mitochondrial dysfunction. As expected, the Vms1 mutants progressively lose mitochondrial respiratory activity, eventually leading to cell death. The VMS1 gene is broadly conserved in eukaryotes, implying an important functional role in a wide range of organisms. The C. elegans Vms1 homolog exhibits a similar pattern of mitochondrial stress responsive translocation and is required for normal lifespan. Additionally, mammalian Vms1 also forms a stable complex with p97. Thus, Vms1 is a conserved component of the UPS-dependent mitochondrial protein quality control system.

The UPS regulates mitochondrial dynamics and initiation of mitophagy

The UPS regulates mitochondrial dynamics. Major proteins involved in mitochondrial fission or fusion (e.g. Mfn1/2, Drp1 and Fis1) are degraded by the UPS.  MITOL, a mitochondrial E3 ubiquitin ligase, is required for Drp1-dependent mitochondrial fission as depletion or inactivation of MITOL blocks mitochondrial fragmentation. Moreover, knockdown of USP30, an OMM-localized deubiquitinating enzyme, induces an elongated mitochondrial morphology, suggesting a defect in fission. Through this regulatory process, the UPS controls mitochondrial dynamics. Parkin, an E3 ligase involved in mitophagy, utilizes the UPS to enhance mitochondrial fission through degradation of components of the fusion machinery. By facilitating fragmentation of damaged mitochondria, which is essential for initiation of mitophagy, Parkin stimulates mitophagy. The underlying mechanisms linking the UPS to the regulation of mitochondrial dynamics remain unclear.

Accumulation of Aberrant Proteins and Human Diseases

In neurodegenerative diseases wherein aberrant pathological proteins accumulate throughout the cell, including sites in mitochondria. Amyloid precursor protein (APP), a protein associated with Alzheimer’s disease, accumulates within mitochondria and is implicated in blockade of mitochondrial protein import. A, a neurotoxic APP cleavage product, can also facilitate the formation of the mitochondrial permeability transition pore (mPTP) by binding to mPTP components VDAC1, CypD and ANT, which provokes cell death.

Synuclein, a protein associated with the development of Parkinson’s disease, is targeted to the IMM where it binds to the mitochondrial respiratory complex I and impairs its function. –Synuclein interferes with mitochondrial dynamics as its unique interaction with the mitochondrial membrane disturbs the fusion process. Finally, in Huntington’s disease, increased association of the mutant huntingtin protein with mitochondria can impair mitochondrial trafficking. Moreover, accumulation of mutant huntingtin protein disrupts cristae structure and it facilitates mitochondrial fragmentation by activation of Drp1. These examples demonstrate the crucial importance of prompt removal of dysfunctional and/or aberrant proteins in maintaining functional mitochondria.

UPS-mediated mitochondrial protein degradation

Misfolded and/or damaged mitochondrial proteins destined for proteasomal degradation in the cytosol are recruited to the outer mitochondrial membrane (OMM) from each mitochondrial compartment by unknown mechanisms. Upon reaching the OMM, these proteins are presented to the proteasome through a series of events. They are K48 polyubiquitinated by the cytoplasmic (e.g. Parkin) or mitochondrial ubiquitin E3 ligases. For proteasomal degradation, polyubiquitinated mitochondrial substrate proteins need to be retrotranslocated to the cytoplasm, probably, either by the proteasome per se or by the help of UPS components such as Vms1, Cdc48/p97 and Npl4. Following dislocation to the cytoplasm, these substrate proteins are degraded by the proteasome.

Treatment of diseases that arise from defects in protein quality control will depend on greater depth in our understanding of this process, which could contribute to the development of novel therapeutic approaches. For instance, both mutant SOD1, a misfolded mitochondrial protein associated with the onset of amyotrophic lateral sclerosis, and polyglutamine expanded ataxin-3, a pathogenic protein causing Machado-Joseph disease, are ubiquitinated by MITOL and then degraded by the proteasome. Facilitating the proteasomal degradation of these aberrant proteins might therefore efficiently control diseases progression and, eventually, cure the diseases. Answering these questions would partially unveil the mysterious physiology of mitochondria, which, in turn, would facilitate the development of therapeutics to prevent and cure devastating human diseases.

Heo JM, Rutter J. Ubiquitin-dependent mitochondrial protein degradation. The International Journal of Biochemistry & Cell Biology 2011; 43:1422– 1426. www.elsevier.com/locate/biocel
http://IntJBiochemCellBiol.com/ Ubiquitin-dependent_mitochondrial_protein_degradation/

UPS Inhibitors and Apoptotic Machinery

Over the past decade, the promising results of UPSIs (UPS inhibitors) in eliciting apoptosis in various cancer cells, and the approval of the first UPSI (Bortezomib/Velcade/PS-341) for the treatment of multiple myeloma have raised interest in assessing the death program activated upon proteasomal blockage. Several reports indicate that UPSIs stimulate apoptosis in malignant cells by operating at multiple levels, possibly by inducing different types of cellular stress. Normally cellular stress signals converge on the core elements of the apoptotic machinery to trigger the cellular demise. In addition to eliciting multiple stresses, UPSIs can directly operate on the core elements of the apoptotic machinery to control their abundance. Alterations in the relative levels of anti and pro-apoptotic factors can render cancer cells more prone to die in response to other anti-cancer treatments. We have reviewed core elements of the apoptotic machinery that are under the control of the UPS.

The UPS (Ubquitin-Proteasome System)

To fulfill the protein-degradation process two branches, operating at different levels, principally comprise the UPS.

  1. enzymatic activities responsible for delivering the substrate to the degradative machinery: the targeting branch.
  2. proteolytic machinery, which ultimately fragments the protein substrate into small oligopeptides.
  • Oligopeptides are further digested to single amino acids by cytosolic proteases.

It is important to remember that conjugation of ubiquitin to a specific protein is not sufficient to determine its degradation. In fact, mono-ubiquitination or poly-monoubiquitination and in certain cases also poly-ubiquitination of proteins are post-translational modifications related to various cellular functions including DNA repair or membrane trafficking . To deliver polypeptides for proteasomal degradation poly-ubiquitin chains of more than 4 ubiquitins must be assembled through lysine-48 linkages.

There are 3 catalytic sites for each polyubiquitin chain. These sites show specific requirements in terms of substrate specificities and catalytic activities, and they are identified as

  1. trypsin-like, which prefer to cleave after hydrophobic bonds, chymotrypsin-like, which cleave at basic residues and
  2. postglutamyl peptide hydrolase-like or
  3. caspase-like activities, which cut after acidic amino acid.

Each proteasome active site uses the side chain hydroxyl group of an NH2-terminal threonine as the catalytic nucleophile, a mechanism that distinguishes the proteasome from other cellular proteases. The presence of substrate proteolysis small size peptides ranging from 3 to 22 residues are generated. Alternative catalytic sites guarantees the efficient processing of several different substrates.

UPS Inhibitors

By UPS inhibitors (UPSI) we mean small molecules that share the ability to target and inhibit specific activities of the UPS, causing the accumulation of poly-ubiquitinated proteosomal substrates. UPSIs are heterogeneous compounds and among them bortezomib is the only one used in clinical practice.

PR-171, a modified peptide related to the natural product epoxomicin, is composed of two key elements:

  1. a peptide portion that selectively binds with high affinity in the substrate binding pocket(s) of the proteasome and
  2. an epoxyketone pharmacophore that stereospecifically interacts with the catalytic threonine residue and irreversibly inhibits enzyme activity.

In comparison to bortezomib, PR-171 exhibits equal potency, but greater selectivity, for the chymotrypsin-like activity of the proteasome. In cell culture PR-171 is more cytotoxic than bortezomib. In mice PR-171 is well tolerated and shows stronger anti-tumor activity when compared with bortezomib . Clinical studies are in progress to test the safety of PR-171 at different dose levels on some hematological cancers.

Cell Death by UPSI

In vitro experiments have unambiguously established that incubation of neoplastic cells with UPSIs including bortezomib triggers their death. Apoptosis or type I cell death relies on the timed activation of caspases, a group of cysteine proteases, which cleave selected cellular substrates after aspartic residues. The turnover of a large number of cellular proteins is under the control of the UPS. Thus in principle any proteosomal substrate could contribute directly or indirectly to the cell death phenotype. Two main apoptotic pathways keep in check caspase activation.This is perfectly exemplified by two master regulators of cell life and death, p53 and NFkB.  UPSIs cause

  • NF-kB inhibition through reduced IkB degradation and,
  • in opposition; they promote stabilization and accumulation of p53.
  • c-FLIP is the most important element of the extrinsic pathway under the direct control of the UPS. Two different FLIP isoforms exist:
  1. c-FLIPL (Long) and
  2. c-FLIPS (Short).

c-FLIPL is highly homologus to caspase-8 and contains two tandem repeat Death Effector Domains (DED) and a catalytically inactive caspase-like domain. Both FLIPs can be degraded by the UPS; however they display distinct half-lives and the unique C terminus of c-FLIPS possesses a destabilizing function. The regulation of c-FLIP levels in response to UPSIs is rather controversial. Some reports indicate that UPSIs can reduce c-FLIP levels and in this manner synergize with TRAIL to promote apoptosis.

UPSIs activate multiple cellular responses and different stress signals that ultimately cause cell death. For this reason they represent broad inducers of apoptosis. In addition, since many of the available UPSIs alter the proteolytic activity of the proteasome, they represent non-specific modulators of the expression/activity of various components of the apoptotic machinery. Paradoxically they can simultaneously favor the accumulation of pro- and anti-apoptotic factors.

Brancolini C. Inhibitors of the Ubiquitin-Proteasome System and the Cell Death Machinery: How Many Pathways are Activated? Current Molecular Pharmacology, 2008; 1:24-37.
http://CurrMolecPharmacol.com/ Inhibitors_of_the_Ubiquitin-Proteasome_System_and_the_Cell_Death_ Machinery:_How_Many_Pathways_are_Activated/

Mitochondrial Quality Control

The PINK1–Parkin pathway plays a critical role in mitochondrial quality control by selectively targeting damaged mitochondria for autophagy. The AAA-type ATPase p97 acts downstream of PINK1 and Parkin to segregate fusion-incompetent mitochondria for turnover. [Tanaka et al. (2010. J. Cell Biol. doi: 10.1083/jcb.201007013)]. p97 acts by targeting the mitochondrial fusion-promoting factor mitofusin for degradation through an endoplasmic reticulum–associated degradation (ERAD)-like mechanism.

Pallanck LJ. Culling sick mitochondria from the herd. J Cell Biol 2012;191(7):1225–1227. www.jcb.org/cgi/doi/10.1083/jcb.201011068
http://jcb.com/ Culling sick mitochondria from the herd/

TRAP1 and TBP7 Interaction in Refolding of Damaged Proteins

TRAP1 is a mitochondrial antiapoptotic heat shock protein. The information available on the TRAP1 pathway describes just a few well-characterized functions of this protein in mitochondria. However, our group’s use of mass spectrometry analysis identified TBP7, an AAA-ATPase of the 19S proteasomal subunit, as a putative TRAP1-interacting protein. Surprisingly, TRAP1 and TBP7 co-localize in the endoplasmic reticulum (ER), as demonstrated by biochemical and confocal/electron microscopy analyses, and directly interact, as confirmed by FRET analysis. This is the first demonstration of TRAP1 presence in this cellular compartment. TRAP1 silencing by shRNAs, in cells exposed to thapsigargin-induced ER stress, correlates with up-regulation of BiP/Grp78, thus suggesting a role of TRAP1 in the

  • refolding of damaged proteins and in
  • ER stress protection.

Consistently, TRAP1 and/or TBP7 interference enhanced stress-induced cell death and increased intracellular protein ubiquitination. These experiments led us to hypothesize an involvement of TRAP1 in protein quality control for mistargeted/misfolded mitochondria-destined proteins, through interaction with the regulatory proteasome protein TBP7. Remarkably, the expression of specific mitochondrial proteins decreased upon TRAP1 interference as a consequence of increased ubiquitination. The proposed TRAP1 network has an impact in vivo, since

  • it is conserved in human colorectal cancers,
  • is controlled by ER-localized TRAP1 interacting with TBP7 and
  • provides a novel model of ER-mitochondria crosstalk.

Amoroso MR, Matassa DS, Laudiero G, Egorova AV. TRAP1 AND THE PROTEASOME REGULATORY PARTICLE TBP7/Rpt3 INTERACT IN THE ENDOPLASMIC RETICULUM AND CONTROL CELLULAR UBIQUITINATION OF SPECIFIC MITOCHONDRIAL PROTEINS. Cell Death and Differentiation 2012; pp? DOI : 10.1038/cdd.2011.128
http://celldeathdifferent.com/TRAP1_AND_THE_PROTEASOME_REGULATORY_PARTICLE_TBP7/Rpt3_INTERACT_IN_THE_ENDOPLASMIC_RETICULUM_AND_CONTROL_CELLULAR_UBIQUITINATION_OF_SPECIFIC
_MITOCHONDRIAL_PROTEINS
.

VMS1 and Mitochondrial Protein Degradation

We show that Ydr049 (renamed VCP/Cdc48-associated mitochondrial stress-responsive—Vms1), a member of an unstudied pan-eukaryotic protein family, translocates from the cytosol to mitochondria upon mitochondrial stress. Cells lacking Vms1 show progressive mitochondrial failure, hypersensitivity to oxidative stress, and decreased chronological life span. Both yeast and mammalian Vms1 stably interact with Cdc48/VCP/p97, a component of the ubiquitin/proteasome system with a well-defined role in endoplasmic reticulum-associated protein degradation (ERAD), wherein misfolded ER proteins are degraded in the cytosol. We show that oxidative stress triggers mitochondrial localization of Cdc48 and this is dependent on Vms1. When this system is impaired by mutation of Vms1,

  • ubiquitin-dependent mitochondrial protein degradation,
  • mitochondrial respiratory function,and
  • cell viability are compromised.

We demonstrate that Vms1 is a required component of an evolutionarily conserved system for mitochondrial protein degradation, which is necessary to maintain

  • mitochondrial,
  • cellular, and
  • organismal viability.

Heo JM, Livnat-Levanon N, Taylor EB, Jones KT. A Stress-Responsive System for Mitochondrial Protein Degradation. Molecular Cell 2010; 40:465–480.  DOI 10.1016/j.molcel.2010.10.021
http://MolecCell.com/ A_Stress-Responsive_System_for_Mitochondrial_Protein_Degradation/

Mitochondrial Protein Degradation

The biogenesis of mitochondria and the maintenance of mitochondrial functions depends on an autonomous proteolytic system in the organelle which is highly conserved throughout evolution. Components of this system include processing

  • peptidases and
  • ATP-dependent proteases, as well as
  • molecular chaperone proteins and
  • protein complexes with apparently regulatory functions.

While processing peptidases mediate maturation of nuclear-encoded mitochondrial preproteins, quality control within various subcompartments of mitochondria is ensured by ATP-dependent proteases which selectively remove non-assembled or misfolded polypeptides. Moreover, these proteases appear to control the activity- or steady-state levels of specific regulatory proteins and thereby ensure mitochondrial genome integrity, gene expression and protein assembly.

Kaser M and Langer T. Protein degradation in mitochondria. CELL & DEVELOPMENTAL BIOLOGY 2000; 11:181–190. doi: 10.1006/10.1006/scdb.2000.0166.
http://CellDevelBiol.com/Protein_degradation_in_mitochondria/

RING finger E3s

Ubiquitin-ligases or E3s are components of the ubiquitin proteasome system (UPS) that coordinate the transfer of ubiquitin to the target protein. A major class of ubiquitin-ligases consists of RING-finger domain proteins that include the substrate recognition sequences in the same polypeptide; these are known as single-subunit RING finger E3s. We are studying a particular family of RING finger E3s, named ATL, that contain a transmembrane domain and the RING-H2 finger domain; none of the member of the family contains any other previously described domain. Although the study of a few members in A. thaliana and O. sativa has been reported, the role of this family in the life cycle of a plant is still vague.

To provide tools to advance on the functional analysis of this family we have undertaken a phylogenetic analysis of ATLs in twenty-four plant genomes. ATLs were found in all the 24 plant species analyzed, in numbers ranging from 20–28 in two basal species to 162 in soybean. Analysis of ATLs arrayed in tandem indicates that sets of genes are expanding in a species-specific manner. To get insights into the domain architecture of ATLs we generated

  • 75 pHMM LOGOs from 1815 ATLs, and
  • unraveled potential protein-protein interaction regions by means of yeast two-hybrid assays.

Several ATLs were found to interact with DSK2a/ubiquilin through a region at the amino-terminal end, suggesting that this is a widespread interaction that may assist in the mode of action of ATLs;

  • the region was traced to a distinct sequence LOGO.

Our analysis provides significant observations on the evolution and expansion of the ATL family in addition to information on the domain structure of this class of ubiquitin-ligases that may be involved in plant adaptation to environmental stress.

Aguilar-Hernandez V, Aguilar-Henonin L, Guzman P. Diversity in the Architecture of ATLs, a Family of Plant Ubiquitin-Ligases, Leads to Recognition and Targeting of Substrates in Different Cellular Environments. PLoS ONE 2011; 6(8): e23934. doi:10.1371/journal.pone.0023934
http://PLoSONE.com/Diversity_in_the_Architecture_of_ATLs_a_Family_of_Plant_Ubiquitin-Ligases_Leads_to_Recognition_and_Targeting_of_Substrates_ in_Different_Cellular_Environments/

UPS Proteolytic Function Inadequate in Proteinopathies

Proteinopathies are a family of human disease caused by toxic aggregation-prone proteins and featured by the presence of protein aggregates in the affected cells. The ubiquitin-proteasome system (UPS) and autophagy are two major intracellular protein degradation pathways. The UPS mediates the targeted degradation of most normal proteins after performing their normal functions as well as the removal of abnormal, soluble proteins. Autophagy is mainly responsible for degradation of defective organelles and the bulk degradation of cytoplasm during starvation. The collaboration between the UPS and autophagy appears to be essential to protein quality control in the cell.

UPS proteolytic function often becomes inadequate in proteinopathies which may lead to activation of autophagy, striving to remove abnormal proteins especially the aggregated forms. HADC6, p62, and FoxO3 may play an important role in mobilizing this proteolytic consortium. Benign measures to enhance proteasome function are currently lacking; however, enhancement of autophagy via pharmacological intervention and/or lifestyle change has shown great promise in alleviating bona fide proteinopathies in the cell and animal models. These pharmacological interventions are expected to be applied clinically to treat human proteinopathies in the near future.

Zheng Q, Li J, Wang X. Interplay between the ubiquitin-proteasome system and autophagy in proteinopathies. Int J Physiol Pathophysiol Pharmacol 2009;1:127-142. www.ijppp.org/IJPPP904002
h
ttp://ijppp.com/Interplay between the ubiquitin-proteasome system and autophagy in proteinopathies

Ubiquitin-associated Protein-Protein Interactions

Applicability of in vitro biotinylated ubiquitin for evaluation of endogenous ubiquitin conjugation and analysis of ubiquitin-associated protein-protein interactions has been investigated. Incubation of rat brain mitochondria with biotinylated ubiquitin followed by affinity chromatography on avidin-agarose, intensive washing, tryptic digestion of proteins bound to the affinity sorbent and their mass spectrometry analysis resulted in reliable identification of 50 proteins belonging to mitochondrial and extramitochondrial compartments. Since all these proteins were bound to avidin-agarose only after preincubation of the mitochondrial fraction with biotinylated ubiquitin, they could therefore be referred to as specifically bound proteins. A search for specific

ubiquitination signature masses revealed several extramitochondrial and intramitochondrial ubiquitinated proteins representing about 20% of total number of proteins bound to avidin-agarose. The interactome analysis suggests that the identified non-ubiquitinated proteins obviously form tight complexes either with ubiquitinated proteins or with their partners and/or mitochondrial membrane components. Results of the present study demonstrate that the use of biotinylated ubiquitin may be considered as the method of choice for in vitro evaluation of endogenous ubiquitin-conjugating machinery in particular subcellular organelles and changes in ubiquitin/organelle associated interactomes. This may be useful for evaluation of changes in interactomes induced by protein ubiquitination.

Buneeva OA, Medvedeva MV, Kopylov AT, Zgoda VG, Medvedev AE. Use of Biotinylated Ubiquitin for Analysis of Rat Brain Mitochondrial Proteome and Interactome. Int J Mol Sci 2012; 13: 11593-11609; doi:10.3390/ijms130911593    http://IntJMolSci.com/Use_of_Biotinylated_Ubiquitin_for_Analysis_of_Rat_Brain_Mitochondrial_Proteome_and_Interactome/

IL-6 regulation on mitochondrial remodeling/dysfunction

Muscle protein turnover regulation during cancer cachexia is being rapidly defined, and skeletal muscle mitochondria function appears coupled to processes regulating muscle wasting. Skeletal muscle oxidative capacity and the expression of proteins regulating mitochondrial biogenesis and dynamics are disrupted in severely cachectic ApcMin/+ mice. It has not been determined if these changes occur at the onset of cachexia and are necessary for the progression of muscle wasting. Exercise and anti-cytokine therapies have proven effective in preventing cachexia development in tumor bearing mice, while their effect on mitochondrial content, biogenesis and dynamics is not well understood.

The purposes of this study were to

1) determine IL-6 regulation on mitochondrial remodeling/dysfunction during the progression of cancer cachexia and

2) to determine if exercise training can attenuate mitochondrial dysfunction and the induction of proteolytic pathways during IL-6 induced cancer cachexia.

ApcMin/+ mice were examined during the progression of cachexia, after systemic interleukin (IL)-6r antibody treatment, or after IL-6 over-expression with or without exercise. Direct effects of IL-6 on mitochondrial remodeling were examined in cultured C2C12 myoblasts.

  • Mitochondrial content was not reduced during the initial development of cachexia, while muscle PGC-1α and fusion (Mfn1, Mfn2) protein expression was repressed.
  • With progressive weight loss mitochondrial content decreased, PGC-1α and fusion proteins were further suppressed, and fission protein (FIS1) was induced.

IL-6 receptor antibody administration after the onset of cachexia improved mitochondrial content,

  • PGC-1α,
  • Mfn1/Mfn2 and
  • FIS1 protein expression.

IL-6 over-expression in pre-cachectic mice accelerated body weight loss and muscle wasting, without reducing mitochondrial content, while PGC-1α and Mfn1/Mfn2 protein expression was suppressed and FIS1 protein expression induced. Exercise normalized these IL-6 induced effects. C2C12 myotubes administered IL-6 had

  • increased FIS1 protein expression,
  • increased oxidative stress, and
  • reduced PGC-1α gene expression
  • without altered mitochondrial protein expression.

Altered expression of proteins regulating mitochondrial biogenesis and fusion are early events in the initiation of cachexia regulated by IL-6, which precede the loss of muscle mitochondrial content. Furthermore, IL-6 induced mitochondrial remodeling and proteolysis can be rescued with moderate exercise training even in the presence of high circulating IL-6 levels.

White JP, Puppa MJ, Sato S, Gao S. IL-6 regulation on skeletal muscle mitochondrial remodeling during cancer cachexia in the ApcMin/+ mouse. Skeletal Muscle 2012; 2:14-30.
http://www.skeletalmusclejournal.com/content/2/1/14

Starvation-induced Autophagy

Upon starvation cells undergo autophagy, a cellular degradation pathway important in the turnover of whole organelles and long lived proteins. Starvation-induced protein degradation has been regarded as an unspecific bulk degradation process. We studied global protein dynamics during amino acid starvation-induced autophagy by quantitative mass spectrometry and were able to record nearly 1500 protein profiles during 36 h of starvation. Cluster analysis of the recorded protein profiles revealed that cytosolic proteins were degraded rapidly, whereas proteins annotated to various complexes and organelles were degraded later at different time periods. Inhibition of protein degradation pathways identified the lysosomal/autophagosomal system as the main degradative route.

Thus, starvation induces degradation via autophagy, which appears to be selective and to degrade proteins in an ordered fashion and not completely arbitrarily as anticipated so far.

Kristensen AR, Schandorff S, Høyer-Hansen M, Nielsen MO, et al. Ordered Organelle Degradation during Starvation-induced Autophagy. Molecular & Cellular Proteomics 2008; 7:2419–2428.
http://MolecCellProteomics.com/Ordered_Organelle_Degradation_during_Starvation-induced_Autophagy/

Skeletal Muscle Macroautophagy

Skeletal muscles are the agent of motion and one of the most important tissues responsible for the control of metabolism. Coordinated movements are allowed by the highly organized structure of the cytosol of muscle fibers (or myofibers), the multinucleated and highly specialized cells of skeletal muscles involved in contraction. Contractile proteins are assembled into repetitive structures, the basal unit of which is the sarcomere, that are well packed into the myofiber cytosol. Myonuclei are located at the edge of the myofibers, whereas the various organelles such as mitochondria and sarcoplasmic reticulum are embedded among the myofibrils. Many different changes take place in the cytosol of myofibers during catabolic conditions:

  • proteins are mobilized
  • organelles networks are reorganized for energy needs
  • the setting of myonuclei can be modified.

Further,

  • strenuous physical activity,
  • improper dietary regimens and
  • aging

lead to mechanical and metabolic damages of

  • myofiber organelles,
  • especially mitochondria, and
  • contractile proteins.

During aging the protein turnover is slowed down, therefore it is easier to accumulate aggregates of dysfunctional proteins. Therefore, a highly dynamic tissue such as skeletal muscle requires a rapid and efficient system for the removal of altered organelles, the elimination of protein aggregates, and the disposal of toxic products.

The two major proteolytic systems in muscle are the ubiquitin-proteasome and the autophagy-lysosome pathways. The proteasome system requires

  • the transcription of the two ubiquitin ligases (atrogin-1 and MuRF1) and
  • the ubiquitination of the substrates.

Therefore, the ubiquitin-proteasome system can provide the rapid elimination of single proteins or small aggregates. Conversely, the autophagic system is able to degrade entire organelles and large proteins aggregates. In the autophagy-lysosome system, double-membrane vesicles named autophagosomes are able to engulf a portion of the cytosol and fuse with lysosomes, where their content is completely degraded by lytic enzymes.

The autophagy flux can be biochemicaly monitored following LC3 lipidation and p62 degradation. LC3 is the mammalian homolog of the yeast Atg8 gene, which is lipidated when recruited for the double-membrane commitment and growth. p62 (SQSTM-1) is a polyubiquitin-binding protein involved in the proteasome system and that can either reside free in the cytosol and nucleus or occur within autophagosomes and lysosomes. The GFP-LC3 transgenic mouse model allows easy detection of autophagosomes by simply monitoring the presence of bright GFP-positive puncta inside the myofibrils and beneath the plasma membrane of the myofibers, thus investigate the activation of autophagy in skeletal muscles with different contents of slow and fast-twitching myofibers and in response to stimuli such as fasting. For example, in the fast-twiching extensor digitorum longus muscle few GFP-LC3 dots were observed before starvation, while many small GFP-LC3 puncta appeared between myofibrils and in the perinuclear regions after 24 h starvation. Conversely, in the slow-twitching soleus muscle, autophagic puncta were almost absent in standard condition and scarcely induced after 24 h starvation.

Autophagy in Muscle Homeostasis

The autophagic flux was found to be increased during certain catabolic conditions, such as fasting, atrophy , and denervation , thus contributing to protein breakdown. Food deprivation is one of the strongest stimuli known to induce autophagy in muscle. Indeed skeletal muscle, after the liver, is the most responsive tissue to autophagy activation during food deprivation. Since muscles are the biggest reserve of amino acids in the body, during fasting autophagy has the vital role to maintain the amino acid pool by digesting muscular protein and organelles. In mammalian cells, mTORC1, which consists of

  • mTOR and
  • Raptor,

is the nutrient sensor that negatively regulates autophagy.

During atrophy, protein breakdown is mediated by atrogenes, which are under the forkhead box O (FoxO) transcription factors control, and activation of autophagy seems to aggravate muscle loss during atrophy. In vivo and in vitro studies demonstrated that several genes coding for components of the autophagic machinery, such as

  • LC3,
  • GABARAP,
  • Vps34,
  • Atg12 and
  • Bnip3,

are controlled by FoxO3 transcription factor. FoxO3 is able to regulate independently

  1. the ubiquitin-proteasome system and
  2. the autophagy-lysosome machinery in vivo and in vitro.

Denervation is also able to induce autophagy in skeletal muscle, although at a slower rate than fasting. This effect is mediated by RUNX1, a transcription factor upregulated during autophagy; the lack of RUNX1 results in

  • excessive autophagic flux in denervated muscle and leads to atrophy.

The generation of Atg5 and Atg7 muscle-specific knockout mice have shown that

  • with suppression of autophagy both models display muscle weakness and atrophy and
  • a significant reduction of weight, which is
  • correlated with the important loss of muscle tissue due to an atrophic condition.

An unbalanced autophagy flux is highly detrimental for muscle, as too much induces atrophy whereas too little leads to muscle weakness and degeneration. Muscle wasting associated with autophagy inhibition becomes evident and symptomatic only after a number of altered proteins and dysfunctional organelles are accumulated, a condition that becomes evident after months or even years. On the other hand, the excessive increase of autophagy flux is able to induce a rapid loss of muscle mass (within days or weeks).  Alterations of autophagy are involved in the pathogenesis of several myopathies and dystrophies.

The maintenance of muscle homeostasis is finely regulated by the balance between catabolic and anabolic process. Macroautophagy (or autophagy) is a catabolic process that provides the degradation of protein aggregation and damaged organelles through the fusion between autophagosomes and lysosomes. Proper regulation of the autophagy flux is fundamental for

  • the homeostasis of skeletal muscles during physiological situations and
  • in response to stress.

Defective as well as excessive autophagy is harmful for muscle health and has a pathogenic role in several forms of muscle diseases.

Grumati P, Bonaldo P. Autophagy in Skeletal Muscle Homeostasis and in Muscular Dystrophies. Cells 2012, 1, 325-345; doi:10.3390/cells1030325. ISSN 2073-4409. www.mdpi.com/journal/cells
http://cell.com/ Autophagy in Skeletal Muscle Homeostasis and in Muscular Dystrophies/

Parkinson’s Disease Mutations

Mutations in parkin, a ubiquitin ligase, cause early-onset familial Parkinson’s disease (AR-JP). How Parkin suppresses Parkinsonism remains unknown. Parkin was recently shown to promote the clearance of impaired mitochondria by autophagy, termed mitophagy. Here, we show that Parkin promotes mitophagy by catalyzing mitochondrial ubiquitination, which in turn recruits ubiquitin-binding autophagic components, HDAC6 and p62, leading to mitochondrial clearance.

During the process, juxtanuclear mitochondrial aggregates resembling a protein aggregate-induced aggresome are formed. The formation of these “mito-aggresome” structures requires microtubule motor-dependent transport and is essential for efficient mitophagy. Importantly, we show that AR-JP–causing Parkin mutations are defective in supporting mitophagy due to distinct defects at

  • recognition,
  • transportation, or
  • ubiquitination of impaired mitochondria,

thereby implicating mitophagy defects in the development of Parkinsonism. Our results show that impaired mitochondria and protein aggregates are processed by common ubiquitin-selective autophagy machinery connected to the aggresomal pathway, thus identifying a mechanistic basis for the prevalence of these toxic entities in Parkinson’s disease.

Lee JY,Nagano Y, Taylor JP,Lim KL, and Yao TP. Disease-causing mutations in Parkin impair mitochondrial ubiquitination, aggregation, and HDAC6-dependent mitophagy. J Cell Biol 2010; 189(4):671-679. www.jcb.org/cgi/doi/10.1083/jcb.201001039
http://JCellBiol.com/Disease-causing_mutations_in_Parkin_impair_mitochondrial_ubiquitination_ aggregation_and_HDAC6-dependent_mitophagy/

Bax Degradation a Novel Mechanism for Survival in Bcl-2 overexpressed cancer cells

The authors previously reported that proteasome inhibitors were able to overcome Bcl-2-mediated protection from apoptosis, and now show that inhibition of the proteasome activity in Bcl-2-overexpressing cells accumulates the proapoptotic Bax protein to mitochondrial cytoplasm, where it interacts to Bcl-2 protein. This event was followed by release of mitochondrial cytochrome c into the cytosol and activation of caspase-mediated apoptosis. In contrast, proteasome inhibition did not induce any apparent changes in Bcl-2 protein levels. In addition, treatment with a proteasome inhibitor increased levels of ubiquitinated forms of Bax protein, without any effects on Bax mRNA expression. They also established a cell-free Bax degradation assay in which an in vitro-translated, 35S-labeled Bax protein can be degraded by a tumor cell protein extract, inhibitable by addition of a proteasome inhibitor or depletion of the proteasome or ATP. The Bax degradation activity can be reconstituted in the proteasome-depleted supernatant by addition of a purified 20S proteasome or proteasome-enriched fraction. Finally, by using tissue samples of human prostate adenocarcinoma, they demonstrated that increased levels of Bax degradation correlated well with decreased levels of Bax protein and increased Gleason scores of prostate cancer. These studies strongly suggest that ubiquitin-proteasome-mediated Bax degradation is a novel survival mechanism in human cancer cells and that selective targeting of this pathway should provide a unique approach for treatment of human cancers, especially those overexpressing Bcl-2.

In the current study, These investigators report that

  • proteasome inhibition results in Bax accumulation before release of cytochrome c and induction of apoptosis, which is associated with the ability of proteasome inhibitors to overcome Bcl-2-mediated antiapoptotic function;
  • Bax is regulated by an ATP-ubiquitin-proteasome-dependent degradation pathway; and
  • decreased levels of Bax protein correlate with increased levels of Bax degradation in aggressive human prostate cancer.

Li B and Dou QP. Bax degradation by the ubiquitin-proteasome-dependent pathway: Involvement in tumor survival and progression. PNAS 2000; 97(8): 3851-3855. www.pnas.org

p97 and DBeQ, ATP-competitive p97 inhibitor

A major limitation to current studies on the biological functions of p97/Cdc48 is that there is no method to rapidly shut off its ATPase activity. Given the range of cellular processes in which Cdc48 participates, it is difficult to determine whether any particular phenotype observed in the existing mutants is due to a direct or indirect effect. Moreover,

  • inhibition of p97 activity in animal cells by siRNA or
  • expression of a dominant-negative version

is challenged by its high abundance and

  • is not suited to evaluating proximal phenotypic effects of p97 loss of function.

A specific small-molecule inhibitor of p97 would provide an important tool to investigate diverse functions of this essential ATPase associated with diverse cellular activities (AAA) ATPase and to evaluate its potential to be a therapeutic target in human disease. Cancer cells may be particularly sensitive to killing by suppression of protein degradation mechanisms, because they may exhibit a heightened dependency on these mechanisms to

  • clear an elevated burden of quality-control substrates.

For example, some cancers produce high levels of a specific protein that is a prominent quality-control substrate (e.g., Ig light chains in multiple myeloma) or produce high levels of reactive oxygen species, which can result in excessive protein damage via oxidation. Therefore,

  • a specific p97 inhibitor would be a valuable research tool to investigate p97 function in cells.

We carried out a high-throughput screen to identify inhibitors of p97 ATPase activity. Dual-reporter cell lines that simultaneously express p97-dependent and p97-independent proteasome substrates were used to stratify inhibitors that emerged from the screen.

  • N2,N4-dibenzylquinazoline-2,4-diamine (DBeQ) was identified as a selective,potent, reversible, and ATP-competitive p97 inhibitor.

DBeQ blocks multiple processes that have been shown by RNAi to depend on p97, including

  • degradation of ubiquitin fusion degradation and endoplasmic reticulum-associated degradation pathway reporters, as well as
  • autophagosome maturation.

DBeQ also potently

  • inhibits cancer cell growth and
  • is more rapid than a proteasome inhibitor at mobilizing the executioner caspases-3 and -7.

Simultaneous inhibition of proteasome and histone deacetylase 6 (HDAC6) [which is required for autophagy results in synergistic killing of multiple myeloma cells]. Interestingly, more than one dozen human clinical trials (www.clinicaltrials.gov) combine bortezomib with the broad-spectrum HDAC inhibitor vorinostat, which is active toward HDAC6. Targeting p97 may provide an alternative route to achieving the same objective. Our results provide a rationale for targeting p97 in cancer therapy. Future work will provide molecular insight into

  • how inhibition of p97 activity by DBeQ results in apoptosis and
  • could strengthen the rationale for a p97-targeted cancer therapeutic.

Chou TF, Brown SJ, Minond D, Nordin BE, et al. Reversible inhibitor of p97, DBeQ, impairs both ubiquitin-dependent and autophagic protein clearance pathways.   PNAS 2011; pp 6 www.pnas.org/cgi/doi/10.1073/pnas.1015312108

The causes of various neurodegenerative diseases, particularly sporadic cases, remain unknown, but increasing evidence suggests that these diseases may share similar molecular and cellular mechanisms of pathogenesis. One prominent feature common to most neurodegenerative diseases is the accumulation of misfolded proteins in the form of insoluble protein aggregates or inclusion bodies. Although these aggregates have different protein compositions, they all contain ubiquitin and proteasome subunits, implying a failure of the ubiquitin-proteasome system (UPS) in the removal of misfolded proteins.

A direct link between UPS dysfunction and neurodegeneration has been provided by recent findings that genetic mutations in UPS components cause several rare, familial forms of neurodegenerative diseases. Furthermore, it is becoming increasingly clear that oxidative stress, which results from aging or exposure to environmental toxins, can directly damage UPS components, thereby contributing to the pathogenesis of sporadic forms of neurodegenerative diseases.

Aberrations in the UPS often result in defective proteasome-mediated protein degradation, leading to accumulation of toxic proteins and eventually to neuronal cell death. Interestingly, emerging evidence has begun to suggest that impairment in substrate-specific components of the UPS, such as E3 ubiquitin-protein ligases, may cause aberrant ubiquitination and neurodegeneration in a proteasome-independent manner. This provides an overview of the molecular components of the UPS and their impairment in familial and sporadic forms of neurodegenerative diseases, and summarizes present knowledge about the pathogenic mechanisms of UPS dysfunction in neurodegeneration.

Molecular mechanisms of protein ubiquitination and degradation by the UPS. Ubiquitination involves a highly specific enzyme cascade in which

  • ubiquitin (Ub) is first activated by the ubiquitinactivating enzyme (E1),
  • then transferred to an ubiquitin-conjugating enzyme (E2), and
  • finally covalently attached to the substrate by an ubiquitin-protein ligase (E3).

Ubiquitination is a reversible posttranslational modification in which the removal of Ub is mediated by a deubiquitinating enzyme (DUB).

  • Substrate proteins can be either monoubiquitinated or polyubiquitinated through successive conjugation of Ub moieties to an internal lysine residue in Ub.
  • K48-linked poly-Ub chains are recognized by the 26S proteasome, resulting in degradation of the substrate and recycling of Ub.

Monoubiquitination or K63-linked polyubiquitination plays a number of regulatory roles in cells that are proteasome-independent.

Parkin

Loss-of-function mutations in parkin, a 465-amino-acid RING-type E3 ligase, were first identified as the cause for autosomal recessive juvenile Parkinsonism (AR-JP) and subsequently found to account for ~50% of all recessively transmitted early-onset PD cases. Interestingly, patients with parkin mutations do not exhibit Lewy body pathology.

Possible pathogenic mechanisms by which impaired UPS components cause neurodegeneration. Genetic mutations or oxidative stress from aging and/or exposure to environmental toxins have been shown to impair the ubiquitination machinery (particularly E3 ubiquitin-protein ligases) and deubiquitinating enzymes (DUBs), resulting in abnormal ubiquitination. Depending on the type of ubiquitination affected, the impairment could cause neurodegeneration through two different mechanisms.

  1. aberrant K48-linked polyubiquitination resulting from impaired E3s or DUBs alters protein degradation by the proteasome, leading to accumulation of toxic proteins and subsequent neurodegeneration. The proteasomes could be directly damaged by oxidative stress or might be inhibited by protein aggregation, which exacerbates the neurotoxicity.
  2. aberrant monoubiquitination or K63-linked polyubiquitination resulting from impaired E3s or DUBs alters crucial non-proteasomal functions, such as gene transcription and protein trafficking, thereby causing neurodegeneration without protein aggregation.

These two models are not mutually exclusive because a single E3 or DUB enzyme, such as parkin or UCH-L1, could regulate more than one type of ubiquitination. In addition, abnormal ubiquitination and neurodegeneration could also result from mutation or oxidative stress-induced structural changes in the protein substrates that alter their recognition and degradation by the UPS.

Lian Li and Chin LS. IMPAIRMENT OF THE UBIQUITIN-PROTEASOME SYSTEM: A COMMON PATHOGENIC MECHANISM IN NEURODEGENERATIVE DISORDERS. In The Ubiquitin Proteasome System…Chapter 23. (Eds: Eds: Mario Di Napoli and Cezary Wojcik) 553-577 © 2007 Nova Science Publishers, Inc. ISBN 978-1-60021-749-4.

filedesc Schematic diagram of the ubiquitylation system. Created by Roger B. Dodd (Photo credit: Wikipedia)

Current Noteworthy Work

Nassif M and Hetz C.  Autophagy impairment: a crossroad between neurodegeneration and tauopathies.  BMC Biology 2012; 10:78. http://www.biomedcentral.com/1741-7007/10/78

Impairment of protein degradation pathways such as autophagy is emerging as a consistent and transversal pathological phenomenon in neurodegenerative diseases, including Alzheimer´s, Huntington´s, and Parkinson´s disease. Genetic inactivation of autophagy in mice has demonstrated a key role of the pathway in maintaining protein homeostasis in the brain, triggering massive neuronal loss and the accumulation of abnormal protein inclusions.  A paper in Molecular Neurodegeneration from Abeliovich´s group now suggests a role for phosphorylation of Tau and the activation of glycogen synthase kinase 3β (GSK3β) in driving neurodegeneration in autophagy-deficient neurons. We discuss the implications of this study for understanding the factors driving neurofibrillary tangle formation in Alzheimer´s disease and tauopathies.

Cajee UF, Hull R and Ntwasa M. Modification by Ubiquitin-Like Proteins: Significance in Apoptosis and Autophagy Pathways. Int. J. Mol. Sci. 2012, 13, 11804-11831; doi:10.3390/ijms130911804

Ubiquitin-like proteins (Ubls) confer diverse functions on their target proteins. The modified proteins are involved in various biological processes, including

  • DNA replication,
  • signal transduction,
  • cell cycle control,
  • embryogenesis,
  • cytoskeletal regulation,
  • metabolism,
  • stress response,
  • homeostasis and
  • mRNA processing.

Modifiers such as SUMO, ATG12, ISG15, FAT10, URM1, and UFM have been shown to modify proteins thus conferring functions related to programmed cell death, autophagy and regulation of the immune system. Putative modifiers such as Domain With No Name (DWNN) have been identified in recent times but not fully characterized. In this review, we focus on cellular processes involving human Ubls and their targets.

Aloy P. Shaping the future of interactome networks. (A report of the third Interactome Networks Conference, Hinxton, UK, 29 August-1 September 2007). Genome Biology 2007; 8:316 (doi:10.1186/gb-2007-8-10-316)

Complex systems are often networked, and biology is no exception. Following on from the genome sequencing projects, experiments show that proteins in living organisms are highly connected, which helps to explain how such great complexity can be achieved by a comparatively small set of gene products. At a recent conference on interactome networks held outside Cambridge, UK, the most recent advances in research on cellular networks were discussed. This year’s conference focused on identifying the strengths and weaknesses of currently resolved interaction networks and the techniques used to determine them – reflecting the fact that the field of mapping interaction networks is maturing.

Peroutka RJ, Orcutt SJ, Strickler JE, and Butt TR. SUMO Fusion Technology for Enhanced Protein Expression and Purification in Prokaryotes and Eukaryotes. Chapter 2. in T.C. Evans, M.-Q. Xu (eds.), Heterologous Gene Expression in E. coli, Methods in Molecular Biology 705:15-29. DOI 10.1007/978-1-61737-967-3_2, © Springer Science+Business Media, LLC 2011

The preparation of sufficient amounts of high-quality protein samples is the major bottleneck for structural proteomics. The use of recombinant proteins has increased significantly during the past decades. The most commonly used host, Escherichia coli, presents many challenges including protein misfolding, protein degradation, and low solubility. A novel SUMO fusion technology appears to enhance protein expression and solubility (www.lifesensors.com). Efficient removal of the SUMO tag by SUMO protease in vitro facilitates the generation of target protein with a native N-terminus. In addition to its physiological relevance in eukaryotes, SUMO can be used as a powerful biotechnology tool for enhanced functional protein expression in prokaryotes and eukaryotes.

Juang YC, Landry MC, et al. OTUB1 Co-opts Lys48-Linked Ubiquitin Recognition to Suppress E2 Enzyme Function. Molecular Cell 2012; 45: 384–397. DOI 10.1016/j.molcel.2012.01.011

Ubiquitylation entails the concerted action of E1, E2, and E3 enzymes. We recently reported that OTUB1, a deubiquitylase, inhibits the DNA damage response independently of its isopeptidase activity. OTUB1 does so by blocking ubiquitin transfer by UBC13, the cognate E2 enzyme for RNF168. OTUB1 also inhibits E2s of the UBE2D and UBE2E families. Here we elucidate the structural mechanism by which OTUB1 binds E2s to inhibit ubiquitin transfer. OTUB1 recognizes ubiquitin-charged E2s through contacts with both donor ubiquitin and the E2 enzyme. Surprisingly, free ubiquitin associates with the canonical distal ubiquitin-binding site on OTUB1 to promote formation of the inhibited E2 complex. Lys48 of donor ubiquitin lies near the OTUB1 catalytic site and the C terminus of free ubiquitin, a configuration that mimics the products of Lys48-linked ubiquitin chain cleavage. OTUB1 therefore co-opts Lys48-linked ubiquitin chain recognition to suppress ubiquitin conjugation and the DNA damage response.

Hunter T. The Age of Crosstalk: Phosphorylation, Ubiquitination, and Beyond. Molecular Cell  2007; 28:730-738. DOI 10.1016/ j.molcel.2007.11.019.

Crosstalk between different types of posttranslational modification is an emerging theme in eukaryotic biology. Particularly prominent are the multiple connections between phosphorylation and ubiquitination, which act either positively or negatively in both directions to regulate these processes.

Tu Y, Chen C, et al. The Ubiquitin Proteasome Pathway (UPP) in the regulation of cell cycle control and DNA damage repair and its implication in tumorigenesis. Int J Clin Exp Pathol 2012;5(8):726-738.               http://www.ijcep.com /ISSN:1936-2625/IJCEP1208018

Accumulated evidence supports that the ubiquitin proteasome pathway (UPP) plays a crucial role in protein metabolism implicated in the regulation of many biological processes such as cell cycle control, DNA damage response, apoptosis, and so on. Therefore, alterations for the ubiquitin proteasome signaling or functional impairments for the ubiquitin proteasome components are involved in the etiology of many diseases, particularly in cancer development.The authors discuss the ubiquitin proteasome pathway in the regulation of cell cycle control and DNA damage response, the relevance for the altered regulation of these signaling pathways in tumorigenesis, and finally assess and summarize the advancement for targeting the ubiquitin proteasome pathway in cancer therapy.

Cebollero E , Reggiori F  and Kraft C.  Ribophagy: Regulated Degradation of Protein Production Factories. Int J Cell Biol. 2012; 2012: 182834. doi:  10.1155/2012/182834 (online).

During autophagy, cytosol, protein aggregates, and organelles are sequestered into double-membrane vesicles called autophagosomes and delivered to the lysosome/vacuole for breakdown and recycling of their basic components. In all eukaryotes this pathway is important for adaptation to stress conditions such as nutrient deprivation, as well as to regulate intracellular homeostasis by adjusting organelle number and clearing damaged structures. For a long time, starvation-induced autophagy has been viewed as a nonselective transport pathway; however, recent studies have revealed that autophagy is able to selectively engulf specific structures, ranging from proteins to entire organelles. In this paper, we discuss recent findings on the mechanisms and physiological implications of two selective types of autophagy: ribophagy, the specific degradation of ribosomes, and reticulophagy, the selective elimination of portions of the ER.

Lee JH, Yu WH,…, Nixon RA.  Lysosomal Proteolysis and Autophagy Require Presenilin 1 and Are Disrupted by Alzheimer-Related PS1 Mutations. Cell 2010; 141, 1146–1158. DOI 10.1016/j.cell.2010.05.008.

Macroautophagy is a lysosomal degradative pathway essential for neuron survival. Here, we show that macroautophagy requires the Alzheimer’s disease (AD)-related protein presenilin-1 (PS1). In PS1 null blastocysts, neurons from mice hypomorphic for PS1 or conditionally depleted of PS1, substrate proteolysis and autophagosome clearance during macroautophagy are prevented as a result of a selective impairment of autolysosome acidification and cathepsin activation. These deficits are caused by failed PS1-dependent targeting of the v-ATPase V0a1 subunit to lysosomes. N-glycosylation of the V0a1 subunit, essential for its efficient ER-to-lysosome delivery, requires the selective binding of PS1 holoprotein to the unglycosylated subunit and the  sec61alpha/ oligosaccharyltransferase complex. PS1 mutations causing early-onset AD produce a similar lysosomal/autophagy phenotype in fibroblasts from AD patients. PS1 is therefore essential for v-ATPase targeting to lysosomes, lysosome acidification, and proteolysis during autophagy. Defective lysosomal proteolysis represents a basis for pathogenic protein accumulations and neuronal cell death in AD and suggests previously unidentified therapeutic targets.

Pohl C and Jentsch S. Midbody ring disposal by autophagy is a post-abscission event of cytokinesis. nature cell biology 2009; 11 (1): 65-70.  DOI: 10.1038/ncb1813.

At the end of cytokinesis, the dividing cells are connected by an intercellular bridge, containing the midbody along with a single, densely ubiquitylated, circular structure called the midbody ring (MR). Recent studies revealed that the MR serves as a target site for membrane delivery and as a physical barrier between the prospective daughter cells. The MR materializes in telophase, localizes to the intercellular bridge during cytokinesis, and moves asymmetrically into one cell after abscission. Daughter cells rarely accumulate MRs of previous divisions, but how these large structures finally disappear remains unknown. Here, we show that MRs are discarded by autophagy, which involves their sequestration into autophagosomes and delivery to lysosomes for degradation. Notably, autophagy factors, such as the ubiquitin adaptor p62 and the ubiquitin-related protein Atg8 , associate with the MR during abscission, suggesting that autophagy is coupled to cytokinesis. Moreover, MRs accumulate in cells of patients with lysosomal storage disorders, indicating that defective MR disposal is characteristic of these diseases. Thus our findings suggest that autophagy has a broader role than previously assumed, and that cell renovation by clearing from superfluous large macromolecular assemblies, such as MRs, is an important autophagic function.

Hanai JI, Cao P, Tanksale P, Imamura S, et al. The muscle-specific ubiquitin ligase atrogin-1/MAFbx mediates statin-induced muscle toxicity. The Journal of Clinical Investigation  2007; 117(12):3930-3951.    http://www.jci.org

Statins inhibit HMG-CoA reductase, a key enzyme in cholesterol synthesis, and are widely used to treat hypercholesterolemia.

These drugs can lead to a number of side effects in muscle, including muscle fiber breakdown; however, the mechanisms of muscle injury by statins are poorly understood. We report that lovastatin induced the expression of atrogin-1, a key gene involved in skeletal muscle atrophy, in humans with statin myopathy, in zebrafish embryos, and in vitro in murine skeletal muscle cells. In cultured mouse myotubes, atrogin-1 induction following lovastatin treatment was accompanied by distinct morphological changes, largely absent in atrogin-1 null cells. In zebrafish embryos, lovastatin promoted muscle fiber damage, an effect that was closely mimicked by knockdown of zebrafish HMG-CoA reductase. Moreover, atrogin-1 knockdown in zebrafish embryos prevented lovastatin-induced muscle injury. Finally, overexpression of PGC-1α, a transcriptional coactivator that induces mitochondrial biogenesis and protects against the development of muscle atrophy, dramatically prevented lovastatin-induced muscle damage and abrogated atrogin-1 induction both in fish and in cultured mouse myotubes. Collectively, our human, animal, and in vitro findings shed light on the molecular mechanism of statin-induced myopathy and suggest that atrogin-1 may be a critical mediator of the muscle damage induced by statins.

Inami Y, Waguri S, Sakamoto A, Kouno T, et al.  Persistent activation of Nrf2 through p62 in hepatocellular carcinoma cells. J. Cell Biol. 2011; 193(2): 275–284. www.jcb.org/cgi/doi/10.1083/jcb.201102031

Macroautophagy (hereafter referred to as autophagy) is a cellular degradation system in which cytoplasmic components, including organelles, are sequestered by double membrane structures called autophagosomes and the sequestered materials are degraded by lysosomal hydrolases for supply of amino acids and for cellular homeostasis. Although autophagy has generally been considered nonselective, recent studies have shed light on another indispensable role for basal autophagy in cellular homeostasis, which is mediated by selective degradation of a specific substrate(s).  p62 is a ubiquitously expressed cellular protein that is conserved in metazoa but not in plants and fungi, and recently it has been known as one of the selective substrates for autophagy.

This protein is localized at the autophagosome formation site and directly interacts with LC3, an autophagosome localizing protein . Subsequently, the p62 is incorporated into the autophagosome and then degraded. Therefore, impaired autophagy is accompanied by accumulation of p62 followed by the formation of p62 and ubiquitinated protein aggregates because of the nature of both self- oligomerization and ubiquitin binding of p62.

Kima K, Khayrutdinov BI, Leeb CK, et al. Solution structure of the Zβ domain of human DNA-dependent activator of IFN-regulatory factors and its binding modes to B- and Z-DNAs. PNAS 2010; Early Ed ∣ pp 6. www.pnas.org/cgi/doi/10.1073/pnas.1014898107

The DNA-dependent activator of IFN-regulatory factors (DAI), also known as DLM-1/ZBP1, initiates an innate immune response by binding to foreign DNAs in the cytosol. For full activation of the immune response, three DNA binding domains at the N terminus are required: two Z-DNA binding domains (ZBDs), Zα and Zβ, and an adjacent putative B-DNA binding domain. The crystal structure of the Zβ domain of human DAI (hZβDAI) in complex with Z-DNA revealed structural features distinct from other known Z-DNA binding proteins, and it was classified as a group II ZBD. To gain structural insights into the DNA binding mechanism of hZβDAI, the solution structure of the free hZβDAI was solved, and its bindings to B- and Z-DNAs were analyzed by NMR spectroscopy. Compared to the Z-DNA–bound structure, the conformation of free hZβDAI has notable alterations in the α3 recognition helix, the “wing,” and Y145, which are critical in Z-DNA recognition. Unlike some other Zα domains, hZβDAI appears to have conformational flexibility, and structural adaptation is required for Z-DNA binding. Chemical-shift perturbation experiments revealed that hZβDAI also binds weakly to B-DNA via a different binding mode. The C-terminal domain of DAI is reported to undergo a conformational change on B-DNA binding; thus, it is possible that these changes are correlated. During the innate immune response, hZβDAI is likely to play an active role in binding to DNAs in both B and Z conformations in the recognition of foreign DNAs.

Epicrisis

This extensive review leaves little left unopened. We have seen the central role that the UPS system plays in normal organelle proteolysis in concert with autophagy. Impaired ubiquitination occurs from aging, and/or toxins, under oxidative stress involving E3s or DUBs.

This leads to altered gene transcripton, altered protein trafficking, and plays a role in neurodegenative disease, muscle malfunction, and cancer as well.

English: A cartoon representation of a lysine 48-linked diubiquitin molecule. The two ubiquitin chains are shown as green cartoons with each chain labelled. The components of the linkage are indicated and shown as orange sticks. Image was created using PyMOL from PDB id 1aar. (Photo credit: Wikipedia)

Different forms of protein ubiquitylation (Photo credit: Wikipedia)

Technion - IIT (logo) Admin

Technion – IIT (logo) Admin (Photo credit: Wikipedia)

The image of Nobel Laureate in Chemistry, Aaro...

The image of Nobel Laureate in Chemistry, Aaron Ciehanover. (Photo credit: Wikipedia)

                              nature10774-f6.2 (1)  tetra-ubiquitin chain conjugated to the undtructured initiation region of a substrate and bound to the ubiquitin receptor Rpn13. substrate poised for deubiquination by Rpn11

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The Ubiquitin Ligase Nedd4-1 Participates in Denervation-Induced Skeletal Muscle Atrophy in Mice (plosone.org)

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Antioxidant Potential of “Maltese Mushroom” (Cynomorium coccineum)

Reporter: Larry H. Bernstein, MD, FCAP

 

Evaluation of Antioxidant Potential of “Maltese Mushroom” (Cynomorium coccineum) by Means of Multiple Chemical and Biological Assays

Zucca P , Rosa A ,  Tuberoso CIG , Piras A ,  Rinaldi AC , Sanjust E , et al.   Nutrients 2013, 5(1), 149-161; doi:10.3390/nu5010149  (just published by Libertas)

http://pharmaceuticalintelligence.com/2013/01/27/antioxidant-po…rium-coccineum/

Cynomorium coccineum is an edible, non-photosynthetic plant widespread along the coasts of the Mediterranean Sea.

The medicinal properties of Maltese mushroom  have been kept in high regard since ancient times.

We evaluated the antioxidant potential of fresh specimens of C. coccineum picked in Sardinia, Italy.

Both aqueous and methanolic extracts were tested by using multiple assay systems (DPPH, FRAP, TEAC, ORAC-PYR).

Total phenolics and flavonoids were also determined.

Gallic acid and cyanidin 3-O-glucoside were identified as the main constituents and measured.

Both extracts showed antioxidant capacities; ORAC-PYR assay gave the highest antioxidant value in both cases.

The methanolic extract was further investigated with in vitro biological models of lipid oxidation;

  • it showed a significant activity in preventing cholesterol degradation and
  • exerted protection against Cu2+-mediated degradation of the liposomal unsaturated fatty acids.

Results of the present study demonstrate that

  • the extracts of C. coccineum show a significant total antioxidant power and also
  • exert an in vitro protective effect in different bio-assays of oxidative stress.

Therefore, Maltese mushroom can be considered a valuable source of antioxidants and phytochemicals

  • useful in the preparation of nutraceuticals and functional foods.

Keywords: plant-based foods; antioxidant; nutraceuticals; Cynomorium coccineum; fungus melitensis; Maltese mushroom

Cynomorium coccineum

Cynomorium coccineum (Photo credit: Alastair Rae)

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 Curator: Ritu Saxena, Ph.D.

Vitamin C or Ascorbic acid (AA) or Ascorbate

Biochemical role: AA serves a basic biochemical role of accelerating hydroxylation in several biochemical reactions. It provides electrons to metal ions, the reduced forms of which are required for the full enzymatic activity of some enzymes. Most emphasized role of AA is as a cofactor for the enzyme required for the biosynthesis of collagen.

Molecular structure and the oxidized form of AA, dihydroascorbic acid, bear similarity to that of glucose.

Biological role: AA is an essential vitamin for humans and its deficiency leads to disease called Scurvy characterized by initial symptoms of malaise and lethargy, followed by formation of spots on the skin, spongy gums, and bleeding from the mucous membranes. As scurvy advances, there can be open, suppurating wounds, loss of teeth, jaundice, fever, neuropathy and death. AA is water soluble and found in high concentrations in several tissues including eye lens, WBCs, adrenal glad and pituitary gland. Some of the roles of ascorbate include:

  1. Carnitine synthesis from lysine
  2. Neurotransmitter synthesis,
  3. Cytochrome P-450 activity,
  4. Cholesterol metabolism,
  5. Detoxification of exogenous compounds,
  6. Antioxidant
  7. Possibly an ergogenic aid (Ergogenic aids are substances, devices, or practices that enhance an individual’s energy use, production, or recovery.)

Vitamin C and Cancer

As early as in 1949, vitamin C was implicated in cancer therapy. Since then, several research articles have been published exploring the role of ascorbate in cancer therapy. Among the plethora of literature discussing the relationship between vitamin C and cancer, one of the very significant and comprehensive reviews was published in 1979 in Cancer Research (2).

Mechanisms of action of AA (1) with respect to cancer have been divided and subdivided into the following:

  1. Primary mechanisms
  2. Secondary mechanisms
  • Preventive mechanism

Ascorbate acts as a cancer preventive agent by virtue of its strong antioxidant activities. Being one of the strongest reductants and radical scavenger, it absorbs unstable oxygen, nitrogen, and sulphur-centered radicals. AA can prevent biomembranes from peroxidative damage from peroxyl radicals. Ascorbate can trap peroxyl radicals and lead to their peroxidation in the aqueous phase before they reach the lipid rich biomembranes and cause damage. Ascorbate has been speculated to have a biomembrane protective action by its synergistic antioxidant activity with vitamin E (tocopherol).  Vitamin E is lipid-soluble and tocopheroxyl radical is generated in the cell membranes as a result of its antioxidant activity.  Ascorbate reacts with the tocopheroxyl radical and regenerates tocopherol transferring the oxidative challenge to the aqueous phase. At this point, the less active ascorbate radical might be reduced to AA by an NADP-dependent system. The probably mechanism might explain the reduction of nitrates via ascorbate to prevent the formation of carcinogenic nitrosamines.

  • Anticancer mechanisms

1. Primary anticancer mechanisms

i.     Oxidative, oxidant and pro-oxidant properties: Ascorbate has been reported to be cytotoxic at high concentrations, which has been demonstrated in a number of malignant cell lines. Transcription factor NFkB is potentially activated via ascorbate and its radicals leading to the inhibition of cell growth. Also, ascorbate inhibits certain prostaglandins leading to decrease in cell proliferation.

ii.     Hydrogen peroxide: On oxidation with oxygen, ascorbate produces a hydrogen peroxide, a reactive oxygen species. Hydrogen peroxide can generate several other reactive species and can have several damaging effects on cells including decrease in cell viability by damaging cell membranes of malignant cells. The amount of these reactive species produced via oxidation is limited in healthy cells unlike that in malignant cells where they exist in large amounts. The amount of hydrogen peroxide generated has been correlated to the amount of ascorbate in the cells. The reactive species can lead to multiple negative effects on cells including DNA strand breaks, lipid peroxidation leading to membrane function disruption, cellular ATP depletion.

Authors state that “the failure to maintain high ATP production may be a consequence of oxidative inactivation of key enzymes especially those related to the Krebs cycle and the electron transport chain.” This might result in alteration of transmembrane potential and distortion of mitochondrial function, suggestive of the important role of mitochondria in the process of carcinogenesis. In this paper, vitamin C has been correlated with cancer with the involvement of altered mitochondrial function. In addition, ascorbate has been detected in mitochondria where it is also regenerated. Different aspects of mitochondrial involvement in cancer have been discussed in several posts published earlier (3-8).

iii.     Other oxidation products of AA: Other oxidation products of AA include 2,3-diketoglutonic acid, and 5-methyl 1-3, 4-dehydrotetrone and other degradation products, have demonstrated antitumor activity. Additionally, some degradation and oxidation products of AA, gamma-cronolactone and 3-hydroxyl-2-pyrone, have been found to inhibit tumor growth. The mechanism of their antitumor actions is complex and might involve multitude of steps, including generation of reactive oxygen species, lipid peroxidation, inducing structural changes in important cellular proteins, inhibition of mitosis and so on.

iv.     Intracellular transport of ascorbate and its tumor specificity: Oxidized ascorbate, dihydroascorbic acid, is transported intracellularly where it is reduced back to ascorbate. Owing to its structural similarity with glucose, dihydroascorbic transport is facilitated via glucose transporters (GLUTs). Ascrobate in its reduced form is transported through a sodium-dependent cotransporter in some cells. Tumor cells require large amounts of glucose, which leads to an increase in the number of GLUTs, hence, resulting in an increase in ascorbate concentration within cancer cells. Because of this selective increased uptake of ascorbate and its cytotoxic effects in cancer cells (generation of hydrogen peroxide, DNA damage, other cytotoxic effects), AA has become a selective, nontoxic chemotherapeutic agent. The difference in the levels of catalase enzyme has been found to lead to intracellular tumor selectivity in cancer cells.

Ascorbate induced cytotoxicity in cancer cells involves its final electron acceptor, oxygen, which interferes with the anaerobic respiration within malignant cells. This gives an important clue for the involvement of mitochondria in malignant cells.

v.     Intravenous AA: High concentrations of AA in plasma (>200mg/dL) have been found to be cytotoxic to cancer cells. Clinically high plasma concentrations of AA can be achieved by its intravenous administration. It was observed that 60g infusion of AA given to cancer patients for 60 minutes followed by 20g given over the next 60 minutes resulted in a 240 minutes high plasma AA concentration of >400mg/dL, that is known to be cytotoxic.

Lipoic acid when administered with AA, is able to reduce the high-dose requirement of AA for its cytotoxic activity reducing it from 700mg/dL to 120mg/dL. Lipoic acid can recycle vitamin C, mediate the reduction of dihydroascorbic acid and improves mitochondrial function. Thus, energy intermediates such as coenzyme Q, vitamin K3, B-complex vitamins, alpha-ketoglutarate aspartate, magnesium might aid in cancer therapy by intercting with ascorbate, directly or indirectly, thereby stimuating/interacting/correcting aerobic mitochondrial respiration.

Hence, the pro-oxidant activity of vitamin C is being referred to as the primary mechanism of anticancer action.

2. Secondary anticancer mechanisms

i.     AA and intracellular matrix: Collagen is an important constituent of the matrix and its concentration determines the strength of the tissue along with its resistance to the infiltration of malignant cancer cells. In Scurvy, a disease resulting from a chronic deficiency of vitamin C, there is generalized tissue disintegration, dissolution of intercellular ground substance and the disruption of collagen bundles. This disintegration leads to ulceration; bacterial colonization and general undifferentiated cellular proliferation with specialized cells reverting back to their primitive form, very much like cancer.  Lack of ascorbate causes a reduction in the hydroxylation of prolyl and lysyl residues into hydroxyproline and hydroxylysine, leading to instability of the collagen triple helix, a common feature in scurvy and also in cancer. Thus, a secondary mechanism of ascorbic acid anticancer mechanism would be to repair these sites, which is emphasized by its role in wound healing, including surgical recovery and other traumatic injuries.

ii.     Ascorbate and immunocompetence: Ascorbate plays several roles for the efficient functioning of immune system in ways that are invoved in both humoral and cell-mediated.  Ascorbate provides humoral immunocompetence as it is essential for immunoglobulin synthesis. In addition, lymphocytes, seminal cells involved in cell-mediated immunity have been found to contain high concentrations of ascorbate. Other immune system roles include, aid in active phagocytosis and enhancing of interferon production.

Classical vitamin C and Cancer controversy-A possible explanation

Conflicting results were obtained from the studies performed by Pauling (Pauling Institute) and Cameron (Mayo Clinic) with vitamin C and its effect on cancer, the issue was debated a few decades ago. Both the studies, however, used oral doses of ascorbate (10g). Gonzalez et al, authors of the review on which the post is based, analyzed and expressed their views on the controversy. They state that the plasma concentration cannot be replicated when the dose is given orally as opposed to when the dose is given intravenously. According to their research, when AA is administered intravenously, higher plasma levels of ascorbate are achieved that could be retained for longer time periods. Also, the authors advocate the use of substantially higher doses (25-200g) to be given intravenously for selective toxicity towards cancer cells.

Modern vitamin C and Cancer controversy-Chemotherapy and radiation

A recent concern regarding the antioxidants like vitamin C is that they might reduce the effectiveness of chemotherapy and radiation by reducing the potency of free radicals necessary for killing cells. A publication by Agus et al (13) has a major role to play in this misconception. The authors describe how cancer cells acquire and concentrate vitamin C providing malignant cells with metabolic advantage. However, details or explanations regarding the theory are missing. Some studies, on the other hand, explain that high concentrations of AA in cancer cells is cytotoxic and is achieved because of similarity in structure between AA and glucose. Cancer cells uptake AA derivative, dehydroascorbic acid via glucose transporters (GLUTs).

In a case report published in PNAS in 1985 (12), two patients with ovarian cancer stage IIIC were found to respond positively to chemotherapy along with high-dose of antioxidants. Antioxidant, AA was administered intravenously to maintain a high plasma dose of 200 mg/dL. The two patients didn’t show disease recurrence after three years of chemotherapy and vitamin C administration. Vast literature exists on the topic indicating that antioxidants, including ascorbate, provide beneficial effects in several cancers without reducing the efficacy of chemotherapy or radiation during treatment of these cancers. Some data, in fact, suggests increase in effectiveness of chemotherapy when supplemented with antioxidants along with an increase in adverse effects. The topic has been summarized and discussed in a series of articles by Lawson and Brignall (9-11).

REFERENCES

The post is primarily based on the following two review articles:

1. González MJ et al. Orthomolecular oncology review: ascorbic acid and cancer 25 years later.  Integr Cancer Ther. 2005 Mar;4(1):32-44.

2. Cameron E, Pauling L, Leibovitz B. Ascorbic acid and cancer: a review. Cancer Res. 1979 Mar;39(3):663-81.

Other articles  on Mitochondria and Cancer were published on this Open Source Online Scientific Journal

3. Ritu Saxena. Mitochondria and Cancer: An overview of mechanisms

4. Ritusaxena. β Integrin emerges as an important player in mitochondrial dysfunction associated Gastric Cancer.

5. Larry H Bernstein. Mitochondria: Origin from oxygen free environment, role in aerobic glycolysis, metabolic adaptation

6. Ritu Saxena. Mitochondria and Cancer: An overview of mechanisms

7. Larry H Bernstein. Mitochondrial Damage and Repair under Oxidative Stress

8. Larry H Bernstein. What can we expect of tumor therapeutic response?

Research articles:

9. Lamson DW, Brignall MS. Antioxidants and cancer, part 3: quercetin. Altern Med Rev. 2000 Jun;5(3):196-208. Review.

10. Lamson DW, Brignall MS. Antioxidants and cancer therapy II: quick reference guide. Altern Med Rev. 2000 Apr;5(2):152-63.

11. Lamson DW, Brignall MS. Antioxidants in cancer therapy; their actions and interactions with oncologic therapies. Altern Med Rev. 1999 Oct;4(5):304-29.

12. Bensch KG, Fleming JE, Lohman W. The role of ascorbic acid in senile cataracts. Proc Natl Acad Sci USA 1985;82:7193-7196.

13. Agus DB, Vera JG, Golde DW. Stand allocation: a mechanism by which tumors obtain vitamin C. Cancer Res. 1999;59:4555-4558.

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