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Molecular targets and the use of biologics in the management of small bowel fibrosis in inflammatory bowel disease. Curr Opin Gastroenterol 2021; 37:275-283. [PMID: 33769380 DOI: 10.1097/mog.0000000000000729] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Small bowel fibrosis is a significant burden on Crohn's disease patients with limited effective medical treatments that then requires surgery. A better understanding of the molecular mechanisms causing fibrosis and the evidence of benefit of available biologics will potentially lighten this burden and avoid the need for surgery. RECENT FINDINGS Transforming growth factor-beta and it's associated pathways remain the central cog in the wheel of fibrosis formation. Various new enzymes, cellular pathways, interleukins and molecules have been associated with beneficial modification of the fibrotic process. Licensed biologics such as antitumour necrosis factors continue to show evidence of efficacy in the treatment of fibrostenotic small bowel disease as well as the newer biologics ustekinumab and vedolizumab. SUMMARY Fibrostenotic disease of the small bowel is a significant and common debilitating complication in Crohn's disease patients. Multiple new molecular targets have been identified that may prove to become effective therapies in future. Antitumour necrosis factors remain the treatment with the best available evidence to date in fibrostenotic Crohn's disease.
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Sleiman J, Ouali SE, Qazi T, Cohen B, Steele SR, Baker ME, Rieder F. Prevention and Treatment of Stricturing Crohn's Disease - Perspectives and Challenges. Expert Rev Gastroenterol Hepatol 2021; 15:401-411. [PMID: 33225766 PMCID: PMC8026566 DOI: 10.1080/17474124.2021.1854732] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Fibrostenosis is a hallmark of Crohn's disease (CD), remains a challenge in today's clinical management of inflammatory bowel disease patients and represents a key event in the disease course necessitating improved preventative strategies and a multidisciplinary approach to diagnosis and management. With the advent of anti-fibrotic therapies and well-defined clinical endpoints for stricturing CD, there is promise to impact the natural history of disease.Areas covered: This review summarizes current evidence in the natural history of stricturing Crohn's disease, discusses management approaches as well as future perspectives on intestinal fibrosis.Expert opinion: Currently, there are no specific therapies to prevent progression to fibrosis or to treat it after it becomes clinically apparent. In addition to the international effort by the Stenosis Therapy and Anti-Fibrotic Research (STAR) consortium to standardize definitions and propose endpoints in the management of stricturing CD, further research to improve our understanding of mechanisms of intestinal fibrosis will help pave the way for the development of future anti-fibrotic therapies.
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Affiliation(s)
- Joseph Sleiman
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sara El Ouali
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Taha Qazi
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott R. Steele
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark E. Baker
- Section Abdominal Imaging, Imaging Institute, Digestive Diseases and Surgery Institute, Cleveland, Ohio, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Corresponding author: Florian Rieder, Address: Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue – NC22, Cleveland, OH, 44195,
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Mahalhal A, Burkitt MD, Duckworth CA, Hold GL, Campbell BJ, Pritchard DM, Probert CS. Long-Term Iron Deficiency and Dietary Iron Excess Exacerbate Acute Dextran Sodium Sulphate-Induced Colitis and Are Associated with Significant Dysbiosis. Int J Mol Sci 2021; 22:3646. [PMID: 33807459 PMCID: PMC8037348 DOI: 10.3390/ijms22073646] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Oral iron supplementation causes gastrointestinal side effects. Short-term alterations in dietary iron exacerbate inflammation and alter the gut microbiota, in murine models of colitis. Patients typically take supplements for months. We investigated the impact of long-term changes in dietary iron on colitis and the microbiome in mice. METHODS We fed mice chow containing differing levels of iron, reflecting deficient (100 ppm), normal (200 ppm), and supplemented (400 ppm) intake for up to 9 weeks, both in absence and presence of dextran sodium sulphate (DSS)-induced chronic colitis. We also induced acute colitis in mice taking these diets for 8 weeks. Impact was assessed (i) clinically and histologically, and (ii) by sequencing the V4 region of 16S rRNA. RESULTS In mice with long-term changes, the iron-deficient diet was associated with greater weight loss and histological inflammation in the acute colitis model. Chronic colitis was not influenced by altering dietary iron however there was a change in the microbiome in DSS-treated mice consuming 100 ppm and 400 ppm iron diets, and control mice consuming the 400 ppm iron diet. Proteobacteria levels increased significantly, and Bacteroidetes levels decreased, in the 400 ppm iron DSS group at day-63 compared to baseline. CONCLUSIONS Long-term dietary iron alterations affect gut microbiota signatures but do not exacerbate chronic colitis, however acute colitis is exacerbated by such dietary changes. More work is needed to understand the impact of iron supplementation on IBD. The change in the microbiome, in patients with colitis, may arise from the increased luminal iron and not simply from colitis.
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Affiliation(s)
- Awad Mahalhal
- Department of Molecular and Cellular Cancer Medicine, Institute of Systems, Molecular and Integrated Biology, University of Liverpool, Liverpool L69 3GE, UK; (A.M.); (D.M.P.)
- Department of Anatomy and Histology, Faculty of Medicine, Benghazi University, Benghazi, Libya
| | - Michael D. Burkitt
- Division of Diabetes Endocrinology and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, UK;
| | - Carrie A. Duckworth
- Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 3GE, UK;
| | - Georgina L. Hold
- Microbiome Research Centre, St George & Sutherland Clinical School, Clinical Sciences (Pitney) Building, University of New South Wales Sydney, Kogarah, NSW 2217, Australia;
| | - Barry J. Campbell
- Department of Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3GE, UK;
| | - David Mark Pritchard
- Department of Molecular and Cellular Cancer Medicine, Institute of Systems, Molecular and Integrated Biology, University of Liverpool, Liverpool L69 3GE, UK; (A.M.); (D.M.P.)
| | - Chris S. Probert
- Department of Molecular and Cellular Cancer Medicine, Institute of Systems, Molecular and Integrated Biology, University of Liverpool, Liverpool L69 3GE, UK; (A.M.); (D.M.P.)
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Li G, Lee C, Read AT, Wang K, Ha J, Kuhn M, Navarro I, Cui J, Young K, Gorijavolu R, Sulchek T, Kopczynski C, Farsiu S, Samples J, Challa P, Ethier CR, Stamer WD. Anti-fibrotic activity of a rho-kinase inhibitor restores outflow function and intraocular pressure homeostasis. eLife 2021; 10:60831. [PMID: 33783352 PMCID: PMC8009676 DOI: 10.7554/elife.60831] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 03/12/2021] [Indexed: 12/22/2022] Open
Abstract
Glucocorticoids are widely used as an ophthalmic medication. A common, sight-threatening adverse event of glucocorticoid usage is ocular hypertension, caused by dysfunction of the conventional outflow pathway. We report that netarsudil, a rho-kinase inhibitor, decreased glucocorticoid-induced ocular hypertension in patients whose intraocular pressures were poorly controlled by standard medications. Mechanistic studies in our established mouse model of glucocorticoid-induced ocular hypertension show that netarsudil both prevented and reduced intraocular pressure elevation. Further, netarsudil attenuated characteristic steroid-induced pathologies as assessed by quantification of outflow function and tissue stiffness, and morphological and immunohistochemical indicators of tissue fibrosis. Thus, rho-kinase inhibitors act directly on conventional outflow cells to prevent or attenuate fibrotic disease processes in glucocorticoid-induced ocular hypertension in an immune-privileged environment. Moreover, these data motivate the need for a randomized prospective clinical study to determine whether netarsudil is indeed superior to first-line anti-glaucoma drugs in lowering steroid-induced ocular hypertension.
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Affiliation(s)
- Guorong Li
- Department of Ophthalmology, Duke University, Durham, United States
| | - Chanyoung Lee
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, United States
| | - A Thomas Read
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, United States
| | - Ke Wang
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, United States
| | - Jungmin Ha
- Department of Mechanical Engineering, Georgia Institute of Technology, Atlanta, United States
| | - Megan Kuhn
- Department of Ophthalmology, Duke University, Durham, United States
| | - Iris Navarro
- Department of Ophthalmology, Duke University, Durham, United States
| | - Jenny Cui
- Department of Ophthalmology, Duke University, Durham, United States
| | - Katherine Young
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, United States
| | - Rahul Gorijavolu
- Department of Ophthalmology, Duke University, Durham, United States
| | - Todd Sulchek
- Department of Mechanical Engineering, Georgia Institute of Technology, Atlanta, United States
| | | | - Sina Farsiu
- Department of Ophthalmology, Duke University, Durham, United States.,Department of Biomedical Engineering, Duke University, Durham, United States
| | - John Samples
- Washington State University Floyd Elson School of Medicine, Spokane, United States
| | - Pratap Challa
- Department of Ophthalmology, Duke University, Durham, United States
| | - C Ross Ethier
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, United States.,Department of Mechanical Engineering, Georgia Institute of Technology, Atlanta, United States
| | - W Daniel Stamer
- Department of Ophthalmology, Duke University, Durham, United States.,Department of Biomedical Engineering, Duke University, Durham, United States
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Yu M, Wu H, Wang J, Chen X, Pan J, Liu P, Zhang J, Chen Y, Zhu W, Tang C, Jin Q, Li C, Lu C, Zeng H, Yu C, Sun J. Vitamin D receptor inhibits EMT via regulation of the epithelial mitochondrial function in intestinal fibrosis. J Biol Chem 2021; 296:100531. [PMID: 33713706 PMCID: PMC8054199 DOI: 10.1016/j.jbc.2021.100531] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/22/2021] [Accepted: 03/09/2021] [Indexed: 01/30/2023] Open
Abstract
We previously showed that the vitamin D receptor (VDR) plays a crucial role in acute inflammatory bowel disease and that intestinal fibrosis is a common complication of Crohn's disease (CD). Epithelial-mesenchymal transition (EMT) is an important hallmark of fibrogenesis through which epithelial cells lose their epithelial phenotype and transform into mesenchymal cells. It is known that the VDR plays an essential role in epithelial integrity and mitochondrial function, but its role in intestinal fibrosis remains unknown. Here, we investigated whether the VDR is involved in epithelial mitochondrial dysfunction that results in EMT in intestinal fibrosis. Using human CD samples, intestine-specific VDR-KO mice, and fibroblast cellular models, we showed that the expression of the VDR was significantly lower in intestinal stenotic areas than in nonstenotic areas in patients with chronic CD. Genetic deletion of the VDR in the intestinal epithelium exacerbated intestinal fibrosis in mice administered with dextran sulfate sodium or 2,4,6-trinitrobenzene sulfonic acid, two experimental colitis inducers. In addition, we found that vitamin D dietary intervention regulated intestinal fibrosis by modulating the intestinal expression of the VDR. Mechanistically, knocking down the VDR in both CCD-18Co cells and human primary colonic fibroblasts promoted fibroblast activation, whereas VDR overexpression or VDR agonist administration inhibited fibroblast activation. Further analysis illustrated that the VDR inhibited EMT in the HT29 cell model and that mitochondrial dysfunction mediated epithelial integrity and barrier function in VDR-deficient epithelial cells. Together, our data for the first time demonstrate that VDR activation alleviates intestinal fibrosis by inhibiting fibroblast activation and epithelial mitochondria-mediated EMT.
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Affiliation(s)
- Mengli Yu
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Wu
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinhai Wang
- Department of Colorectal Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xueyang Chen
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiaqi Pan
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Peihao Liu
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Zhang
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yishu Chen
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Zhu
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chenxi Tang
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qi Jin
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chunxiao Li
- Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
| | - Chao Lu
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hang Zeng
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chaohui Yu
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
| | - Jing Sun
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Soluble Fraction from Lysate of a High Concentration Multi-Strain Probiotic Formulation Inhibits TGF-β1-Induced Intestinal Fibrosis on CCD-18Co Cells. Nutrients 2021; 13:nu13030882. [PMID: 33803197 PMCID: PMC7998462 DOI: 10.3390/nu13030882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/05/2021] [Accepted: 02/11/2021] [Indexed: 01/18/2023] Open
Abstract
Fibrosis is a severe complication of chronic inflammatory disorders, such as inflammatory bowel disease (IBD). Current strategies are not fully effective in treating fibrosis; therefore, innovative anti-fibrotic approaches are urgently needed. TGF-β1 plays a central role in the fibrotic process by inducing myofibroblast differentiation and excessive extracellular matrix (ECM) protein deposition. Here, we explored the potential anti-fibrotic impact of two high concentration multi-strain probiotic formulations on TGF-β1-activated human intestinal colonic myofibroblast CCD-18Co. Human colonic fibroblast CCD-18Co cells were cultured in the presence of TGF-β1 to develop a fibrotic phenotype. Cell viability and growth were measured using the Trypan Blue dye exclusion test. The collagen-I, α-SMA, and pSmad2/3 expression levels were evaluated by Western blot analysis. Fibrosis markers were also analyzed by immunofluorescence and microscopy. The levels of TGF-β1 in the culture medium were assessed by ELISA. The effects of commercially available probiotic products VSL#3® and Vivomixx® were evaluated as the soluble fraction of bacterial lysates. The results suggested that the soluble fraction of Vivomixx® formulation, but not VSL#3®, was able to antagonize the pro-fibrotic effects of TGF-β1 on CCD-18Co cells, being able to prevent all of the cellular and molecular parameters that are related to the fibrotic phenotype. The mechanism underlying the observed effect appeared to be associated with inhibition of the TGF-β1/Smad signaling pathway. To our knowledge, this study provides the first experimental evidence that Vivomixx® could be considered to be a promising candidate against intestinal fibrosis, being able to antagonize TGF-β1 pro-fibrotic effects. The differences that were observed in our fibrosis model between the two probiotics used could be attributable to the different number of strains in different proportions.
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Liu B, Yang MQ, Yu TY, Yin YY, Liu Y, Wang XD, He ZG, Yin L, Chen CQ, Li JY. Mast Cell Tryptase Promotes Inflammatory Bowel Disease-Induced Intestinal Fibrosis. Inflamm Bowel Dis 2021; 27:242-255. [PMID: 32507895 DOI: 10.1093/ibd/izaa125] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intestinal fibrosis is the final pathological outcome of chronic intestinal inflammation without specific therapeutic drugs, which leads to ileus and surgical intervention. Intestinal fibrosis is characterized by excessive deposition of extracellular matrix (ECM). The role of mast cells (MCs), which are members of the sentinel immune cell population, is unknown in intestinal fibrosis. METHODS In this study, we analyzed changes in MCs, tryptase proteins, and ECM components in human fibrotic and control patient intestines. We constructed dextran sodium sulfate-induced intestinal fibrosis models using wild-type mice, MC-reconstituted mice, and MC-deficient mice to explore the role of MCs and tryptase in intestinal fibrosis. The roles and mechanisms of MCs and tryptase on fibroblasts were evaluated using human MCs (HMC-1 and LAD-2), commercial tryptase proteins, human colon fibroblasts (CCD-18Co fibroblasts), the tryptase inhibitor APC366, and the protease-activated receptor-2 (PAR-2) antagonist ENMD-1068. RESULTS Regardless of whether the colon was a human colon or a mouse colon, the fibrotic intestinal tissue had increased MC infiltration and a higher expression of ECM proteins or genes than that of the control group. The dextran sodium sulfate-induced intestinal fibrosis in MC-deficient mice was alleviated compared with that in wild-type mice. After MC reconstruction in MC-deficient mice, the alleviating effect disappeared. Tryptase, as a content stored in MC granules, was released into fibrotic intestinal tissues in the form of degranulation, resulting in an increased expression of tryptase. Compared with the control group, the tryptase inhibition group (the APC366 group) had reduced intestinal fibrosis. The CCD-18Co fibroblasts, when cocultured with MCs or treated with tryptase proteins, were activated to differentiate into myofibroblasts and secrete more ECM proteins (such as collagen and fibronectin). The underlying mechanism of fibroblast activation by tryptase was the activation of the PAR-2/Akt/mTOR pathway. CONCLUSIONS We found that MC tryptase promotes inflammatory bowel disease-induced intestinal fibrosis. The underlying mechanism is that tryptase promotes the differentiation of fibroblasts into fibrotic-phenotype myofibroblasts by activating the PAR-2/Akt/ mTOR pathway of fibroblasts.
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Affiliation(s)
- Bin Liu
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China.,Department of General Surgery, Shanghai Clinical Medical College, Anhui Medical University, Anhui, China
| | - Mu-Qing Yang
- Department of General Surgery, Shanghai Clinical Medical College, Anhui Medical University, Anhui, China
| | - Tian-Yu Yu
- Department of General Surgery, Shanghai Clinical Medical College, Anhui Medical University, Anhui, China
| | - Yang-Yang Yin
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China
| | - Ying Liu
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China
| | - Xiao-Dong Wang
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China.,Department of General Surgery, Shanghai Clinical Medical College, Anhui Medical University, Anhui, China
| | - Zhi-Gang He
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China
| | - Lu Yin
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China
| | - Chun-Qiu Chen
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China
| | - Ji-Yu Li
- Department of General Surgery, Shanghai Tenth People's Hospital of Tongji University, Tongji University, Shanghai, China.,Department of General Surgery, Shanghai Clinical Medical College, Anhui Medical University, Anhui, China
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58
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Di Gregorio J, Robuffo I, Spalletta S, Giambuzzi G, De Iuliis V, Toniato E, Martinotti S, Conti P, Flati V. The Epithelial-to-Mesenchymal Transition as a Possible Therapeutic Target in Fibrotic Disorders. Front Cell Dev Biol 2020; 8:607483. [PMID: 33409282 PMCID: PMC7779530 DOI: 10.3389/fcell.2020.607483] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/25/2020] [Indexed: 12/11/2022] Open
Abstract
Fibrosis is a chronic and progressive disorder characterized by excessive deposition of extracellular matrix, which leads to scarring and loss of function of the affected organ or tissue. Indeed, the fibrotic process affects a variety of organs and tissues, with specific molecular background. However, two common hallmarks are shared: the crucial role of the transforming growth factor-beta (TGF-β) and the involvement of the inflammation process, that is essential for initiating the fibrotic degeneration. TGF-β in particular but also other cytokines regulate the most common molecular mechanism at the basis of fibrosis, the Epithelial-to-Mesenchymal Transition (EMT). EMT has been extensively studied, but not yet fully explored as a possible therapeutic target for fibrosis. A deeper understanding of the crosstalk between fibrosis and EMT may represent an opportunity for the development of a broadly effective anti-fibrotic therapy. Here we report the evidences of the relationship between EMT and multi-organ fibrosis, and the possible therapeutic approaches that may be developed by exploiting this relationship.
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Affiliation(s)
- Jacopo Di Gregorio
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, United States
| | - Iole Robuffo
- Institute of Molecular Genetics, National Research Council, Section of Chieti, Chieti, Italy
| | - Sonia Spalletta
- Department of Clinical Pathology, E. Profili Hospital, Fabriano, Ancona, Italy
| | - Giulia Giambuzzi
- Department of Medical and Oral Sciences and Biotechnologies, University “G. d’Annunzio”, Chieti, Italy
| | - Vincenzo De Iuliis
- Department of Medical and Oral Sciences and Biotechnologies, University “G. d’Annunzio”, Chieti, Italy
| | - Elena Toniato
- Department of Medical and Oral Sciences and Biotechnologies, University “G. d’Annunzio”, Chieti, Italy
| | - Stefano Martinotti
- Department of Medical and Oral Sciences and Biotechnologies, University “G. d’Annunzio”, Chieti, Italy
| | - Pio Conti
- Postgraduate Medical School, University of Chieti-Pescara, Chieti, Italy
| | - Vincenzo Flati
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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59
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Alfredsson J, Wick MJ. Mechanism of fibrosis and stricture formation in Crohn's disease. Scand J Immunol 2020; 92:e12990. [PMID: 33119150 PMCID: PMC7757243 DOI: 10.1111/sji.12990] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/06/2020] [Accepted: 10/25/2020] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract that leads to substantial suffering for millions of patients. In some patients, the chronic inflammation leads to remodelling of the extracellular matrix and fibrosis. Fibrosis, in combination with expansion of smooth muscle layers, leaves the bowel segment narrowed and stiff resulting in strictures, which often require urgent medical intervention. Although stricture development is associated with inflammation in the affected segment, anti‐inflammatory therapies fall far short of treating strictures. At best, current therapies might allow some patients to avoid surgery in a shorter perspective and no anti‐fibrotic therapy is yet available. This likely relates to our poor understanding of the mechanism underlying stricture development. Chronic inflammation is a prerequisite, but progression to strictures involves changes in fibroblasts, myofibroblasts and smooth muscle cells in a poorly understood interplay with immune cells and environmental cues. Much of the experimental evidence available is from animal models, cell lines or non‐strictured patient tissue. Accordingly, these limitations create the basis for many previously published reviews covering the topic. Although this information has contributed to the understanding of fibrotic mechanisms in general, in the end, data must be validated in strictured tissue from patients. As stricture formation is a serious complication of CD, we endeavoured to summarize findings exclusively performed using strictured tissue from patients. Here, we give an update of the mechanism driving this serious complication in patients, and how the strictured tissue differs from adjacent unaffected tissue and controls.
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Affiliation(s)
- Johannes Alfredsson
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Mary Jo Wick
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
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60
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Jacob N, Kumagai K, Abraham JP, Shimodaira Y, Ye Y, Luu J, Blackwood AY, Castanon SL, Stamps DT, Thomas LS, Gonsky R, Shih DQ, Michelsen KS, Targan SR. Direct signaling of TL1A-DR3 on fibroblasts induces intestinal fibrosis in vivo. Sci Rep 2020; 10:18189. [PMID: 33097818 PMCID: PMC7584589 DOI: 10.1038/s41598-020-75168-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022] Open
Abstract
Tumor necrosis factor-like cytokine 1A (TL1A, TNFSF15) is implicated in inflammatory bowel disease, modulating the location and severity of inflammation and fibrosis. TL1A expression is increased in inflamed mucosa and associated with fibrostenosing Crohn's disease. Tl1a-overexpression in mice causes spontaneous ileitis, and exacerbates induced proximal colitis and fibrosis. Intestinal fibroblasts express Death-receptor 3 (DR3; the only know receptor for TL1A) and stimulation with TL1A induces activation in vitro. However, the contribution of direct TL1A-DR3 activation on fibroblasts to fibrosis in vivo remains unknown. TL1A overexpressing naïve T cells were transferred into Rag-/- , Rag-/- mice lacking DR3 in all cell types (Rag-/-Dr3-/-), or Rag-/- mice lacking DR3 only on fibroblasts (Rag-/-Dr3∆Col1a2) to induce colitis and fibrosis, assessed by clinical disease activity index, intestinal inflammation, and collagen deposition. Rag-/- mice developed overt colitis with intestinal fibrostenosis. In contrast, Rag-/-Dr3-/- demonstrated decreased inflammation and fibrosis. Despite similar clinical disease and inflammation as Rag-/-, Rag-/-Dr3∆Col1a2 exhibited reduced intestinal fibrosis and attenuated fibroblast activation and migration. RNA-Sequencing of TL1A-stimulated fibroblasts identified Rho signal transduction as a major pathway activated by TL1A and inhibition of this pathway modulated TL1A-mediated fibroblast functions. Thus, direct TL1A signaling on fibroblasts promotes intestinal fibrosis in vivo. These results provide novel insight into profibrotic pathways mediated by TL1A paralleling its pro-inflammatory effects.
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Affiliation(s)
- Noam Jacob
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10945 Le Conte Ave., Suite 2114, Los Angeles, CA, 90095, USA.
- Division of Gastroenterology, Hepatology and Parenteral Nutrition, VA Greater Los Angeles Healthcare System, Los Angeles, CA, 90073, USA.
| | - Kotaro Kumagai
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Jay P Abraham
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Yosuke Shimodaira
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Yuefang Ye
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Justin Luu
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Anna Y Blackwood
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Sofi L Castanon
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Dalton T Stamps
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Lisa S Thomas
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Rivkah Gonsky
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - David Q Shih
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Kathrin S Michelsen
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
| | - Stephan R Targan
- F. Widjaja Foundation, Cedars-Sinai Medical Center, Inflammatory Bowel & Immunobiology Research Institute, Los Angeles, CA, 90048, USA
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van Haaften WT, Blokzijl T, Hofker HS, Olinga P, Dijkstra G, Bank RA, Boersema M. Intestinal stenosis in Crohn's disease shows a generalized upregulation of genes involved in collagen metabolism and recognition that could serve as novel anti-fibrotic drug targets. Therap Adv Gastroenterol 2020; 13:1756284820952578. [PMID: 32922514 PMCID: PMC7457685 DOI: 10.1177/1756284820952578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Crohn's disease (CD) can be complicated by intestinal fibrosis. Pharmacological therapies against intestinal fibrosis are not available. The aim of this study was to determine whether pathways involved in collagen metabolism are upregulated in intestinal fibrosis, and to discuss which drugs might be suitable to inhibit excessive extracellular matrix formation targeting these pathways. METHODS Human fibrotic and non-fibrotic terminal ileum was obtained from patients with CD undergoing ileocecal resection due to stenosis. Genes involved in collagen metabolism were analyzed using a microfluidic low-density TaqMan array. A literature search was performed to find potential anti-fibrotic drugs that target proteins/enzymes involved in collagen synthesis, its degradation and its recognition. RESULTS mRNA expression of collagen type I (COL1A1, 0.76 ± 0.28 versus 37.82 ± 49.85, p = 0.02) and III (COL3A1, 2.01 ± 2.61 versus 68.65 ± 84.07, p = 0.02) was increased in fibrotic CD compared with non-fibrotic CD. mRNA expression of proteins involved in both intra- and extracellular post-translational modification of collagens (prolyl- and lysyl hydroxylases, lysyl oxidases, chaperones), collagen-degrading enzymes (MMPs and cathepsin-K), and collagen receptors were upregulated in the fibrosis-affected part. A literature search on the upregulated genes revealed several potential anti-fibrotic drugs. CONCLUSION Expression of genes involved in collagen metabolism in intestinal fibrosis affected terminal ileum of patients with CD reveals a plethora of drug targets. Inhibition of post-translational modification and altering collagen metabolism might attenuate fibrosis formation in the intestine in CD. Which compound has the highest potential depends on a combination anti-fibrotic efficacy and safety, especially since some of the enzymes play key roles in the physiology of collagen.
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Affiliation(s)
- Wouter Tobias van Haaften
- Department of Gastroenterology and Hepatology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Groningen, the Netherlands
| | - Tjasso Blokzijl
- Department of Laboratory Medicine, University of
Groningen, University Medical Center Groningen, Groningen, The
Netherlands
| | - Hendrik Sijbrand Hofker
- Department of Surgery, University Medical Center
Groningen, University of Groningen, Groningen, the Netherlands
| | - Peter Olinga
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Ant. Deusinglaan 1, Groningen, 9713
AV, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | - Ruud A. Bank
- Department of Pathology and Medical Biology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | - Miriam Boersema
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Groningen, the Netherlands
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62
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Biel C, Bigaeva E, Hesse M, Bomers JJM, van Summeren K, Teunis MAT, Vaessen S, Ten Klooster JP, Olinga P. Survival and cellular heterogeneity of epithelium in cultured mouse and rat precision-cut intestinal slices. Toxicol In Vitro 2020; 69:104974. [PMID: 32828807 DOI: 10.1016/j.tiv.2020.104974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/05/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022]
Abstract
Precision-cut intestinal slices (PCIS) are used to study intestinal (patho)physiology, drug efficacy, toxicity, transport and metabolism ex vivo. One of the factors that limit the use of PCIS is a relatively short life-span. Moreover, culture-induced changes in cellular composition of PCIS remain largely uncharacterized. In this study, we demonstrated the epithelial cell heterogeneity in mouse and rat PCIS and its alterations during culture. In addition, we evaluated whether the presence of niche growth factors impacts the survival of PCIS epithelial cells. We showed that freshly prepared PCIS retained the main epithelial cell types, namely absorptive enterocytes, goblet cells, enteroendocrine cells, stem cells, transit-amplifying cells and Paneth cells. Once placed in culture, PCIS displayed progressive epithelial damage, and loss of these epithelial cell types. Cells comprising the intestinal stem cell niche were especially sensitive to the damage, and the addition of niche growth factors beneficially affected the survival of stem cells and transit-amplifying cells in PCIS during culture. In conclusion, this study provides new insights into the dynamic changes in cellular composition of epithelium in cultured PCIS, paving the way to future toxicological and pharmacological studies in an informed and reliable ex vivo setting.
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Affiliation(s)
- Carin Biel
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, the Netherlands
| | - Emilia Bigaeva
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, the Netherlands; Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Melanie Hesse
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, the Netherlands
| | - Jordy J M Bomers
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, the Netherlands; PROdermpath, Labor für Dermatohistopathology, Vreden, Germany
| | - Kitty van Summeren
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, the Netherlands
| | - Marc A T Teunis
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, the Netherlands
| | - Stefan Vaessen
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, the Netherlands
| | - Jean Paul Ten Klooster
- Research Centre for Healthy and Sustainable Living, Innovative Testing in Life Sciences and Chemistry, University of Applied Sciences, Utrecht, the Netherlands
| | - Peter Olinga
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, the Netherlands.
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63
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Nobis M, Herrmann D, Warren SC, Strathdee D, Cox TR, Anderson KI, Timpson P. Shedding new light on RhoA signalling as a drug target in vivo using a novel RhoA-FRET biosensor mouse. Small GTPases 2020; 11:240-247. [PMID: 29457531 PMCID: PMC7549666 DOI: 10.1080/21541248.2018.1438024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/02/2018] [Indexed: 12/26/2022] Open
Abstract
The small GTPase RhoA is a master regulator of signalling in cell-extracellular matrix interactions. RhoA signalling is critical to many cellular processes including migration, mechanotransduction, and is often disrupted in carcinogenesis. Investigating RhoA activity in a native tissue environment is challenging using conventional biochemical methods; we therefore developed a RhoA-FRET biosensor mouse, employing the adaptable nature of intravital imaging to a variety of settings. Mechanotransduction was explored in the context of osteocyte processes embedded in the calvaria responding in a directional manner to compression stress. Further, the migration of neutrophils was examined during in vivo "chemotaxis" in wound response. RhoA activity was tightly regulated during tissue remodelling in mammary gestation, as well as during mammary and pancreatic carcinogenesis. Finally, pharmacological inhibition of RhoA was temporally resolved by the use of optical imaging windows in fully developed pancreatic and mammary tumours in vivo. The RhoA-FRET mouse therefore constitutes a powerful tool to facilitate development of new inhibitors targeting the RhoA signalling axis.
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Affiliation(s)
- Max Nobis
- The Garvan Institute of Medical Research, St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, 2010NSW, Australia
| | - David Herrmann
- The Garvan Institute of Medical Research, St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, 2010NSW, Australia
| | - Sean C. Warren
- The Garvan Institute of Medical Research, St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, 2010NSW, Australia
| | - Douglas Strathdee
- Cancer Research UK Beatson Institute, Switchback Road, Bearsden, GlasgowG611BD, UK
| | - Thomas R. Cox
- The Garvan Institute of Medical Research, St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, 2010NSW, Australia
| | | | - Paul Timpson
- The Garvan Institute of Medical Research, St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, 2010NSW, Australia
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64
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Strictures in Crohn's Disease: From Pathophysiology to Treatment. Dig Dis Sci 2020; 65:1904-1916. [PMID: 32279173 DOI: 10.1007/s10620-020-06227-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/19/2020] [Indexed: 12/16/2022]
Abstract
Despite recent advances aimed to treat transmural inflammation in Crohn's disease (CD) patients, the progression to a structuring behavior still represents an issue for clinicians. As inflammation becomes chronic and severe, the attempt to repair damaged tissue can result in an excessive production of extracellular matrix components and deposition of connective tissue, thus favoring the formation of strictures. No specific and accurate clinical predictors or diagnostic tools for intestinal fibrosis exist, and to date, no genetic or serological marker is in routine clinical use. Therefore, intestinal fibrosis is usually diagnosed when it becomes clinically evident and strictures have already occurred. Anti-fibrotic agents such as tranilast, peroxisome proliferator-activated receptor gamma agonists, rho kinase inhibitors, and especially mesenchymal stem cell therapy have provided interesting results, but most of the evidence has been derived from studies performed in vitro. Therefore, current therapy of fibrotic strictures relies mainly on endoscopic and surgical procedures. Although its long-term outcomes may be debated, endoscopic balloon dilation appears to be the safest and most effective approach to treat appropriately selected strictures. The use of endoscopic stricturotomy is currently limited by the expertise needed to perform it and by the few data available in the literature. Some good results have been achieved by the positioning of self-expandable metal stents (SEMS). However, there is no concordance regarding the type of stent to use and for how long it should be left in place. The development of new specific SEMS may lead to better outcomes and to an increased use of this alternative in CD-related strictures.
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65
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Zhao JF, Ling FM, Li JR, Chen YD, Huang L, Zhu LR. Role of non-inflammatory factors in intestinal fibrosis. J Dig Dis 2020; 21:315-318. [PMID: 32406603 DOI: 10.1111/1751-2980.12883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Intestinal fibrosis is a common complication of inflammatory bowel disease (IBD), resulting in strictures and ultimately obstruction, which is a significant clinical problem. Fibrosis is mainly triggered by local chronic inflammation and occurs when excessive extracellular matrix deposition is caused by activated mesenchymal cells. Despite the advance of anti-inflammatory therapies in IBD, the incidence and preventive strategies of intestinal fibrosis and strictures in IBD have not significantly changed over time. This shows that inflammation is necessary for fibrosis, but it does not necessarily affect the fibrotic progression. This review summarizes current knowledge about the non-inflammatory mechanisms implicated in the gut fibrotic process of IBD, which may pave the way for new mechanisms and anti-fibrotic therapies.
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Affiliation(s)
- Jin Fang Zhao
- Comprehensive AIDS Research Center and Research Center for Public Health, School of Medicine, Tsinghua University, Beijing, China.,Research Center for Biological Therapy, Beijing Institute of Infectious Diseases, Beijing, China
| | - Fang Mei Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Jun Rong Li
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yi Dong Chen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Liang Huang
- Division of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Liang Ru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
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66
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Zhong YK, Lu BL, Huang SY, Chen YJ, Li ZP, Rimola J, Li XH. Cross-sectional imaging for assessing intestinal fibrosis in Crohn's disease. J Dig Dis 2020; 21:342-350. [PMID: 32418328 DOI: 10.1111/1751-2980.12881] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
More than 30% of patients with Crohn's disease (CD) develop fibrotic strictures in the bowel as the disease progresses. Excessive deposition of extracellular matrix components in the submucosa and smooth muscle hypertrophy or hyperplasia are the main features of fibrosis in CD. Cross-sectional imaging technology provides a wealth of information on the anatomy, histological composition, and physiological function of the bowel, allowing for a non-invasive and complete evaluation of associated abnormalities. This review summarizes recent advances in and the potential technologies of cross-sectional imaging for assessing intestinal fibrosis in CD, including ultrasound imaging, computed tomography, and magnetic resonance imaging.
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Affiliation(s)
- Ying Kui Zhong
- Department of Radiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Bao Lan Lu
- Department of Radiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Si Yun Huang
- Department of Radiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yu Jun Chen
- Department of Ultrasound, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zi Ping Li
- Department of Radiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Xue Hua Li
- Department of Radiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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67
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Abstract
Intestinal fibrosis is one of the biggest challenges in the therapeutic management of inflammatory bowel diseases (IBD). Patients with Crohn's disease, in particular, suffer from fibrotic complications, which are manifested by the clinical stenosis of the bowel. Although fibrosis is caused by recurrent episodes of inflammation and wound healing, current therapies for IBD do not seem to reduce the incidence of stenosis, suggesting that inflammation-independent mechanisms also contribute to intestinal fibrogenesis. The lack of anti-fibrotic therapies for IBD and the huge burden this complication places on patients has prompted us to redirect inflammation research toward understanding the mechanisms that drive gut fibrosis. Based on data from other fibroproliferative diseases, metabolic modifications are increasingly recognized as pathogenic processes that may generate new therapeutic opportunities. These metabolic alterations result from a switch in the cellular metabolism of activated fibroblasts, which are the key mediator cells of fibrosis. Here, we review the metabolic changes associated with fibrotic disease and summarize the evidence of a metabolic shift during intestinal fibrosis.
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Affiliation(s)
- Simon Bos
- Department of Gastroenterology, Ghent University, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent, Belgium
| | - Debby Laukens
- Department of Gastroenterology, Ghent University, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent, Belgium
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68
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Abstract
Fibrostenosis occurs in both Crohn's disease (CD) and ulcerative colitis (UC). Up to 21% of patients with CD present with strictures at diagnosis, while the rate of stenosis varies from 1% to 11% in UC. Despite the increasing use of immunomodulators and biologics in treatment, there has been no decrease in the rate of progression from inflammatory to complicated disease phenotypes (either stricturing or penetrating). The presence of stenosis is an independent risk factor for surgery in patients with CD, who are at a risk of postoperative recurrence at a rate of up to 55% at 10 years after surgery. Patients with inflammatory bowel disease (IBD) strictures are at risk of malignant transformation. Thus, surveillance colonoscopy should be offered to this group of patients. Several risk factors for the development of stricture have been identified. In CD, patients aged less than 40-years old, with perianal disease at diagnosis, who need steroids at the first flare up or have ileal disease are at the risk of developing strictures; while in UC, patients with extensive colitis and long-standing disease are at risk. Recently, microbiota signatures have also been identified as markers for stricture development. The presence of Ruminococcus spp. is associated with the development of stricture in pediatric patients with CD. In this review, we highlight the epidemiology, risk factors and natural history of fibrostenosing IBD.
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Affiliation(s)
- Joyce Wing Yan Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Science, Chinese University of Hong Kong, Hong Kong SAR, China
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69
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Zhang Y, Saradna A, Ratan R, Ke X, Tu W, Do DC, Hu C, Gao P. RhoA/Rho-kinases in asthma: from pathogenesis to therapeutic targets. Clin Transl Immunology 2020; 9:e01134. [PMID: 32355562 PMCID: PMC7190398 DOI: 10.1002/cti2.1134] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022] Open
Abstract
Asthma is a chronic and heterogeneous disease characterised by airway inflammation and intermittent airway narrowing. The key obstacle in the prevention and treatment of asthma has been our incomplete understanding of its aetiology and biological mechanisms. The ras homolog family member A (RhoA) of the Rho family GTPases has been considered to be one of the most promising and novel therapeutic targets for asthma. It is well known that RhoA/Rho‐kinases play an important role in the pathophysiology of asthma, including airway smooth muscle contraction, airway hyper‐responsiveness, β‐adrenergic desensitisation and airway remodelling. However, recent advances have suggested novel roles for RhoA in regulating allergic airway inflammation. Specifically, RhoA has been shown to regulate allergic airway inflammation through controlling Th2 or Th17 cell differentiation and to regulate airway remodelling through regulating mesenchymal stem cell (MSC) differentiation. In this review, we evaluate the literature regarding the recent advances in the activation of RhoA/Rho‐kinase, cytokine and epigenetic regulation of RhoA/Rho‐kinase, and the role of RhoA/Rho‐kinase in regulating major features of asthma, such as airway hyper‐responsiveness, remodelling and inflammation. We also discuss the importance of the newly identified role of RhoA/Rho‐kinase signalling in MSC differentiation and bronchial epithelial barrier dysfunction. These findings indicate the functional significance of the RhoA/Rho‐kinase pathway in the pathophysiology of asthma and suggest that RhoA/Rho‐kinase signalling may be a promising therapeutic target for the treatment of asthma.
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Affiliation(s)
- Yan Zhang
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA.,Department of Respiratory Medicine Xiangya Hospital Central South University Changsha China
| | - Arjun Saradna
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA.,Division of Pulmonary Critical Care and Sleep Medicine State University of New York at Buffalo Buffalo NY USA
| | - Rhea Ratan
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA
| | - Xia Ke
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA.,Department of Otorhinolaryngology First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Wei Tu
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA.,Department of Respirology and Allergy Third Affiliated Hospital of Shenzhen University Shenzhen China
| | - Danh C Do
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA
| | - Chengping Hu
- Department of Respiratory Medicine Xiangya Hospital Central South University Changsha China
| | - Peisong Gao
- Division of Allergy and Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA
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70
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Li H, Feng C, Fan C, Yang Y, Yang X, Lu H, Lu Q, Zhu F, Xiang C, Zhang Z, He P, Zuo J, Tang W. Intervention of oncostatin M-driven mucosal inflammation by berberine exerts therapeutic property in chronic ulcerative colitis. Cell Death Dis 2020; 11:271. [PMID: 32332711 PMCID: PMC7181765 DOI: 10.1038/s41419-020-2470-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 12/14/2022]
Abstract
Ulcerative colitis (UC) is a chronic and etiologically refractory inflammatory gut disorder. Although berberine, an isoquinoline alkaloid, has been revealed to exert protective effects on experimental colitis, the underlying molecular mechanism in chronic intestinal inflammation remains ill-defined. This study was designed to uncover the therapeutic efficacy and immunomodulatory role of berberine in chronic UC. Therapeutic effects of oral administration of berberine were investigated in dextran sodium sulfate (DSS)-induced murine chronic UC and the underlying mechanisms were further identified by si-OSMR transfection in human intestinal stromal cells. Berberine significantly attenuated the experimental symptoms and gut inflammation of chronic UC. Berberine treatment could also maintain the intestinal barrier function and rectify tissue fibrosis. In accordance with infiltrations of antigen-presenting cells (APCs), innate lymphoid cells (ILCs), and activated NK cells in colonic lamina propria, increased expression of OSM and OSMR were observed in the inflamed tissue of chronic UC, which were decreased following berberine treatment. Moreover, berberine inhibited the overactivation of human intestinal stromal cells through OSM-mediated JAK-STAT pathway, which was obviously blocked upon siRNA targeting OSMR. The research provided an infusive mechanism of berberine and illustrated that OSM and OSMR intervention might function as the potential target in chronic UC.
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Affiliation(s)
- Heng Li
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China.,School of Pharmacy, University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Chunlan Feng
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Chen Fan
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Yang Yang
- Laboratory of Immunology and Virology, Shanghai University of Traditional Chinese Medicine, 201203, Shanghai, China
| | - Xiaoqian Yang
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Huimin Lu
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China.,School of Pharmacy, University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Qiukai Lu
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China.,School of Pharmacy, University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Fenghua Zhu
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Caigui Xiang
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China.,School of Pharmacy, University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Zongwang Zhang
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Peilan He
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Jianping Zuo
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China. .,School of Pharmacy, University of Chinese Academy of Sciences, 100049, Beijing, China. .,Laboratory of Immunology and Virology, Shanghai University of Traditional Chinese Medicine, 201203, Shanghai, China.
| | - Wei Tang
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China. .,School of Pharmacy, University of Chinese Academy of Sciences, 100049, Beijing, China.
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71
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Experimental Models of Partial Intestinal Obstruction in Young Mice: Establishment, and Evaluation. J Surg Res 2020; 252:206-215. [PMID: 32283334 DOI: 10.1016/j.jss.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Partial small bowel obstruction (SBO) is a common, potentially hazardous, surgical entity caused by numerous factors in humans. A number of techniques have been reported as efficient to simulate partial SBO in murine models. However, there is little data concerning their long-term survival. Our study presents a novel technique and evaluates its long-term efficiency compared with other commonly used techniques. MATERIALS AND METHODS Sixty C57BL/6 mice aged 6 to 8 wk were randomly divided into five intervention groups: ligation, intestinal ring, partial ligation, microclips, and the novel triple suture technique. The ring groups were subdivided into narrow, medium, and wide ring and partial ligation groups were subdivided at 1/3, 1/2, and 2/3 of the lumen. Survival cutoff time was set at 4 wk. Animals were then euthanized and small bowel muscle layer thickness was histopathologically evaluated. RESULTS None of the animals of the ligation and the ring groups reached the cutoff survival time. The mortality rate of the partial ligation and the microclips groups at the 4-week period were 33.3% and 0%, respectively. However, elimination of the performed intervention was revealed at the time of euthanasia and no alterations of the muscle layer were revealed at histopathology. The "triple suture" group had a survival rate of 90% until euthanasia and the sutures were apparent in all cases. Macroscopic evaluation showed small to mild proximal lumen dilatation in 6 of 10 animals. Histopathological evaluation of the specimens confirmed the partial obstruction. CONCLUSIONS The "triple suture" technique is a new, robust, reliable, and inexpensive technique for experimental long-standing partial SBO, with very low mortality.
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72
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Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn's disease. Intest Res 2020; 18:379-401. [PMID: 32259917 PMCID: PMC7609387 DOI: 10.5217/ir.2019.09148] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/26/2020] [Indexed: 12/15/2022] Open
Abstract
The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.
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Affiliation(s)
- Jun Hwan Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Stefan Holubar
- Department of Colorectal Surgery, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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73
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Diminished Vitamin D Receptor Protein Levels in Crohn's Disease Fibroblasts: Effects of Vitamin D. Nutrients 2020; 12:nu12040973. [PMID: 32244667 PMCID: PMC7230839 DOI: 10.3390/nu12040973] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 12/24/2022] Open
Abstract
Vitamin D (VD) deficiency has been associated to Crohn’s disease (CD) pathogenesis, and the exogenous administration of VD improves the course of the disease, but the mechanistic basis of these observations remains unknown. Vitamin D receptor (VDR) mediates most of the biological functions of this hormone, and we aim to analyze here the expression of VDR in intestinal tissue, epithelial cells, and fibroblasts from CD patients. The effects of VD on a fibroblast wound healing assay and murine intestinal fibrosis are also analyzed. Our data show diminished VDR protein levels in surgical resections and epithelial cells from CD patients. In intestinal fibroblasts isolated from damaged tissue of CD patients, we detected enhanced migration and decreased VDR expression compared with both fibroblasts from non-damaged tissue of the same CD patient or control fibroblasts. Treatment with VD increased VDR protein levels, avoided the accelerated migration in CD fibroblasts, and prevented murine intestinal fibrosis induced by the heterotopic transplant model. In conclusion, our study demonstrates diminished VDR protein levels associated with enhanced migration in intestinal fibroblasts from damaged tissue of CD patients. In these cells, VD accumulates VDR and normalizes migration, which supports that CD patients would benefit from the VD anti-fibrotic therapeutic value that we demonstrate in a murine experimental model.
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74
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El Ouali S, Click B, Holubar SD, Rieder F. Natural history, diagnosis and treatment approach to fibrostenosing Crohn's disease. United European Gastroenterol J 2020; 8:263-270. [PMID: 32213020 DOI: 10.1177/2050640620901960] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Stricturing Crohn's disease (CD) is a significant clinical problem. The presence of a stricture may be suggested by clinical symptoms. Cross-sectional imaging using computed tomography or magnetic resonance enterography is essential in diagnosing strictures as it allows further characterization and evaluation for complications such as abscess, fistulizing disease or malignancy. Managing small bowel stricturing CD should be approached in a multidisciplinary fashion. Medical therapy can be considered in strictures which are not associated with complications, with most of the data supporting anti-TNF strategies in this setting. If the disease is refractory to medical therapy, endoscopic therapy or surgery should be performed. Endoscopic balloon dilation (EBD) is an option for short, uncomplicated and straight strictures that are within reach of a colonoscope. Although EBD has good short-term outcomes, repeat dilation is often required. Surgical options mainly include resection and strictureplasty. Strictures refractory to medical therapy, not amenable or refractory to EBD, or associated with complications or malignancy should be managed surgically. However, surgery may also be considered at an earlier stage depending on disease characteristics and patient preference. Postoperative recurrence is common, highlighting the importance of careful monitoring of the patient postoperatively and optimization of medical management accordingly. There is a pressing need to develop anti-fibrotics for the treatment of stricturing CD. This requires the development of standardized diagnostic criteria, patient-reported outcome measures and validation of endpoints in fibrostenotic CD. The STAR consortium is pioneering this effort in order to allow development and testing of anti-fibrotics in future clinical trials.
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Affiliation(s)
- Sara El Ouali
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin Click
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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75
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Schwab R, Lim R, Goldberg R. Resolving intestinal fibrosis through regenerative medicine. Curr Opin Pharmacol 2019; 49:90-94. [DOI: 10.1016/j.coph.2019.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/24/2019] [Indexed: 01/10/2023]
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76
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Allocca M, Fiorino G, Bonifacio C, Peyrin-Biroulet L, Danese S. Noninvasive Multimodal Methods to Differentiate Inflamed vs Fibrotic Strictures in Patients With Crohn's Disease. Clin Gastroenterol Hepatol 2019; 17:2397-2415. [PMID: 30995529 DOI: 10.1016/j.cgh.2019.04.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
Fibrotic strictures occur in 30% of patients with Crohn's disease (CD). However, there are no therapeutic agents that prevent or reverse fibrotic strictures. Strictures are treated by endoscopic dilatation procedures and surgical procedures, but there are high rates of recurrence. Two antifibrotic agents (nintedanib and pirfenidone) recently were approved for the treatment of idiopathic pulmonary fibrosis and inhibitors of Rho-associated protein kinases 1 and 2 reversed fibrosis in mice with chronic intestinal inflammation. Cross-sectional imaging techniques, such as magnetic resonance (MR) enterography, computed tomography enterography, and bowel ultrasound, are used to assess small-bowel and CD-related complications, including strictures. It is important to be able to determine the degree of inflammation and fibrosis in strictures to select the best therapy; this can be a challenge because inflammation and fibrosis co-exist to varying degrees in a damaged bowel segment. Delayed gadolinium enhancement, magnetization transfer MR imaging, and ultrasound elastography seem to be promising tools for assessing fibrosis in patients with CD. We review noninvasive techniques for fibrosis assessment, including analyses of genetic, epigenetic, and protein markers. We discuss the potential of imaging techniques such as diffusion-weighted and magnetization transfer MR imaging, strain elastography, shear-wave imaging, and positron emission tomography to guide therapeutic decisions for patients with stricturing CD.
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Affiliation(s)
- Mariangela Allocca
- Inflammatory Bowel Disease Centre, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Gionata Fiorino
- Inflammatory Bowel Disease Centre, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Cristiana Bonifacio
- Division of Diagnostic Radiology, Humanitas Clinical and Research Centre, Rozzano, Milano, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Nancy, France
| | - Silvio Danese
- Inflammatory Bowel Disease Centre, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
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77
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Intestinal and hepatic fibrosis: how are they similar? Lancet Gastroenterol Hepatol 2019; 4:820-822. [PMID: 31609236 DOI: 10.1016/s2468-1253(19)30249-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 12/18/2022]
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78
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Choi YJ, Koo JB, Kim HY, Seo JW, Lee EJ, Kim WR, Cho JY, Hahm KB, Hong SP, Kim DH, Yoo JH. Umbilical cord/placenta-derived mesenchymal stem cells inhibit fibrogenic activation in human intestinal myofibroblasts via inhibition of myocardin-related transcription factor A. Stem Cell Res Ther 2019; 10:291. [PMID: 31547873 PMCID: PMC6757442 DOI: 10.1186/s13287-019-1385-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 12/22/2022] Open
Abstract
Background The lack of anti-fibrotic agents targeting intestinal fibrosis is a large unmet need in inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis. Previous studies have found that perinatal tissue (umbilical cord, UC; placenta, PL)-derived mesenchymal stem cells (MSCs) reduce fibrosis in several organs. However, their effects on human intestinal fibrosis are poorly understood. This study investigated the anti-fibrogenic properties and mechanisms of MSCs derived from UC and PL (UC/PL-MSCs) on human primary intestinal myofibroblasts (HIMFs). Methods The HIMFs were treated with TGF-β1 and co-cultured with UC/PL-MSCs. We used a small molecular inhibitor CCG-100602 to examine whether serum response factor (SRF) and its transcriptional cofactor myocardin-related transcription factor A (MRTF-A) are involved in TGF-β1-induced fibrogenic activation in HIMFs. The anti-fibrogenic mechanism of UC/PL-MSCs on HIMFs was analyzed by detecting the expression of RhoA, MRTF-A, and SRF in HIMFs. Results UC/PL-MSCs reduced TGF-β1-induced procollagen1A1, fibronectin, and α-smooth muscle actin expression in HIMFs. This anti-fibrogenic effect was more apparent in the UC-MSCs. TGF-β1 stimulation increased the expressions of RhoA, MRTF-A, and SRF in the HIMFs. TGF-β1 induced the synthesis of procollagen1A1, fibronectin, and α-smooth muscle actin through a MRTF-A/SRF-dependent mechanism. Co-culture with the UC/PL-MSCs downregulated fibrogenesis by inhibition of RhoA, MRTF-A, and SRF expression. Conclusions UC/PL-MSCs suppress TGF-β1-induced fibrogenic activation in HIMFs by blocking the Rho/MRTF/SRF pathway and could be considered as a novel candidate for stem cell-based therapy of intestinal fibrosis. Electronic supplementary material The online version of this article (10.1186/s13287-019-1385-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yoon Jeong Choi
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, 463-712, South Korea.,Institute of Basic Medical Sciences, School of Medicine, CHA University, Seongnam, South Korea
| | - Jun Bon Koo
- Clinical Research Center, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | | | - Jin Won Seo
- CHA Biotech, Co. Ltd., Seongnam, South Korea
| | | | - Woo Ram Kim
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, 463-712, South Korea
| | - Ki Baik Hahm
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, 463-712, South Korea
| | - Sung Pyo Hong
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, 463-712, South Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, 463-712, South Korea.
| | - Jun-Hwan Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, 463-712, South Korea. .,Institute of Basic Medical Sciences, School of Medicine, CHA University, Seongnam, South Korea.
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Kanehara K, Ohnuma S, Kanazawa Y, Sato K, Kokubo S, Suzuki H, Karasawa H, Suzuki T, Suzuki C, Naitoh T, Unno M, Abe T. The indole compound MA-35 attenuates tumorigenesis in an inflammation-induced colon cancer model. Sci Rep 2019; 9:12739. [PMID: 31484999 PMCID: PMC6726640 DOI: 10.1038/s41598-019-48974-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
In inflammatory bowel disease, chronic inflammation results in the development of colon cancer known as colitis-associated cancer. This disease is associated with tumor necrosis factor-α (TNF-α) signaling. In addition, intestinal fibrosis is a common clinical complication that is promoted by transforming growth factor β1 (TGF-β1). In our previous study, MA-35 attenuated renal fibrosis by inhibiting both TNF-α and TGF-β1 signaling. This study aimed to identify the possible antitumor effects and antifibrotic effects of MA-35 using an AOM/DSS mouse model. MA-35 was orally administered every day for 70 days in the AOM/DSS mouse model. There was no difference in weight loss between the AOM/DSS group and the AOMDSS + MA-35 group, but the disease activity index score and the survival rate were improved by MA-35. MA-35 blocked the anemia and shortening of the colon induced by AOM/DSS. MA-35 reduced the macroscopic formation of tumors in the colon. In the microscopic evaluation, MA-35 reduced inflammation and fibrosis in areas with dysplasia. Furthermore, the TNF-α mRNA level in the colon tended to be reduced, and the interleukin 6, TGF-β1 and fibronectin 1 mRNA levels in the colon were significantly reduced by MA-35. These results suggested that MA-35 inhibited AOM/DSS-induced carcinogenesis by reducing inflammation and fibrosis.
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Affiliation(s)
- Keigo Kanehara
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Shinobu Ohnuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan.
| | - Yoshitake Kanazawa
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Keisuke Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Shoji Kokubo
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Hideyuki Suzuki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Hideaki Karasawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Takehiro Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Chitose Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Takeshi Naitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan
| | - Takaaki Abe
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan. .,Department of Medical Science, Tohoku University Graduate School of Biomedical Engineering, Sendai, 980-8574, Japan. .,Department of Clinical Biology and Hormonal Regulation, Tohoku University Graduate School of Medicine, Sendai, 980-8574, Japan.
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80
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Li J, Mao R, Kurada S, Wang J, Lin S, Chandra J, Rieder F. Pathogenesis of fibrostenosing Crohn's disease. Transl Res 2019; 209:39-54. [PMID: 30981697 DOI: 10.1016/j.trsl.2019.03.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/07/2019] [Accepted: 03/21/2019] [Indexed: 02/06/2023]
Abstract
Crohn's disease (CD) is a chronic inflammatory disease, which could affect any part of the gastrointestinal tract. A severe complication of CD is fibrosis-associated strictures, which can cause bowel obstruction. Unfortunately, there is no specific antifibrotic therapy available. More than 80% of the patients with CD will have to undergo at least 1 surgery in their life and recurrence of strictures after surgery is common. Investigations on the mechanism of fibrostenosing CD have revealed that fibrosis is mainly driven by expansion of mesenchymal cells including fibroblasts, myofibroblasts, and smooth muscle cells. Being exposed to a pro-fibrotic milieu, these cells increase the secretion of extracellular matrix, as well as crosslinking enzymes, which drive tissue stiffness and remodeling. Fibrogenesis can become independent of inflammation in later stages of disease, which offers unique therapeutic potential. Exciting new evidence suggests smooth muscle cell hyperplasia as a strong contributor to luminal narrowing in fibrostenotic CD. Approval of new drugs in other fibrotic diseases, such as idiopathic pulmonary fibrosis, as well as new targets associated with fibrosis found in CD, such as cadherins or specific integrins, shed light on the development of novel antifibrotic approaches in CD.
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Affiliation(s)
- Jiannan Li
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ren Mao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Satya Kurada
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jie Wang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio; School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, China
| | - Sinan Lin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jyotsna Chandra
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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81
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Treatments for Crohn's Disease-Associated Bowel Damage: A Systematic Review. Clin Gastroenterol Hepatol 2019; 17:847-856. [PMID: 30012430 DOI: 10.1016/j.cgh.2018.06.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite significant advances in the treatment of Crohn's disease (CD), most patients still develop stricturing or penetrating complications that require surgical resections. We performed a systematic review of mechanisms and potential treatments for tissue damage lesions in CD patients. METHODS We searched the PubMed, MBASE, and Cochrane databases from January 1960 to July 2017 for full-length articles on CD, fibrosis, damage lesions, mesenchymal stem cells, and/or treatment. We also searched published conference abstracts and performed manual searches of all reference lists of relevant articles. RESULTS Mechanisms of intestinal damage in patients with CD include fibroblast proliferation and migration, activation of stellate cells, recruitment of intestinal or extra-intestinal fibroblast, and cell trans-differentiation. An altered balance of metalloproteinases and tissue inhibitors of metalloproteinases might contribute to fistula formation. Treatment approaches that reduce excessive transforming growth factor beta (TGFB) activation might be effective in treating established intestinal damage. Stem cell therapies have been effective in tissue damage lesions in CD. Particularly, randomized controlled trials have shown local injections of mesenchymal stem cells to heal perianal fistulas. CONCLUSION In a systematic review of mechanisms and treatments of bowel wall damage in patients with CD, we found a need to test drugs that reduce TGFB and increase healing of transmural damage lesions and to pursue research on local injection of mesenchymal stem cells.
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82
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Scheibe K, Kersten C, Schmied A, Vieth M, Primbs T, Carlé B, Knieling F, Claussen J, Klimowicz AC, Zheng J, Baum P, Meyer S, Schürmann S, Friedrich O, Waldner MJ, Rath T, Wirtz S, Kollias G, Ekici AB, Atreya R, Raymond EL, Mbow ML, Neurath MF, Neufert C. Inhibiting Interleukin 36 Receptor Signaling Reduces Fibrosis in Mice With Chronic Intestinal Inflammation. Gastroenterology 2019; 156:1082-1097.e11. [PMID: 30452921 DOI: 10.1053/j.gastro.2018.11.029] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Intestinal fibrosis is a long-term complication in inflammatory bowel diseases (IBD) that frequently results in functional damage, bowel obstruction, and surgery. Interleukin (IL) 36 is a group of cytokines in the IL1 family with inflammatory effects. We studied the expression of IL36 and its receptor, interleukin 1 receptor like 2 (IL1RL2 or IL36R) in the development of intestinal fibrosis in human tissues and mice. METHODS We obtained intestinal tissues from 92 patients with Crohn's disease (CD), 48 patients with ulcerative colitis, and 26 patients without inflammatory bowel diseases (control individuals). Tissues were analyzed by histology to detect fibrosis and by immunohistochemistry to determine the distribution of fibroblasts and levels of IL36R ligands. Human and mouse fibroblasts were incubated with IL36 or control medium, and transcriptome-wide RNA sequences were analyzed. Mice were given neutralizing antibodies against IL36R, and we studied intestinal tissues from Il1rl2-/- mice; colitis and fibrosis were induced in mice by repetitive administration of DSS or TNBS. Bone marrow cells were transplanted from Il1rl2-/- to irradiated wild-type mice and intestinal tissues were analyzed. Antibodies against IL36R were applied to mice with established chronic colitis and fibrosis and intestinal tissues were studied. RESULTS Mucosal and submucosal tissue from patients with CD or ulcerative colitis had higher levels of collagens, including type VI collagen, compared with tissue from control individuals. In tissues from patients with fibrostenotic CD, significantly higher levels of IL36A were noted, which correlated with high numbers of activated fibroblasts that expressed α-smooth muscle actin. IL36R activation of mouse and human fibroblasts resulted in expression of genes that regulate fibrosis and tissue remodeling, as well as expression of collagen type VI. Il1rl2-/- mice and mice given injections of an antibody against IL36R developed less severe colitis and fibrosis after administration of DSS or TNBS, but bone marrow cells from Il1rl2-/- mice did not prevent induction of colitis and fibrosis. Injection of antibodies against IL36R significantly reduced established fibrosis in mice with chronic intestinal inflammation. CONCLUSION We found higher levels of IL36A in fibrotic intestinal tissues from patients with IBD compared with control individuals. IL36 induced expression of genes that regulate fibrogenesis in fibroblasts. Inhibition or knockout of the IL36R gene in mice reduces chronic colitis and intestinal fibrosis. Agents designed to block IL36R signaling could be developed for prevention and treatment of intestinal fibrosis in patients with IBD.
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Affiliation(s)
- Kristina Scheibe
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christina Kersten
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Anabel Schmied
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Tatjana Primbs
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Birgitta Carlé
- Institute of Medical Biotechnology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ferdinand Knieling
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany; Department of Pediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Jie Zheng
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Patrick Baum
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Sebastian Meyer
- Institute of Medical Informatics, Biometry, and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Schürmann
- Institute of Medical Biotechnology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Friedrich
- Institute of Medical Biotechnology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Maximilian J Waldner
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Timo Rath
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Wirtz
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - George Kollias
- Biomedical Sciences Research Center Alexander Fleming, Vari, Greece
| | - Arif B Ekici
- Institute of Human Genetics, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Raja Atreya
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ernest L Raymond
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - M Lamine Mbow
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Markus F Neurath
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Clemens Neufert
- First Department of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
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83
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Yun SM, Kim SH, Kim EH. The Molecular Mechanism of Transforming Growth Factor-β Signaling for Intestinal Fibrosis: A Mini-Review. Front Pharmacol 2019; 10:162. [PMID: 30873033 PMCID: PMC6400889 DOI: 10.3389/fphar.2019.00162] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/11/2019] [Indexed: 01/01/2023] Open
Abstract
Inflammatory bowel disease is known as the most chronic inflammatory disorder in colon, which subsequently progresses to intestinal obstruction and fistula formation. Many studies to date for the treatment of IBD have been focused on inflammation. However, most of the anti-inflammatory agents do not have anti-fibrotic effects and could not relieve intestinal stricture in IBD patients. Because preventing or reversing intestinal fibrosis in IBD is a major therapeutic target, we analyzed the papers focusing on TGF-β signaling in intestinal fibrosis. TGF-β is a good candidate to treat the intestinal fibrosis in IBD which involves TGF-β signaling pathway, EMT, EndMT, ECM, and other regulators. Understanding the mechanism involved in TGF-β signaling will contribute to the treatment and diagnosis of intestinal fibrosis occurring in IBD as well as the understanding of the molecular mechanisms underlying the pathogenesis.
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Affiliation(s)
- Sun-Mi Yun
- College of Pharmacy and Institute of Pharmaceutical Sciences, CHA University, Seongnam, South Korea
| | - Seok-Ho Kim
- College of Pharmacy and Institute of Pharmaceutical Sciences, CHA University, Seongnam, South Korea
| | - Eun-Hee Kim
- College of Pharmacy and Institute of Pharmaceutical Sciences, CHA University, Seongnam, South Korea
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84
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Zhang L, Liu B. Targeting Autophagy with Small-Molecule Modulators in Immune-Related Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1209:181-203. [PMID: 31728871 DOI: 10.1007/978-981-15-0606-2_11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Autophagy, a highly conserved and multistep lysosomal degradation process, plays a pivotal role in maintaining cellular and physiological homeostasis. Of note, autophagy controls intracellular homeostasis and cell responses to stresses by regulating the self-renewal, maturation, and survival of immune cells. And dysregulation of autophagy in immune cells may contribute to the inflammatory disorders and defect in immune responses against invasive pathogens. Accumulating evidence have indicated that dysregulated autophagy participates in the pathology of immune-related diseases. Therefore, targeting autophagy might represent a promising therapeutic strategy for treatment of immune-related diseases. In this chapter, we focus on discussing the link between autophagy and pathogenesis of immune-related diseases, as well as the dysregulation of autophagy-related signaling pathways, in different diseases. Moreover, we highlight the therapeutic potential of currently used small-molecule modulators of autophagy for treatment of immune-related diseases and illustrate the mechanisms of these small-molecule modulators.
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Affiliation(s)
- Lan Zhang
- School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, 610031, China
| | - Bo Liu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, 610041, China.
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85
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Lenti MV, Di Sabatino A. Intestinal fibrosis. Mol Aspects Med 2018; 65:100-109. [PMID: 30385174 DOI: 10.1016/j.mam.2018.10.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/19/2018] [Accepted: 10/28/2018] [Indexed: 02/07/2023]
Abstract
Extensive tissue fibrosis is the end-stage process of a number of chronic conditions affecting the gastrointestinal tract, including inflammatory bowel disease (Crohn's disease, ulcerative colitis), ulcerative jejunoileitis, and radiation enteritis. Fibrogenesis is a physiological, reparative process that may become harmful as a consequence of the persistence of a noxious agent, after an excessive duration of the healing process. In this case, after replacement of dead or injured cells, fibrogenesis continues to substitute normal parenchymal tissue with fibrous connective tissue, leading to uncontrolled scar formation and, ultimately, permanent organ damage, loss of function, and/or strictures. Several mechanisms have been implicated in sustaining the fibrogenic process. Despite their obvious etiological and clinical distinctions, most of the above-mentioned fibrotic disorders have in common a persistent inflammatory stimulus which sustains the production of growth factors, proteolytic enzymes, and pro-fibrogenic cytokines that activate both non-immune (i.e., myofibroblasts, fibroblasts) and immune (i.e., monocytes, macrophages, T-cells) cells, the interactions of which are crucial in the progressive tissue remodeling and destroy. Here we summarize the current status of knowledge regarding the mechanisms implicated in gut fibrosis with a clinical approach, also focusing on possible targets of antifibrogenic therapies.
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Affiliation(s)
- Marco Vincenzo Lenti
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.
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86
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Ke X, Do DC, Li C, Zhao Y, Kollarik M, Fu Q, Wan M, Gao P. Ras homolog family member A/Rho-associated protein kinase 1 signaling modulates lineage commitment of mesenchymal stem cells in asthmatic patients through lymphoid enhancer-binding factor 1. J Allergy Clin Immunol 2018; 143:1560-1574.e6. [PMID: 30194990 DOI: 10.1016/j.jaci.2018.08.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/31/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Numbers of mesenchymal stem cells (MSCs) are increased in the airways after allergen challenge. Ras homolog family member A (RhoA)/Rho-associated protein kinase 1 (ROCK) signaling is critical in determining the lineage fate of MSCs in tissue repair/remodeling. OBJECTIVES We sought to investigate the role of RhoA/ROCK signaling in lineage commitment of MSCs during allergen-induced airway remodeling and delineate the underlying mechanisms. METHODS Active RhoA expression in lung tissues of asthmatic patients and its role in cockroach allergen-induced airway inflammation and remodeling were investigated. RhoA/ROCK signaling-mediated MSC lineage commitment was assessed in an asthma mouse model by using MSC lineage tracing mice (nestin-Cre; ROSA26-EYFP). The role of RhoA/ROCK in MSC lineage commitment was also examined by using MSCs expressing constitutively active RhoA (RhoA-L63) or dominant negative RhoA (RhoA-N19). Downstream RhoA-regulated genes were identified by using the Stem Cell Signaling Array. RESULTS Lung tissues from asthmatic mice showed increased expression of active RhoA when compared with those from control mice. Inhibition of RhoA/ROCK signaling with fasudil, a RhoA/ROCK inhibitor, reversed established cockroach allergen-induced airway inflammation and remodeling, as assessed based on greater collagen deposition/fibrosis. Furthermore, fasudil inhibited MSC differentiation into fibroblasts/myofibroblasts but promoted MSC differentiation into epithelial cells in asthmatic nestin-Cre; ROSA26-EYFP mice. Consistently, expression of RhoA-L63 facilitated differentiation of MSCs into fibroblasts/myofibroblasts, whereas expression of RhoA-19 switched the differentiation toward epithelial cells. The gene array identified the Wnt signaling effector lymphoid enhancer-binding factor 1 (Lef1) as the most upregulated gene in RhoA-L63-transfected MSCs. Knockdown of Lef1 induced MSC differentiation away from fibroblasts/myofibroblasts but toward epithelial cells. CONCLUSIONS These findings uncover a previously unrecognized role of RhoA/ROCK signaling in MSC-involved airway repair/remodeling in the setting of asthma.
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Affiliation(s)
- Xia Ke
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Otorhinolaryngology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Danh C Do
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Changjun Li
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Yilin Zhao
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Respiratory Medicine, Fourth Military Medical University, Xi'an, China
| | - Marian Kollarik
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Qingling Fu
- Otorhinolaryngology Hospital, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mei Wan
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Peisong Gao
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md.
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87
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Danese S, Bonovas S, Lopez A, Fiorino G, Sandborn WJ, Rubin DT, Kamm MA, Colombel JF, Sands BE, Vermeire S, Panes J, Rogler G, D'Haens G, Peyrin-Biroulet L. Identification of Endpoints for Development of Antifibrosis Drugs for Treatment of Crohn's Disease. Gastroenterology 2018; 155:76-87. [PMID: 29601825 DOI: 10.1053/j.gastro.2018.03.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/20/2018] [Accepted: 03/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Intestinal fibrosis is a challenge to management of patients with Crohn's disease (CD); there is an urgent need to expedite development of antifibrosis drugs for this disease. The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) aimed to identify a set of endpoints that can be used to determine efficacy of antifibrosis agents tested in clinical trials of patients with CD. METHODS We conducted a systematic review to identify clinical, radiologic, biochemical, endoscopic, and composite endpoints used in assessing activity of fibrostenosing CD and response to treatment, and determined their operational properties. A panel of IOIBD experts performed a consensus process to identify the best endpoints for inclusion in clinical trials, through a 2-round, Delphi-style online survey. RESULTS A total of 36 potentially relevant endpoints for intestinal fibrosis were selected and assessed. Forty-eight physicians with expertise in inflammatory bowel disease, from 5 regions (North America, Europe, Middle East, Asia/Pacific, and Latin America), participated in the Delphi consensus process. A core set of 13 endpoints (complete clinical response, long-term efficacy, sustained clinical benefit, treatment failure, radiological remission, normal quality of life, clinical remission without steroids, therapeutic failure, deep remission, complete absence of occlusive symptoms, symptom-free survival, bowel damage progression, and no disability) were rated as critical. Agreement was high among the experts. CONCLUSIONS Members of the IOIBD reached expert consensus on a set of endpoints that can be used to assess antifibrosis agents in trials of patients with CD. Studies are needed to clarify methods for measuring these outcomes and validate measurement instruments.
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Affiliation(s)
- Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy.
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Anthony Lopez
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Gionata Fiorino
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | | | - Michael A Kamm
- Departments of Gastroenterology and Medicine, St Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Severine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Julian Panes
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | | | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
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88
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Lian L, Huang Q, Zhang L, Qin H, He X, He X, Ke J, Xie M, Lan P. Anti-fibrogenic Potential of Mesenchymal Stromal Cells in Treating Fibrosis in Crohn's Disease. Dig Dis Sci 2018; 63:1821-1834. [PMID: 29704139 DOI: 10.1007/s10620-018-5082-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 04/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intestinal fibrosis is a major complication of CD and may result in stricture formation leading to intestinal obstruction. MSCs play multiple roles in active CD and fibrosis-associated diseases. AIMS This study was designed to investigate the role of MSCs in CD-associated intestinal fibrosis. METHODS Intestinal fibrosis was induced over 7 weeks of enema with increasing doses of TNBS and assessed by Masson's trichrome staining. Transcriptome sequencing and gene set enrichment analysis were conducted to reveal the transcriptome changes among groups at the mRNA level. Immunofluorescence assays were used to validate the role of EMT in intestinal fibrosis. Quantitative real-time PCR and immunohistochemistry analyses were performed to clarify the association between the anti-fibrogenic properties of MSCs and the immune microenvironment. Western blotting was used to verify the potential signaling pathways. RESULTS Fibrotic tissue accumulation and inflammatory cell infiltration were detected in the colon tissue after TNBS induction treatment. Prophylactic MSCs treatment inhibited colon shortening, while therapeutic treatment decreased colon weight. Prophylactic treatment with MSCs inhibited the accumulation of fibrotic tissue, the expression of fibrotic proteins and EMT. Therapeutic MSCs treatment reversed the established intestinal fibrosis and reduced EMT. The secretion of the fibrogenic factors IL-1beta, IL-6 and IL-13 was down-regulated after both MSCs treatment approaches, while IL-10, an anti-fibrogenic factor, was up-regulated. Both MSCs therapies inhibited the expression of TGF-beta and the phosphorylation of Smad2 and Smad3 after TNBS induction. CONCLUSION MSCs exert anti-fibrogenic activity against CD-associated fibrosis by regulating the inflammatory environment, inhibiting the TGF-beta/Smad signaling pathway and ameliorating EMT.
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Affiliation(s)
- Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China. .,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Qunsheng Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Longjuan Zhang
- Laboratory of Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Huabo Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Department of General and Pediatric Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Xiaosheng He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xin He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou City, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Minghao Xie
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Department of General Surgery, The Affiliated Hospital of Jiujiang University, Jiujiang, Jiangxi, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China. .,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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89
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Chan WPW, Mourad F, Leong RW. Crohn's disease associated strictures. J Gastroenterol Hepatol 2018; 33:998-1008. [PMID: 29427364 DOI: 10.1111/jgh.14119] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/23/2018] [Accepted: 01/25/2018] [Indexed: 12/13/2022]
Abstract
Crohn's disease (CD) is a chronic relapsing and remitting disease that can affect any segments of the gastrointestinal tract. More than 50% of patients with CD develop stricturing or penetrating complications within the first 10 years after diagnosis. Strictures can lead to intestinal obstruction, which is a common indication for surgery. Despite significant advances in the understanding of the pathogenesis of intestinal fibrostenosis, imaging and therapeutic armamentarium of CD, the risk of intestinal surgery remained significantly high. Endoscopic balloon dilation is a promising first-line alternative to surgery as it is less invasive and could preserve intestinal length. In this review, we will evaluate the literature on the mechanism of intestinal fibrosis, emerging imaging techniques, and management strategies for CD associated strictures.
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Affiliation(s)
- Webber Pak Wo Chan
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Fadi Mourad
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Rupert Wl Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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90
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He S, Xue M, Liu C, Xie F, Bai L. Parathyroid Hormone-Like Hormone Induces Epithelial-to-Mesenchymal Transition of Intestinal Epithelial Cells by Activating the Runt-Related Transcription Factor 2. THE AMERICAN JOURNAL OF PATHOLOGY 2018; 188:1374-1388. [PMID: 29577935 DOI: 10.1016/j.ajpath.2018.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/04/2018] [Accepted: 03/06/2018] [Indexed: 01/18/2023]
Abstract
Epithelial-to-mesenchymal transition (EMT) is a key contributor to fibroblast activation in fibrosis of multiple organs, including the intestine. Parathyroid hormone-like hormone (PTHLH) is an important factor in renal fibrosis and regulates several processes, including EMT. Herein, we investigated the role of PTHLH-induced EMT in intestinal fibrosis associated with Crohn disease. The expression levels of the EMT-related proteins, PTHLH, and parathyroid hormone receptor 1 (PTH1R) in intestinal tissues were determined by immunohistochemistry, and our results revealed that PTHLH and PTH1R were significantly elevated and associated with EMT marker expression. Moreover, neutralizing PTH1R and antagonizing PTHLH bioactivity prevented transforming growth factor-β1-induced EMT. PTH1R can propagate the protein kinase A (PKA) signal and activate downstream nuclear transcription factors, including runt-related transcription factor 2 (Runx2). In addition, lentiviral vector-PTHLH-treated mice were highly sensitive to 2,4,6-trinitrobenzene sulfonic acid, and analysis of the PTHLH-PTH1R axis revealed the involvement of PKA-Runx2 in PTHLH-induced EMT. Our results indicate that PTHLH triggered EMT in intestinal epithelial cells through the PKA-Runx2 pathway, which might serve as a therapeutic target for intestinal fibrosis in Crohn disease.
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Affiliation(s)
- Shuying He
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Minmin Xue
- Department of Gastroenterology, Chinese People's Liberation Army 254 Hospital, Tianjin, China
| | - Cuiping Liu
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Fang Xie
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lan Bai
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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91
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Vennin C, Murphy KJ, Morton JP, Cox TR, Pajic M, Timpson P. Reshaping the Tumor Stroma for Treatment of Pancreatic Cancer. Gastroenterology 2018; 154:820-838. [PMID: 29287624 DOI: 10.1053/j.gastro.2017.11.280] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/14/2017] [Accepted: 11/16/2017] [Indexed: 12/16/2022]
Abstract
Pancreatic cancer is accompanied by a fibrotic reaction that alters interactions between tumor cells and the stroma to promote tumor progression. Consequently, strategies to target the tumor stroma might be used to treat patients with pancreatic cancer. We review recently developed approaches for reshaping the pancreatic tumor stroma and discuss how these might improve patient outcomes. We also describe relationships between the pancreatic tumor extracellular matrix, the vasculature, the immune system, and metabolism, and discuss the implications for the development of stromal compartment-specific therapies.
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Affiliation(s)
- Claire Vennin
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia; The Kinghorn Cancer Center, Sydney, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kendelle J Murphy
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia; The Kinghorn Cancer Center, Sydney, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer P Morton
- Cancer Research UK, The Beatson Institute for Cancer Research, Glasgow, Scotland, United Kingdom
| | - Thomas R Cox
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia; The Kinghorn Cancer Center, Sydney, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marina Pajic
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia; The Kinghorn Cancer Center, Sydney, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| | - Paul Timpson
- The Garvan Institute of Medical Research, Sydney, New South Wales, Australia; The Kinghorn Cancer Center, Sydney, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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92
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Yao J, Dai Q, Liu Z, Zhou L, Xu J. Circular RNAs in Organ Fibrosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1087:259-273. [DOI: 10.1007/978-981-13-1426-1_21] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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93
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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