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Dudek M, Pathiranage DRJ, Bano-Otalora B, Paszek A, Rogers N, Gonçalves CF, Lawless C, Wang D, Luo Z, Yang L, Guilak F, Hoyland JA, Meng QJ. Mechanical loading and hyperosmolarity as a daily resetting cue for skeletal circadian clocks. Nat Commun 2023; 14:7237. [PMID: 37963878 PMCID: PMC10646113 DOI: 10.1038/s41467-023-42056-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 09/28/2023] [Indexed: 11/16/2023] Open
Abstract
Daily rhythms in mammalian behaviour and physiology are generated by a multi-oscillator circadian system entrained through environmental cues (e.g. light and feeding). The presence of tissue niche-dependent physiological time cues has been proposed, allowing tissues the ability of circadian phase adjustment based on local signals. However, to date, such stimuli have remained elusive. Here we show that daily patterns of mechanical loading and associated osmotic challenge within physiological ranges reset circadian clock phase and amplitude in cartilage and intervertebral disc tissues in vivo and in tissue explant cultures. Hyperosmolarity (but not hypo-osmolarity) resets clocks in young and ageing skeletal tissues and induce genome-wide expression of rhythmic genes in cells. Mechanistically, RNAseq and biochemical analysis revealed the PLD2-mTORC2-AKT-GSK3β axis as a convergent pathway for both in vivo loading and hyperosmolarity-induced clock changes. These results reveal diurnal patterns of mechanical loading and consequent daily oscillations in osmolarity as a bona fide tissue niche-specific time cue to maintain skeletal circadian rhythms in sync.
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Affiliation(s)
- Michal Dudek
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Dharshika R J Pathiranage
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Beatriz Bano-Otalora
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - Anna Paszek
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Natalie Rogers
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Cátia F Gonçalves
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Craig Lawless
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Dong Wang
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhuojing Luo
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Liu Yang
- Institute of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Farshid Guilak
- Department of Orthopedic Surgery and Department of Biomedical Engineering, Center of Regenerative Medicine, Washington University, St. Louis, MO, 63110, USA
- Shriners Hospitals for Children - St. Louis, St. Louis, MO, 63110, USA
| | - Judith A Hoyland
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
- NIHR Manchester Biomedical Research Centre, Central Manchester Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Qing-Jun Meng
- Wellcome Centre for Cell Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK.
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK.
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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2
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Pang H, Chen S, Klyne DM, Harrich D, Ding W, Yang S, Han FY. Low back pain and osteoarthritis pain: a perspective of estrogen. Bone Res 2023; 11:42. [PMID: 37542028 PMCID: PMC10403578 DOI: 10.1038/s41413-023-00280-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/28/2023] [Accepted: 07/10/2023] [Indexed: 08/06/2023] Open
Abstract
Low back pain (LBP) is the world's leading cause of disability and is increasing in prevalence more rapidly than any other pain condition. Intervertebral disc (IVD) degeneration and facet joint osteoarthritis (FJOA) are two common causes of LBP, and both occur more frequently in elderly women than in other populations. Moreover, osteoarthritis (OA) and OA pain, regardless of the joint, are experienced by up to twice as many women as men, and this difference is amplified during menopause. Changes in estrogen may be an important contributor to these pain states. Receptors for estrogen have been found within IVD tissue and nearby joints, highlighting the potential roles of estrogen within and surrounding the IVDs and joints. In addition, estrogen supplementation has been shown to be effective at ameliorating IVD degeneration and OA progression, indicating its potential use as a therapeutic agent for people with LBP and OA pain. This review comprehensively examines the relationship between estrogen and these pain conditions by summarizing recent preclinical and clinical findings. The potential molecular mechanisms by which estrogen may relieve LBP associated with IVD degeneration and FJOA and OA pain are discussed.
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Affiliation(s)
- Huiwen Pang
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia
| | - Shihui Chen
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia
| | - David M Klyne
- NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia
| | - David Harrich
- Department of Cell and Molecular Biology, QIMR Berghofer Medical Research Institute, Herston, QLD, 4006, Australia
| | - Wenyuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
- Hebei Joint International Research Center for Spinal Diseases, 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Sidong Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China.
- Hebei Joint International Research Center for Spinal Diseases, 139 Ziqiang Road, Shijiazhuang, 050051, China.
| | - Felicity Y Han
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St. Lucia, Brisbane, QLD, 4072, Australia.
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3
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Krull CM, Rife J, Klamer B, Purmessur D, Walter BA. Pericellular heparan sulfate proteoglycans: Role in regulating the biosynthetic response of nucleus pulposus cells to osmotic loading. JOR Spine 2022; 5:e1209. [PMID: 35783912 PMCID: PMC9238280 DOI: 10.1002/jsp2.1209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/26/2022] [Accepted: 05/12/2022] [Indexed: 12/04/2022] Open
Abstract
Background Daily physiologic loading causes fluctuations in hydration of the intervertebral disc (IVD); thus, the embedded cells experience cyclic alterations to their osmotic environment. These osmotic fluctuations have been described as a mechanism linking mechanics and biology, and have previously been shown to promote biosynthesis in chondrocytes. However, this phenomenon has yet to be fully interrogated in the IVD. Additionally, the specialized extracellular matrix surrounding the cells, the pericellular matrix (PCM), transduces the biophysical signals that cells ultimately experience. While it is known that the PCM is altered in disc degeneration, whether it disrupts normal osmotic mechanotransduction has yet to be determined. Thus, our objectives were to assess: (1) whether dynamic osmotic conditions stimulate biosynthesis in nucleus pulposus cells, and (2) whether pericellular heparan sulfate proteoglycans (HSPGs) modulate the biosynthetic response to osmotic loading. Methods Bovine nucleus pulposus cells isolated with retained PCM were encapsulated in 1.5% alginate beads and treated with or without heparinase III, an enzyme that degrades the pericellular HSPGs. Beads were subjected to 1 h of daily iso-osmotic, hyper-osmotic, or hypo-osmotic loading for 1, 2, or 4 weeks. At each timepoint the total amount of extracellular and pericellular sGAG/DNA were quantified. Additionally, whether osmotic loading triggered alterations to HSPG sulfation was assessed via immunohistochemistry for the heparan sulfate 6-O-sulfertransferase 1 (HS6ST1) enzyme. Results Osmotic loading significantly influenced sGAG/DNA accumulation with a hyper-osmotic change promoting the greatest sGAG/DNA accumulation in the pericellular region compared with iso-osmotic conditions. Heparanase-III treatment significantly reduced extracellular sGAG/DNA but pericellular sGAG was not affected. HS6ST1 expression was not affected by osmotic loading. Conclusion Results suggest that hyper-osmotic loading promotes matrix synthesis and that modifications to HSPGs directly influence the metabolic responses of cells to osmotic fluctuations. Collectively, results suggest degeneration-associated modifications to pericellular HSPGs may contribute to the altered mechanobiology observed in disease.
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Affiliation(s)
- Carly M. Krull
- Department of Biomedical EngineeringThe Ohio State UniversityColumbusOhioUSA
| | - Jordan Rife
- Department of Biomedical EngineeringThe Ohio State UniversityColumbusOhioUSA
| | - Brett Klamer
- Department of Biomedical Informatics, Center for BiostatisticsThe Ohio State UniversityColumbusOhioUSA
| | - Devina Purmessur
- Department of Biomedical EngineeringThe Ohio State UniversityColumbusOhioUSA
- Department of OrthopedicsThe Ohio State University Wexner Medical CenterColumbusOhioUSA
- Spine Research InstituteThe Ohio State UniversityColumbusOhioUSA
| | - Benjamin A. Walter
- Department of Biomedical EngineeringThe Ohio State UniversityColumbusOhioUSA
- Department of OrthopedicsThe Ohio State University Wexner Medical CenterColumbusOhioUSA
- Spine Research InstituteThe Ohio State UniversityColumbusOhioUSA
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Overexpression of Aquaporin-3 Alleviates Hyperosmolarity-Induced Nucleus Pulposus Cell Apoptosis via Regulating the ERK1/2 Pathway. Pain Res Manag 2022; 2022:1639560. [PMID: 35437455 PMCID: PMC9013301 DOI: 10.1155/2022/1639560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/23/2021] [Accepted: 03/18/2022] [Indexed: 12/03/2022]
Abstract
Intervertebral disc degeneration (IDD) is closely related to osmolarity, which fluctuates with daily activities, and hyperosmolarity may be a contributor to nucleus pulposus (NP) cells apoptosis. Aquaporin-3 (AQP-3) belongs to the family of aquaporins and mainly transports water and other small molecular proteins, which is reduced with the aging of the intervertebral disc. ERK1/2 pathway is one type of mitogen-activated protein kinase (MAPK) and is associated with cellular apoptosis. This study was aimed to investigate the effects of AQP-3 on NP cells apoptosis induced by a hyperosmolarity and focused on the role of the ERK1/2 signaling pathway. We found that NP apoptosis could be induced by hyperosmolarity (550 mOsm/kg), and downregulation of AQP-3 and inhibition of ERK1/2 could be simultaneously observed. Therefore, lentivirus was used to enhance the expression of AQP-3 to compare apoptosis between AQP-3-overexpressed NP cells and the control NP cells. The results showed that apoptosis could be alleviated by overexpression of AQP-3 and the activity of ERK1/2 could also be promoted. Furthermore, we found that the inhibitor U0126 could partly aggravate apoptosis of the AQP-3-overexpressed NP cells. In summary, our results suggested that overexpression of AQP-3 could protect against hyperosmolarity-induced NP cell apoptosis via promoting the activity of the ERK1/2 pathway. This study may shed light on a better understanding of the pathologic mechanism of IDD and bring AQP-3 into the therapeutic approaches for IDD treatment.
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Zheng K, Du D. Recent advances of hydrogel-based biomaterials for intervertebral disc tissue treatment: A literature review. J Tissue Eng Regen Med 2021; 15:299-321. [PMID: 33660950 DOI: 10.1002/term.3172] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
Low back pain is an increasingly prevalent symptom mainly associated with intervertebral disc (IVD) degeneration. It is highly correlated with aging, as the nucleus pulposus (NP) dehydrates and annulus fibrosus fissure formatting, which finally results in the IVD herniation and related clinical symptoms. Hydrogels have been drawing increasing attention as the ideal candidates for IVD degeneration because of their unique properties such as biocompatibility, highly tunable mechanical properties, and especially the water absorption and retention ability resembling the normal NP tissue. Numerous innovative hydrogel polymers have been generated in the most recent years. This review article will first briefly describe the anatomy and pathophysiology of IVDs and current therapies with their limitations. Following that, the article introduces the hydrogel materials in the classification of their origins. Next, it reviews the recent hydrogel polymers explored for IVD regeneration and analyses what efforts have been made to overcome the existing limitations. Finally, the challenges and prospects of hydrogel-based treatments for IVD tissue are also discussed. We believe that these novel hydrogel-based strategies may shed light on new possibilities in IVD degeneration disease.
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Affiliation(s)
- Kaiwen Zheng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Dajiang Du
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Morris H, Gonçalves CF, Dudek M, Hoyland J, Meng QJ. Tissue physiology revolving around the clock: circadian rhythms as exemplified by the intervertebral disc. Ann Rheum Dis 2021; 80:828-839. [PMID: 33397731 DOI: 10.1136/annrheumdis-2020-219515] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 01/07/2023]
Abstract
Circadian clocks in the brain and peripheral tissues temporally coordinate local physiology to align with the 24 hours rhythmic environment through light/darkness, rest/activity and feeding/fasting cycles. Circadian disruptions (during ageing, shift work and jet-lag) have been proposed as a risk factor for degeneration and disease of tissues, including the musculoskeletal system. The intervertebral disc (IVD) in the spine separates the bony vertebrae and permits movement of the spinal column. IVD degeneration is highly prevalent among the ageing population and is a leading cause of lower back pain. The IVD is known to experience diurnal changes in loading patterns driven by the circadian rhythm in rest/activity cycles. In recent years, emerging evidence indicates the existence of molecular circadian clocks within the IVD, disruption to which accelerates tissue ageing and predispose animals to IVD degeneration. The cell-intrinsic circadian clocks in the IVD control key aspects of physiology and pathophysiology by rhythmically regulating the expression of ~3.5% of the IVD transcriptome, allowing cells to cope with the drastic biomechanical and chemical changes that occur throughout the day. Indeed, epidemiological studies on long-term shift workers have shown an increased incidence of lower back pain. In this review, we summarise recent findings of circadian rhythms in health and disease, with the IVD as an exemplar tissue system. We focus on rhythmic IVD functions and discuss implications of utilising biological timing mechanisms to improve tissue health and mitigate degeneration. These findings may have broader implications in chronic rheumatic conditions, given the recent findings of musculoskeletal circadian clocks.
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Affiliation(s)
- Honor Morris
- Wellcome Centre for Cell Matrix Research, University of Manchester, Manchester, UK.,Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Cátia F Gonçalves
- Wellcome Centre for Cell Matrix Research, University of Manchester, Manchester, UK.,Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Michal Dudek
- Wellcome Centre for Cell Matrix Research, University of Manchester, Manchester, UK.,Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Judith Hoyland
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, University of Manchester, Manchester, UK .,NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University, NHS Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Qing-Jun Meng
- Wellcome Centre for Cell Matrix Research, University of Manchester, Manchester, UK .,Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
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Xu P, Guan J, Chen Y, Xiao H, Yang T, Sun H, Wu N, Zhang C, Mao Y. Stiffness of photocrosslinkable gelatin hydrogel influences nucleus pulposus cell propertiesin vitro. J Cell Mol Med 2020; 25:880-891. [PMID: 33289319 PMCID: PMC7812302 DOI: 10.1111/jcmm.16141] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/18/2022] Open
Abstract
A key early sign of degenerative disc disease (DDD) is the loss of nucleus pulposus (NP) cells (NPCs). Accordingly, NPC transplantation is a treatment strategy for intervertebral disc (IVD) degeneration. However, in advanced DDD, due to structural damage of the IVD and scaffold mechanical properties, the transplanted cells are less viable and secrete less extracellular matrix, and thus, are unable to efficiently promote NP regeneration. In this study, we evaluated the encapsulation of NPCs in a photosensitive hydrogel made of collagen hydrolysate gelatin and methacrylate (GelMA) to improve NP regeneration. By adjusting the concentration of GelMA, we prepared hydrogels with different mechanical properties. After examining the mechanical properties, cell compatibility and tissue engineering indices of the GelMA-based hydrogels, we determined the optimal hydrogel concentration of the NPC-encapsulating GelMA hydrogel for NP regeneration as 5%. NPCs effectively combined with GelMA and proliferated. As the concentration of the GelMA hydrogel increased, the survival, proliferation and matrix deposition of the encapsulated NPCs gradually decreased, which is the opposite of NPCs grown on the surface of the hydrogel. The controllability of the GelMA hydrogels suggests that these NPC-encapsulating hydrogels are promising candidates to aid in NP tissue engineering and repairing endogenous NPCs.
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Affiliation(s)
- Panpan Xu
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China.,Anhui Province Key Laboratory of Tissue Transplantation, Bengbu Medical College, Bengbu, China
| | - Jingjing Guan
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China
| | - Yu Chen
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China.,School of Life Sciences, Bengbu Medical College, Bengbu, China.,Department of Plastic Surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Hui Xiao
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China
| | - Tianhao Yang
- School of Life Sciences, Bengbu Medical College, Bengbu, China
| | - Hengheng Sun
- School of Life Sciences, Bengbu Medical College, Bengbu, China
| | - Nan Wu
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China
| | - Changchun Zhang
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China.,Anhui Province Key Laboratory of Tissue Transplantation, Bengbu Medical College, Bengbu, China
| | - Yingji Mao
- Department of Orthopaedics, First Affiliated Hospital, Bengbu Medical College, Bengbu, China.,Anhui Province Key Laboratory of Tissue Transplantation, Bengbu Medical College, Bengbu, China.,School of Life Sciences, Bengbu Medical College, Bengbu, China
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Interaction between Mesenchymal Stem Cells and Intervertebral Disc Microenvironment: From Cell Therapy to Tissue Engineering. Stem Cells Int 2019; 2019:2376172. [PMID: 32587618 PMCID: PMC7294366 DOI: 10.1155/2019/2376172] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/20/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
Low back pain (LBP) in one of the most disabling symptoms affecting nearly 80% of the population worldwide. Its primary cause seems to be intervertebral disc degeneration (IDD): a chronic and progressive process characterized by loss of viable cells and extracellular matrix (ECM) breakdown within the intervertebral disc (IVD) especially in its inner region, the nucleus pulposus (NP). Over the last decades, innovative biological treatments have been investigated in order to restore the original healthy IVD environment and achieve disc regeneration. Mesenchymal stem cells (MSCs) have been widely exploited in regenerative medicine for their capacity to be easily harvested and be able to differentiate along the osteogenic, chondrogenic, and adipogenic lineages and to secrete a wide range of trophic factors that promote tissue homeostasis along with immunomodulation and anti-inflammation. Several in vitro and preclinical studies have demonstrated that MSCs are able to acquire a NP cell-like phenotype and to synthesize structural components of the ECM as well as trophic and anti-inflammatory mediators that may support resident cell activity. However, due to its unique anatomical location and function, the IVD presents distinctive features: avascularity, hypoxia, low glucose concentration, low pH, hyperosmolarity, and mechanical loading. Such conditions establish a hostile microenvironment for both resident and exogenously administered cells, which limited the efficacy of intradiscal cell therapy in diverse investigations. This review is aimed at describing the characteristics of the healthy and degenerated IVD microenvironment and how such features influence both resident cells and MSC viability and biological activity. Furthermore, we focused on how recent research has tried to overcome the obstacles coming from the IVD microenvironment by developing innovative cell therapies and functionalized bioscaffolds.
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Wang T, Wang CJ, Tian S, Song HB. Overexpressed IGFBP5 promotes cell proliferation and inhibits apoptosis of nucleus pulposus derived from rats with disc degeneration through inactivating the ERK/MAPK axis. J Cell Biochem 2019; 120:18782-18792. [PMID: 31310371 DOI: 10.1002/jcb.29191] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/29/2019] [Indexed: 12/19/2022]
Abstract
It is previously suggested that insulin-like growth factor binding proteins (IGFBPs) potentially share an association with disc degeneration (DD) that causes back pain. This study aimed at exploring the functional relevance of IGFBP5 in DD by establishing a rat model of DD. The nucleus pulposus (NP) cells were transduced with IGFBP5-shRNA or IGFBP5 overexpression to determine the cellular processes (proliferation, apoptosis, as well as colony formation). The protein levels of apoptosis-related proteins were evaluated. Furthermore, NP cells were treated with the extracellular signal-regulated kinases/mitogen-activated protein kinase (ERK/MAPK) pathway inhibitor (PD98059) followed by measurement of ERK protein level and ERK phosphorylation content. The NP cells showed suppressed proliferation and colony formation ability, yet promoted apoptosis after transfection with IGFBP5-shRNA. It was found that silencing of IGFBP5 could lead to the ERK/MAPK axis activation, as indicated by an elevated ERK protein level and ERK phosphorylation content. However, overexpression of IGFBP5 could reverse all the reaction induced by silenced IGFBP5. These key findings demonstrate that overexpressed IGFBP5 inactivates the ERK/MAPK axis to stimulate the proliferation and inhibit apoptosis of NP cells in a rat model of DD.
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Affiliation(s)
- Tao Wang
- Department of Spine Surgery, Dongying People's Hospital, Dongying, Shandong, P.R. China
| | - Chun-Ju Wang
- Department of Spine Surgery, Dongying People's Hospital, Dongying, Shandong, P.R. China
| | - Shuang Tian
- Department of Spine Surgery, Dongying People's Hospital, Dongying, Shandong, P.R. China
| | - Hai-Bo Song
- Department of Spine Surgery, Dongying People's Hospital, Dongying, Shandong, P.R. China
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10
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Lin W, Shi C, Wang W, Wu H, Yang C, Wang A, Shen X, Tian Y, Cao P, Yuan W. Osmolarity and calcium regulate connective tissue growth factor (CTGF/CCN2) expression in nucleus pulposus cells. Gene 2019; 704:15-24. [PMID: 30965128 DOI: 10.1016/j.gene.2019.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/26/2019] [Accepted: 04/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of our study was to verify the hypothesis that the expression of connective tissue growth factor (CTGF/CCN2), a key molecule essential for the maintenance of nucleus pulposus (NP) matrix homeostasis, is regulated by osmolarity and intracellular calcium in NP cells. METHODS Gene and protein expression levels of CCN2 were assessed using quantitative real-time PCR and western blot. Transfections and dual luciferase assays were performed to measure the effect of hyperosmolarity, tonicity enhancer binding protein (TonEBP) and Ca2+-calcineurin (Cn)-NFAT signaling on CCN2 promoter activity. RESULTS Cultured in hyperosmotic media, there was a significant decrease in the levels of CCN2 promoter activity, gene and protein expression in NP cells. The JASPAR database was used to analyze the construction of human CCN2 promoter, we found conserved TonE and NFAT binding sites. We then investigated whether TonEBP controlled CCN2 expression. Forced expression of TonEBP in NP cells showed that TonEBP negatively regulated CCN2 promoter activity, while suppression of TonEBP induced CCN2 promoter activity and expression. We then examined if Ca2+-Cn-NFAT signaling participated in the regulation of CCN2 expression. Co-expression of CCN2 reporter with individual NFAT1-4 expression plasmids and/or calcineurin A/B constructs suggested this signaling pathway played a role in the regulation of CCN2expression in NP cells. CONCLUSIONS Results of these studies illustrated that the expression of CCN2 in NP cells was regulated by the NFAT family through a signaling pathway network involving both activator (Ca2+-Cn-NFAT signaling) and suppressor (Hyperosmolarity-TonEBP) molecules.
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Affiliation(s)
- Wenbo Lin
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
| | - Changgui Shi
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
| | - Weiheng Wang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
| | - Huiqiao Wu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
| | - Chen Yang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - An Wang
- Department of Orthopaedics, Shanghai Armed Police Force Hospital, Shanghai 201103, China
| | - Xiaolong Shen
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Ye Tian
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Peng Cao
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
| | - Wen Yuan
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
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Yang Y, Wang X, Liu Z, Xiao X, Hu W, Sun Z. Osteogenic protein-1 attenuates nucleus pulposus cell apoptosis through activating the PI3K/Akt/mTOR pathway in a hyperosmotic culture. Biosci Rep 2018; 38:BSR20181708. [PMID: 30459239 PMCID: PMC6294645 DOI: 10.1042/bsr20181708] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Previous studies have indicated that osteogenic protein-1 has protective effects on the biological functions of intervertebral disc cells. Hyperosmolarity is an important physicochemical factor within the disc nucleus pulposus (NP) region, which obviously promotes NP cell apoptosis. OBJECTIVE To study the effects of osteogenic protein-1 (OP-1) on NP cell apoptosis induced by hyperosmolarity and the potential signaling transduction pathway. METHODS Rat NP cells were cultured in a hyperosmotic medium with or without OP-1 addition for 7 days. Inhibitor 294002 and inhibitor FK-506 were used to investigate the role of the PI3K/Akt/mTOR pathway in this process. NP cell apoptosis were evaluated by cell apoptosis ratio, activity of caspase-3/9 and gene/protein expression of apoptosis-related molecules (Bax, Bcl-2, caspase-3/cleaved caspase-3 and cleaved PARP). RESULTS OP-1 addition obviously decreased cell apoptosis ratio and caspase-3/9 activity, down-regulated gene/protein expression of pro-apoptosis molecules (Bax, caspase-3/cleaved casepase-3 and cleaved PARP), up-regulated gene/protein expression of anti-apoptosis molecule (Bcl-2) in a hyperosmotic culture. Moreover, OP-1 addition significantly increased protein expression of p-Akt and p-mTOR. Further analysis showed that addition of LY294002 and FK-506 partly attenuated these protective effects of OP-1 against NP cell apoptosis and activation of the PI3K/Akt/mTOR pathway in a hyperosmotic culture. CONCLUSION OP-1 can attenuate NP cell apoptosis through activating the PI3K/Akt/mTOR pathway in a hyperosmotic culture. The present study sheds a new light on the protective role of OP-1 in regulating disc cell biology and provides some theoretical basis for the application of OP-1 in retarding/regenerating disc degeneration.
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Affiliation(s)
- Yan Yang
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
- Hunan Engineering Laboratory of Advanced Artificial Osteo-Materials, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
| | - Xiyang Wang
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
- Hunan Engineering Laboratory of Advanced Artificial Osteo-Materials, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
| | - Zheng Liu
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
- Hunan Engineering Laboratory of Advanced Artificial Osteo-Materials, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
| | - Xiao Xiao
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
- Hunan Engineering Laboratory of Advanced Artificial Osteo-Materials, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
| | - Wenkai Hu
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
- Hunan Engineering Laboratory of Advanced Artificial Osteo-Materials, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
| | - Zhicheng Sun
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
- Hunan Engineering Laboratory of Advanced Artificial Osteo-Materials, Xiangya Hospital, Central South University, Changsha 410008, Hunan, People's Republic of China
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Han X, Leng X, Zhao M, Wu M, Chen A, Hong G, Sun P. Resveratrol increases nucleus pulposus matrix synthesis through activating the PI3K/Akt signaling pathway under mechanical compression in a disc organ culture. Biosci Rep 2017; 37:BSR20171319. [PMID: 29074559 PMCID: PMC5700294 DOI: 10.1042/bsr20171319] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 10/20/2017] [Accepted: 10/25/2017] [Indexed: 11/17/2022] Open
Abstract
Disc nucleus pulposus (NP) matrix homeostasis is important for normal disc function. Mechanical overloading seriously decreases matrix synthesis and increases matrix degradation. The present study aims to investigate the effects of resveratrol on disc NP matrix homeostasis under a relatively high-magnitude mechanical compression and the potential mechanism underlying this process. Porcine discs were perfusion-cultured and subjected to a relatively high-magnitude mechanical compression (1.3 MPa at a frequency of 1.0 Hz for 2 h once per day) for 7 days in a mechanically active bioreactor. The non-compressed discs were used as controls. Resveratrol was added along with culture medium to observe the effects of resveratrol on NP matrix synthesis under mechanical load respectively. NP matrix synthesis was evaluated by histology, biochemical content (glycosaminoglycan (GAG) and hydroxyproline (HYP)), and expression of matrix macromolecules (aggrecan and collagen II). Results showed that this high-magnitude mechanical compression significantly decreased NP matrix content, indicated by the decreased staining intensity of Alcian Blue and biochemical content (GAG and HYP), and the down-regulated expression of NP matrix macromolecules (aggrecan and collagen II). Further analysis indicated that resveratrol partly stimulated NP matrix synthesis and increased activity of the PI3K/Akt pathway in a dose-dependent manner under mechanical compression. Together, resveratrol is beneficial for disc NP matrix synthesis under mechanical overloading, and the activation of the PI3K/Akt pathway may participate in this regulatory process. Resveratrol may be promising to regenerate mechanical overloading-induced disc degeneration.
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Affiliation(s)
- Xiaorui Han
- Guangzhou First People’s Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Xiaoming Leng
- Universal Medical Imaging Diagnostic Center, Guangzhou, China
| | - Man Zhao
- Department of Radiography, The First Affiliated Hospital of Clinical Medicine of Guangdong Pharmaceutical University, Guangzhou, China
| | - Mei Wu
- Guangzhou First People’s Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Amei Chen
- Guangzhou First People’s Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Guoju Hong
- Guangzhou University of Chinese Medicine, and Biomedical Science School, University of Western Australia, Australia
| | - Ping Sun
- Department of Orthopedic, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, ChinInsert Affiliation Text Here
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13
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Li P, Hou G, Zhang R, Gan Y, Xu Y, Song L, Zhou Q. High-magnitude compression accelerates the premature senescence of nucleus pulposus cells via the p38 MAPK-ROS pathway. Arthritis Res Ther 2017; 19:209. [PMID: 28923094 PMCID: PMC5604423 DOI: 10.1186/s13075-017-1384-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 07/07/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Mechanical overloading can lead to disc degeneration. Nucleus pulposus (NP) cell senescence is aggravated within the degenerated disc. This study was designed to investigate the effects of high compression on NP cell senescence and the underlying molecular mechanism of this process. METHODS Rat NP cells seeded in decalcified bone matrix were subjected to non-compression (control) or compression (2% or 20% deformation, 1.0 Hz, 6 hours/day). The reactive oxygen species (ROS) scavenger N-acetylcysteine (NAC) and the p38 MAPK inhibitor SB203580 were used to investigate the roles of the ROS and p38 MAPK pathway under high-magnitude compression. Additionally, we studied the effects of compression (0.1 or 1.3 MPa, 1.0 Hz, 6 hours/day) in a rat disc organ culture. RESULTS Both in scaffold and organ cultures, high-magnitude compression (20% deformation or 1.3 MPa) increased senescence-associated β-galactosidase (SA-β-Gal) activity, senescence marker (p16 and p53) expression, G1 cell cycle arrest, and ROS generation, and decreased cell proliferation, telomerase activity and matrix (aggrecan and collagen II) synthesis. Further analysis of the 20% deformation group showed that NAC inhibited NP cell senescence but had no obvious effect on phospho-p38 MAPK expression and that SB203580 significantly attenuated ROS generation and NP cell senescence. CONCLUSIONS High-magnitude compression can accelerate NP cell senescence through the p38 MAPK-ROS pathway.
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Affiliation(s)
- Pei Li
- Department of Orthopaedic Surgery, No. 89 hospital of PLA, Weifang, Shandong, 261026, China.,Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Gang Hou
- Department of Orthopaedics, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510700, China
| | - Ruijie Zhang
- Department of Respiratory Medicine, the Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China.
| | - Yibo Gan
- Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Yuan Xu
- Department of Orthopaedic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Lei Song
- Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Qiang Zhou
- Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China.
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14
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Li P, Gan Y, Wang H, Xu Y, Song L, Wang L, Ouyang B, Zhou Q. A Substance Exchanger-Based Bioreactor Culture of Pig Discs for Studying the Immature Nucleus Pulposus. Artif Organs 2017; 41:E308-E319. [PMID: 28188657 DOI: 10.1111/aor.12834] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/17/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
Various research models have been developed to study the biology of disc cells. Recently, the adult disc nucleus pulposus (NP) has been well studied. However, the immature NP is underinvestigated due to a lack of a suitable model. This study aimed to establish an organ culture of immature porcine disc by optimizing culture conditions and using a self-developed substance exchanger-based bioreactor. Immature porcine discs were first cultured in the bioreactor for 7 days at various levels of glucose (low, medium, high), osmolarity (hypo-, iso-, hyper-) and serum (5, 10, 20%) to determine the respective optimal level. The porcine discs were then cultured under the optimized conditions in the novel bioreactor, and were compared with fresh discs at day 14. For high-glucose, iso-osmolarity, or 10% serum, cell viability, the gene expression profile (for anabolic genes and catabolic genes), and glycosaminoglycan (GAG) and hydroxyproline (HYP) contents were more favorable than for other levels of glucose, osmolarity, and serum. When the immature discs were cultured under the optimized conditions using the novel bioreactor for 14 days, the viability of the immature NP was maintained based on histology, cell viability, GAG and HYP contents, and matrix molecule expression. In conclusion, the viability of the immature NP in organ culture could be maintained under the optimized culture conditions (high-glucose, iso-osmolarity, and 10% serum) in the substance exchanger-based bioreactor.
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Affiliation(s)
- Pei Li
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University
| | - Yibo Gan
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University
| | - Haoming Wang
- Department of Orthopedic Surgery, Chongqing Three Gorges Central Hospital
| | - Yuan Xu
- Department of Orthopedic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Lei Song
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University
| | - Liyuan Wang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University
| | - Bin Ouyang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University
| | - Qiang Zhou
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University
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15
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Li P, Gan Y, Wang H, Xu Y, Li S, Song L, Zhang C, Ou Y, Wang L, Zhou Q. Role of the ERK1/2 pathway in osmolarity effects on nucleus pulposus cell apoptosis in a disc perfusion culture. J Orthop Res 2017; 35:86-92. [PMID: 27035885 DOI: 10.1002/jor.23249] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/23/2016] [Indexed: 02/04/2023]
Abstract
Osmolarity fluctuations are inevitable within the nucleus pulposus (NP). However, the effects of osmolarity on NP cell apoptosis within the organ-cultured disc remain unclear. The objective of this study was to investigate effects of different osmolarity levels (hypo-, iso-, and hyper-) and osmolarity modes (constant and cyclic) on NP cell apoptosis in a disc perfusion culture and to study the role of the ERK1/2 pathway in this regulatory process. Porcine discs were cultured for 7 days in different osmotic medium, including constant hypo-, iso-, and hyper-osmolarity (330, 430, and 550 mOsm/L, respectively) and cyclic-osmolarity (430 mOsm/L for 8 h, followed by 550 mOsm/L for 16 h). The role of the ERK1/2 pathway was investigated by using the pharmacological inhibitor U0126. NP cell apoptosis was analyzed by TUNEL staining, caspase-3 activity, gene expression of Bcl-2, Bax and caspase-3 and protein expression of cleaved caspase-3, and cleaved PARP. Our results showed that NP cell apoptosis was increased in hypo- and hyper-osmolarity cultures compared to iso- or cyclic-osmolarity culture, whereas the level of apoptosis in the iso-osmolarity culture was lower than that in the cyclic-osmolarity culture. When the ERK1/2 pathway was inhibited in the iso- and cyclic-osmolarity cultures, the level of NP cell apoptosis was significantly increased. In conclusion, the effects of osmolarity on NP cell apoptosis depend on the osmolarity level (hypo-, iso-, or hyper-) and osmolarity mode (constant or cyclic). Futhermore, inhibition of the ERK1/2 pathway promotes NP cell apoptosis in this process. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:86-92, 2017.
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Affiliation(s)
- Pei Li
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
| | - Yibo Gan
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
| | - Haoming Wang
- Department of Orthopedic Surgery, Chongqing Three Gorges Central Hospital, Chongqing 404000, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Songtao Li
- Department of Orthopedic Surgery, No. 181 Hospital of PLA, Guilin, Guangxi 541002, China
| | - Lei Song
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
| | - Chengmin Zhang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
| | - Yangbin Ou
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
| | - Liyuan Wang
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
| | - Qiang Zhou
- Department of Orthopedic Surgery, Southwest Hospital, Third Military Medical University, GaoTanYan 29, Chongqing 400038, China
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