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Li DH, Liu XK, Tian XT, Liu F, Yao XJ, Dong JF. PPARG: A Promising Therapeutic Target in Breast Cancer and Regulation by Natural Drugs. PPAR Res 2023; 2023:4481354. [PMID: 37334066 PMCID: PMC10270765 DOI: 10.1155/2023/4481354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/02/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Breast cancer (BC) is the most common type of cancer among females. Peroxisome proliferator-activated receptor gamma (PPARG) can regulate the production of adipocyte-related genes and has anti-inflammatory and anti-tumor effects. Our aim was to investigate PPARG expression, its possible prognostic value, and its effect on immune cell infiltration in BC, and explore the regulatory effects of natural drugs on PPARG to find new ways to treat BC. Using different bioinformatics tools, we extracted and comprehensively analyzed the data from the Cancer Genome Atlas, Genotype-Tissue Expression, and BenCaoZuJian databases to study the potential anti-BC mechanism of PPARG and potential natural drugs targeting it. First, we found that PPARG was downregulated in BC and its expression level correlates with pathological tumor stage (pT-stage) and pathological tumor-node-metastasis stage (pTNM-stage) in BC. PPARG expression was higher in estrogen receptor-positive (ER+) BC than in estrogen receptor-negative (ER-) BC, which tends to indicate a better prognosis. Meanwhile, PPARG exhibited a significant positive correlation with the infiltration of immune cells and correlated with better cumulative survival in BC patients. In addition, PPARG levels were shown to be positively associated with the expression of immune-related genes and immune checkpoints, and ER+ patients had better responses to immune checkpoint blocking. Correlation pathway research revealed that PPARG is strongly associated with pathways, such as angiogenesis, apoptosis, fatty acid biosynthesis, and degradation in ER+ BC. We also found that quercetin is the most promising natural anti-BC drug among natural medicines that upregulate PPARG. Our research showed that PPARG may reduce BC development by regulating the immune microenvironment. Quercetin as PPARG ligands/agonists is a potential natural drug for BC treatment.
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Affiliation(s)
- De-Hui Li
- The First Affiliated Hospital of Hebei University of Chinese Medicine, Hebei Province Hospital of Chinese Medicine, Shijiazhuang 050011, China
| | - Xu-Kuo Liu
- Graduate School of Hebei University of Chinese Medicine, Shijiazhuang 050091, China
| | - Xiao-Tong Tian
- Graduate School of Hebei University of Chinese Medicine, Shijiazhuang 050091, China
| | - Fei Liu
- Hebei University of Chinese Medicine, Shijiazhuang 050091, China
| | - Xu-Jiong Yao
- The First Affiliated Hospital of Hebei University of Chinese Medicine, Hebei Province Hospital of Chinese Medicine, Shijiazhuang 050011, China
| | - Jing-Fei Dong
- The First Affiliated Hospital of Hebei University of Chinese Medicine, Hebei Province Hospital of Chinese Medicine, Shijiazhuang 050011, China
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Sisto M, Lisi S. Towards a Unified Approach in Autoimmune Fibrotic Signalling Pathways. Int J Mol Sci 2023; 24:ijms24109060. [PMID: 37240405 DOI: 10.3390/ijms24109060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
Autoimmunity is a chronic process resulting in inflammation, tissue damage, and subsequent tissue remodelling and organ fibrosis. In contrast to acute inflammatory reactions, pathogenic fibrosis typically results from the chronic inflammatory reactions characterizing autoimmune diseases. Despite having obvious aetiological and clinical outcome distinctions, most chronic autoimmune fibrotic disorders have in common a persistent and sustained production of growth factors, proteolytic enzymes, angiogenic factors, and fibrogenic cytokines, which together stimulate the deposition of connective tissue elements or epithelial to mesenchymal transformation (EMT) that progressively remodels and destroys normal tissue architecture leading to organ failure. Despite its enormous impact on human health, there are currently no approved treatments that directly target the molecular mechanisms of fibrosis. The primary goal of this review is to discuss the most recent identified mechanisms of chronic autoimmune diseases characterized by a fibrotic evolution with the aim to identify possible common and unique mechanisms of fibrogenesis that might be exploited in the development of effective antifibrotic therapies.
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Affiliation(s)
- Margherita Sisto
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Section of Human Anatomy and Histology, University of Bari "Aldo Moro", Piazza Giulio Cesare 1, I-70124 Bari, Italy
| | - Sabrina Lisi
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Section of Human Anatomy and Histology, University of Bari "Aldo Moro", Piazza Giulio Cesare 1, I-70124 Bari, Italy
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Porcuna J, Mínguez-Martínez J, Ricote M. The PPARα and PPARγ Epigenetic Landscape in Cancer and Immune and Metabolic Disorders. Int J Mol Sci 2021; 22:ijms221910573. [PMID: 34638914 PMCID: PMC8508752 DOI: 10.3390/ijms221910573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023] Open
Abstract
Peroxisome proliferator-activated receptors (PPARs) are ligand-modulated nuclear receptors that play pivotal roles in nutrient sensing, metabolism, and lipid-related processes. Correct control of their target genes requires tight regulation of the expression of different PPAR isoforms in each tissue, and the dysregulation of PPAR-dependent transcriptional programs is linked to disorders, such as metabolic and immune diseases or cancer. Several PPAR regulators and PPAR-regulated factors are epigenetic effectors, including non-coding RNAs, epigenetic enzymes, histone modifiers, and DNA methyltransferases. In this review, we examine advances in PPARα and PPARγ-related epigenetic regulation in metabolic disorders, including obesity and diabetes, immune disorders, such as sclerosis and lupus, and a variety of cancers, providing new insights into the possible therapeutic exploitation of PPAR epigenetic modulation.
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A Review of the Evidence for and against a Role for Mast Cells in Cutaneous Scarring and Fibrosis. Int J Mol Sci 2020; 21:ijms21249673. [PMID: 33353063 PMCID: PMC7766369 DOI: 10.3390/ijms21249673] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/01/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022] Open
Abstract
Scars are generated in mature skin as a result of the normal repair process, but the replacement of normal tissue with scar tissue can lead to biomechanical and functional deficiencies in the skin as well as psychological and social issues for patients that negatively affect quality of life. Abnormal scars, such as hypertrophic scars and keloids, and cutaneous fibrosis that develops in diseases such as systemic sclerosis and graft-versus-host disease can be even more challenging for patients. There is a large body of literature suggesting that inflammation promotes the deposition of scar tissue by fibroblasts. Mast cells represent one inflammatory cell type in particular that has been implicated in skin scarring and fibrosis. Most published studies in this area support a pro-fibrotic role for mast cells in the skin, as many mast cell-derived mediators stimulate fibroblast activity and studies generally indicate higher numbers of mast cells and/or mast cell activation in scars and fibrotic skin. However, some studies in mast cell-deficient mice have suggested that these cells may not play a critical role in cutaneous scarring/fibrosis. Here, we will review the data for and against mast cells as key regulators of skin fibrosis and discuss scientific gaps in the field.
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Liu Y, Wang J, Luo S, Zhan Y, Lu Q. The roles of PPARγ and its agonists in autoimmune diseases: A comprehensive review. J Autoimmun 2020; 113:102510. [PMID: 32622513 PMCID: PMC7327470 DOI: 10.1016/j.jaut.2020.102510] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 01/10/2023]
Abstract
Autoimmune diseases are common diseases of the immune system that are characterized by the loss of self-tolerance and the production of autoantibodies; the breakdown of immune tolerance and the prolonged inflammatory reaction are undisputedly core steps in the initiation and maintenance of autoimmunity. Peroxisome proliferator-activated receptors (PPARs) are ligand-dependent transcription factors that belong to the nuclear hormone receptor family and act as ligand-activated transcription factors. There are three different isotypes of PPARs: PPARα, PPARγ, and PPARβ/δ. PPARγ is an established regulator of glucose homeostasis and lipid metabolism. Recent studies have demonstrated that PPARγ exhibits anti-inflammatory and anti-fibrotic effects in multiple disease models. PPARγ can also modulate the activation and polarization of macrophages, regulate the function of dendritic cells and mediate T cell survival, activation, and differentiation. In this review, we summarize the signaling pathways and biological functions of PPARγ and focus on how PPARγ and its agonists play protective roles in autoimmune diseases, including autoimmune thyroid diseases, multiple sclerosis, rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, primary Sjogren syndrome and primary biliary cirrhosis.
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Affiliation(s)
- Yu Liu
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenetics, Changsha, Hunan, 410011, PR China
| | - Jiayu Wang
- Xiangya Medical School, Central South University, #176 Tongzipo Rd, Changsha, Hunan, 410013, PR China
| | - Shuangyan Luo
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenetics, Changsha, Hunan, 410011, PR China
| | - Yi Zhan
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenetics, Changsha, Hunan, 410011, PR China
| | - Qianjin Lu
- Department of Dermatology, Second Xiangya Hospital, Central South University, Hunan Key Laboratory of Medical Epigenetics, Changsha, Hunan, 410011, PR China.
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Napimoga MH, Clemente-Napimoga JT, Machabanski NM, Juliani MEA, Acras PHBC, Macedo CG, Abdalla HB, de Pinho AJ, Soares AB, Sperandio M, de Araújo DR. The 15d‑PGJ2 hydrogel ameliorates atopic dermatitis through suppression of the immune response. Mol Med Rep 2019; 19:4536-4544. [PMID: 31059034 PMCID: PMC6522822 DOI: 10.3892/mmr.2019.10156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/15/2019] [Indexed: 01/30/2023] Open
Abstract
The present study examined the efficacy of the topical 15d-PGJ2-poloxamer 407 hydrogel in an atopic dermatitis (AD) animal model. The 15d-PGJ2 hydrogel was prepared and characterized. The examined rats possessed AD-Like cutaneous lesions, which were induced using 2,4-dinitrochlorobenzene, the rats were then treated with a hydrogel vehicle, 15d-PGJ2 hydrogel or tacrolimus for 14 days. The rats were sacrificed and blood samples were collected to quantify the IgE levels. Subsequently, skin biopsies were stained with toluidine blue to identify mast cells and immunohistochemistry was performed for ROR-γt and TNF-α. Histological analyses demonstrated that 15d-PGJ2 hydrogel significantly decreased mast cell infiltration (P<0.05) when compared with the AD-group. Tacrolimus at 0.1% exhibited decreased mast cell infiltration; however, this difference was not statistically significant from the AD-group. Topical 15d-PGJ2 hydrogel and Tacrolimus 0.1% significantly reduced the serum levels of IgE (P<0.05) compared with the AD-group. Immunohistochemistry revealed a significant decrease in ROR-γt and TNF-α positive cell expression (P<0.05) in the 15d-PGJ2 hydrogel group compared with the AD-group. In summary, topical administration of 15d-PGJ2 hydrogel had a beneficial effect on AD symptoms, suggesting that this formulation may be a useful strategy for the treatment of AD.
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Affiliation(s)
- Marcelo H Napimoga
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Juliana T Clemente-Napimoga
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Nina M Machabanski
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Maria Eduarda A Juliani
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Pedro Henrique B C Acras
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Cristina G Macedo
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Henrique B Abdalla
- Laboratory of Orofacial Pain, Department of Physiology, Piracicaba Dental School, State University of Campinas, Piracicaba, São Paulo 13414‑903, Brazil
| | - Antônio José de Pinho
- Laboratory of Immunology and Molecular Biology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Andresa B Soares
- Department of Oral Pathology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Marcelo Sperandio
- Department of Oral Pathology, São Leopoldo Mandic Institute and Research Center, Campinas, São Paulo 13045‑755, Brazil
| | - Daniele R de Araújo
- Center of Human and Natural Sciences, Federal University of ABC, Santo André, São Paulo 09210‑580, Brazil
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Maier NK, Leppla SH, Moayeri M. The cyclopentenone prostaglandin 15d-PGJ2 inhibits the NLRP1 and NLRP3 inflammasomes. THE JOURNAL OF IMMUNOLOGY 2015; 194:2776-85. [PMID: 25681332 DOI: 10.4049/jimmunol.1401611] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Inflammasomes are cytosolic protein complexes that respond to diverse danger signals by activating caspase-1. The sensor components of the inflammasome, often proteins of the nucleotide-binding oligomerization domain-like receptor (NLR) family, detect stress, danger stimuli, and pathogen-associated molecular patterns. We report that the eicosanoid 15-deoxy-Δ(12,14)-PGJ2 (15d-PGJ2) and related cyclopentenone PGs inhibit caspase-1 activation by the NLR family leucine-rich repeat protein (NLRP)1 and NLRP3 inflammasomes. This inhibition was independent of the well-characterized role of 15d-PGJ2 as a peroxisome proliferator receptor-γ agonist, its activation of NF erythroid 2-related factor 2, or its anti-inflammatory function as an inhibitor of NF-κB. Instead, 15d-PGJ2 prevents the autoproteolytic activation of caspase-1 and the maturation of IL-1β through induction of a cellular state inhibitory to caspase-1 proteolytic function. The eicosanoid does not directly modify or inactivate the caspase-1 enzyme. Rather, inhibition is dependent on de novo protein synthesis. In a mouse peritonitis model of gout, using monosodium urate crystals to activate NLRP3, 15d-PGJ2 caused a significant inhibition of cell recruitment and associated IL-1β release. Furthermore, in a murine anthrax infection model, 15d-PGJ2 reversed anthrax lethal toxin-mediated NLRP1-dependent resistance. The findings reported in this study suggest a novel mechanism for the anti-inflammatory properties of the cyclopentenone PGs through inhibition of caspase-1 and the inflammasome.
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Affiliation(s)
- Nolan K Maier
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Stephen H Leppla
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
| | - Mahtab Moayeri
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
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Antonelli A, Ferri C, Ferrari SM, Colaci M, Ruffilli I, Sebastiani M, Fallahi P. Peroxisome proliferator-activated receptor γ agonists reduce cell proliferation and viability and increase apoptosis in systemic sclerosis fibroblasts. Br J Dermatol 2012; 168:129-35. [PMID: 22860752 DOI: 10.1111/j.1365-2133.2012.11199.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND No study has evaluated the effect of the peroxisome proliferator-activated receptor γ (PPARγ) agonists on cell viability, proliferation and apoptosis in cultured systemic sclerosis (SSc) fibroblasts. OBJECTIVES The effects of two pure PPARγ agonists (rosiglitazone and pioglitazone) in cultured SSc fibroblasts were evaluated and compared with effects in normal fibroblasts. METHODS The study included evaluation of cell viability and proliferation (based on the cleavage of tetrazolium salts and measurement of absorbance of the cell proliferation reagent WST-1), and determination of cell apoptosis (by means of the Hoechst dye uptake). RESULTS Rosiglitazone or pioglitazone (20μmolL(-1) ) significantly reduced cell proliferation (cell count of 75% and 83% compared with baseline, respectively, after 2h) and cell viability (absorbance reductions of 25% and 22% compared with baseline, respectively, after 2 h), and increased apoptosis (apoptotic cell percentages 9·9% and 8·6%, respectively, after 48h of incubation) in SSc fibroblasts, whereas they did not present a significant influence on control fibroblasts. CONCLUSIONS The effects of rosiglitazone or pioglitazone shown on SSc fibroblasts raise the hypothesis of a therapeutic role for PPARγ agonists in patients affected by SSc.
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Affiliation(s)
- A Antonelli
- Department of Internal Medicine, Metabolism Unit, University of Pisa School of Medicine, Via Roma 67, I-56100 Pisa, Italy.
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Abstract
An understanding of the complex pathogenesis of systemic sclerosis (SSc) has been slow to emerge, due in large part to the lack of an animal model recapitulating the three cardinal attributes of SSc: autoimmunity, vasculopathy, and fibrosis. Experimental manipulations in inbred murine strains can lead to conditions that mimic SSc fibrosis. Furthermore, genetic engineering has enabled the creation of novel murine strains that spontaneously develop fibrosis or are protected from fibrosis development. Studies of these mice shed light on the cell types, cell interactions, molecules, and pathways that contribute to SSc manifestations. High-throughput discovery technologies such as DNA microarrays in animal models can identify novel genes and regulatory networks that are important for disease manifestations and that may be targets for therapy. In this brief review, we highlight recent progress in the field and attempt to place the strengths and limitations of popular SSc murine models in perspective.
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Xu Y, Farmer SR, Smith BD. Peroxisome proliferator-activated receptor gamma interacts with CIITA x RFX5 complex to repress type I collagen gene expression. J Biol Chem 2007; 282:26046-56. [PMID: 17611194 DOI: 10.1074/jbc.m703652200] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Recent reports demonstrate that peroxisome proliferator-activated receptor gamma (PPARgamma), a member of the nuclear receptor superfamily, acts as a repressor of type I collagen synthesis. Our data demonstrate that exogenously expressed PPARgamma down-regulates collagen expression in a dose-responsive manner in human lung fibroblast cells. Silencing PPARgamma using lentiviruses expressing short hairpin RNAs partially reverses interferon-gamma (IFN-gamma)-induced repression and activates collagen mRNA levels. Previous studies indicate that IFN-gamma represses collagen gene expression and induces major histocompatibility complex II (MHC II) expression by activating the formation of a regulatory factor for X-box 5 (RFX5) complex with class II transactivator (CIITA). This report demonstrates that PPARgamma is within the RFX5.CIITA complex as judged by co-immunoprecipitation and DNA affinity precipitation studies. Most importantly, occupancy of PPARgamma on the collagen transcription start site and MHC II promoter increases with IFN-gamma treatment. The PPARgamma agonist, troglitazone, sensitizes the cells to IFN-gamma treatment by increasing recruitment of PPARgamma to collagen gene while repressing collagen expression, and these effects are blocked by the PPARgamma antagonist T0070907. PPARgamma may mediate IFN-gamma-stimulated collagen transcription down-regulation and MHC II up-regulation by interacting with CIITA as well as regulating CIITA expression. Therefore, PPARgamma is a critical target for investigations into therapeutics of diseases involving extracellular matrix remodeling and the immune response.
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Affiliation(s)
- Yong Xu
- Department of Biochemistry, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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Kapoor M, Kojima F, Yang L, Crofford LJ. Sequential induction of pro- and anti-inflammatory prostaglandins and peroxisome proliferators-activated receptor-gamma during normal wound healing: a time course study. Prostaglandins Leukot Essent Fatty Acids 2007; 76:103-12. [PMID: 17239574 PMCID: PMC1847382 DOI: 10.1016/j.plefa.2006.11.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 11/22/2006] [Accepted: 11/29/2006] [Indexed: 10/23/2022]
Abstract
Lipid mediators generated from metabolism of arachidonic acid play a crucial role in the initiating and resolution of acute inflammation by shifting from pro-inflammatory prostaglandin (PG) E2 to anti-inflammatory PGD2 and its metabolites. The changes in PG levels over time during the normal wound-repair process have not, however, been reported. We determined the temporal expression of PG and their biosynthetic enzymes using the full thickness incisional model of normal wound healing in mice. We demonstrate that during normal wound repair, there is a shift in the metabolism of arachidonate from PGE2 during the acute inflammatory phase to PGD2 during the repair phase. This shift is mediated by temporal changes in the expression of cyclooxygenases (COX) and microsomal PGES (mPGES)-1. Inducible COX (COX-2) expression is sustained throughout the initiation and repair process, but mPGES-1 is increased only during the acute inflammatory phase and its disappearance coincides with increased PGD2. PGD2 and its degradation products are known to mediate their anti-inflammatory effects by binding to peroxisome proliferators-activated receptor gamma (PPARgamma). In this study, we show that PPARgamma is upregulated during the resolution phase of wound repair concomitant with the shift to PGD2, and may be responsible for initiating endogenous mechanism resulting in healing/resolution.
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Affiliation(s)
- Mohit Kapoor
- Department of Internal Medicine, Division of Rheumatology, Room J-509, Kentucky Clinic, University of Kentucky, Lexington, KY 40536-0284, USA
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