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Tawfik A, Mohamed R, Kira D, Alhusban S, Al-Shabrawey M. N-Methyl-D-aspartate receptor activation, novel mechanism of homocysteine-induced blood-retinal barrier dysfunction. J Mol Med (Berl) 2021; 99:119-130. [PMID: 33159240 PMCID: PMC7785674 DOI: 10.1007/s00109-020-02000-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/18/2020] [Accepted: 10/27/2020] [Indexed: 12/14/2022]
Abstract
Elevated levels of amino acid homocysteine (Hcy) recognized as hyperhomocysteinemia (HHcy) was reported in several human visual disorders, such as diabetic retinopathy (DR) and age-related macular degeneration (AMD). Breakdown of blood-retinal barrier (BRB) is concomitant with vision loss in DR and AMD. We previously reported that HHcy alters BRB. Here, we tested the hypothesis that HHcy alters BRB via activation of N-methyl-D-aspartate receptor (NMDAR). Human retinal endothelial cells subjected to high level of Hcy and mouse model of HHcy were used. We injected Hcy intravitreal and used a mouse model of HHcy that lacks cystathionine-β-synthase (CBS). RT-PCR, western blot, and immunofluorescence showed that retinal endothelial cells (RECs) express NMDAR at the gene and protein levels both in vitro and in vivo and this was increased by HHcy. We assessed BRB function and retinal morphology using fluorescein angiogram and optical coherence tomography (OCT) under HHcy with and without pharmacological inhibition of NMDAR by (MK801) or in mice lacking endothelial NMDAR (NMDARE-/- mouse). Additionally, retinal albumin leakage and tight junction proteins ZO-1 and occludin were assessed by western blotting analysis. Inhibition or elimination of NMDAR was able to improve the altered retinal hyperpermeability and morphology under HHcy as indicated by significant decrease in retinal albumin leakage and restoration of tight junction proteins ZO-1 and occludin. Our findings underscore a potential role for endothelial NMDAR in mediating Hcy-induced breakdown of BRB and subsequently as a potential therapeutic target in retinal diseases associated with HHcy such as DR and AMD. KEY MESSAGES: • Elevated levels of homocysteine (Hcy) are defined as hyperhomocysteinemia (HHcy). • HHcy is implicated in diabetic retinopathy and age-related macular degeneration. • HHcy alters BRB via activation of N-methyl-D-aspartate receptor.
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Affiliation(s)
- Amany Tawfik
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, 1120 15th Street, CB 1114, Augusta, GA, 30912-2000, USA.
- James and Jean Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA.
- Department of Cellular Biology and Anatomy, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA.
- Department of Ophthalmology, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA.
| | - Riyaz Mohamed
- Department of Physiology Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA
| | - Dina Kira
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, 1120 15th Street, CB 1114, Augusta, GA, 30912-2000, USA
- James and Jean Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA
| | - Suhib Alhusban
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, 1120 15th Street, CB 1114, Augusta, GA, 30912-2000, USA
- James and Jean Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA
| | - Mohamed Al-Shabrawey
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, 1120 15th Street, CB 1114, Augusta, GA, 30912-2000, USA
- James and Jean Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA
- Department of Cellular Biology and Anatomy, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA
- Department of Ophthalmology, Medical College of Georgia (MCG), Augusta University, Augusta, GA, 30912, USA
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Implication of Hyperhomocysteinemia in Blood Retinal Barrier (BRB) Dysfunction. Biomolecules 2020; 10:biom10081119. [PMID: 32751132 PMCID: PMC7463551 DOI: 10.3390/biom10081119] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
Elevated plasma homocysteine (Hcy) level, known as hyperhomocysteinemia (HHcy) has been linked to different systemic and neurological diseases, well-known as a risk factor for systemic atherosclerosis and cardiovascular disease (CVD) and has been identified as a risk factor for several ocular disorders, such as diabetic retinopathy (DR) and age-related macular degeneration (AMD). Different mechanisms have been proposed to explain HHcy-induced visual dysfunction, including oxidative stress, upregulation of inflammatory mediators, retinal ganglion cell apoptosis, and extracellular matrix remodeling. Our previous studies using in vivo and in vitro models of HHcy have demonstrated that Hcy impairs the function of both inner and outer blood retinal barrier (BRB). Dysfunction of BRB is a hallmark of vision loss in DR and AMD. Our findings highlighted oxidative stress, ER stress, inflammation, and epigenetic modifications as possible mechanisms of HHcy-induced BRB dysfunction. In addition, we recently reported HHcy-induced brain inflammation as a mechanism of blood–brain barrier (BBB) dysfunction and pathogenesis of Alzheimer’s disease (AD). Moreover, we are currently investigating the activation of glutamate receptor N-methyl-d-aspartate receptor (NMDAR) as the molecular mechanism for HHcy-induced BRB dysfunction. This review focuses on the studied effects of HHcy on BRB and the controversial role of HHcy in the pathogenesis of aging neurological diseases such as DR, AMD, and AD. We also highlight the possible mechanisms for such deleterious effects of HHcy.
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Francija E, Petrovic Z, Brkic Z, Mitic M, Radulovic J, Adzic M. Disruption of the NMDA receptor GluN2A subunit abolishes inflammation-induced depression. Behav Brain Res 2018; 359:550-559. [PMID: 30296532 DOI: 10.1016/j.bbr.2018.10.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022]
Abstract
Recent reports have demonstrated that lipopolysaccharide (LPS)-induced depressive-like behaviour is mediated via NMDA receptor. In this study, we further investigated the role of GluN2 A subunit of NMDA receptor in synaptic processes in the prefrontal cortex (PFC) and hippocampus of GluN2 A knockout (KO) mice in LPS-induced depressive-like behavior. Our data suggest that LPS-treated mice, lacking GluN2 A subunit, did not exhibit depressive-like behaviour. This was accompanied by unaltered levels of IL-6 and significant changes in neuroplasticity markers and glutamate receptor subunits composition in PFC and hippocampus. In particular, an immune challenge in GluN2 A KO mice resulted in unchanged PSA-NCAM levels and proBDNF increase in both brain structures as well as in increase in BDNF levels in hippocampus. Furthermore, the absence of GluN2 A resulted in increased levels of all NCAM isoforms in PFC upon LPS which was followed with a decrease in GluN1 and GluN2B subunits. The levels of AMPA receptor subunits (GluA1, GluA3, and GluA4) in the hippocampus of GluN2 A mice were unaltered upon the treatment and abundantly present in the PFC of KO mice. These results indicate that the GluN2 A subunit is critical in neuroinflammation-related depression, that its absence abolishes LPS-induced depressive phenotype, sustains PSA-NCAM levels, increases proBDNF signalling in the PFC and hippocampus and potentiates synaptic stabilization through NCAM in the PFC upon an immune challenge.
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Affiliation(s)
- Ester Francija
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, University of Belgrade, Serbia
| | - Zorica Petrovic
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, University of Belgrade, Serbia
| | - Zeljka Brkic
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, University of Belgrade, Serbia
| | - Milos Mitic
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, University of Belgrade, Serbia
| | - Jelena Radulovic
- Department of Psychiatry and Behavioural Sciences, The Asher Center of Study and Treatment of Depressive Disorders, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Miroslav Adzic
- Department of Molecular Biology and Endocrinology, VINCA Institute of Nuclear Sciences, University of Belgrade, Serbia.
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Neural Cell Adhesion Molecules of the Immunoglobulin Superfamily Regulate Synapse Formation, Maintenance, and Function. Trends Neurosci 2017; 40:295-308. [PMID: 28359630 DOI: 10.1016/j.tins.2017.03.003] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/03/2017] [Accepted: 03/06/2017] [Indexed: 02/05/2023]
Abstract
Immunoglobulin superfamily adhesion molecules are among the most abundant proteins in vertebrate and invertebrate nervous systems. Prominent family members are the neural cell adhesion molecules NCAM and L1, which were the first to be shown to be essential not only in development but also in synaptic function and as key regulators of synapse formation, synaptic activity, plasticity, and synaptic vesicle recycling at distinct developmental and activity stages. In addition to interacting with each other, adhesion molecules interact with ion channels and cytokine and neurotransmitter receptors. Mutations in their genes are linked to neurological disorders associated with abnormal development and synaptic functioning. This review presents an overview of recent studies on these molecules and their crucial impact on neurological disorders.
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Mehrabian M, Hildebrandt H, Schmitt-Ulms G. NCAM1 Polysialylation: The Prion Protein's Elusive Reason for Being? ASN Neuro 2016; 8:8/6/1759091416679074. [PMID: 27879349 PMCID: PMC5122176 DOI: 10.1177/1759091416679074] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/08/2016] [Accepted: 10/02/2016] [Indexed: 01/06/2023] Open
Abstract
Much confusion surrounds the physiological function of the cellular prion protein (PrPC). It is, however, anticipated that knowledge of its function will shed light on its contribution to neurodegenerative diseases and suggest ways to interfere with the cellular toxicity central to them. Consequently, efforts to elucidate its function have been all but exhaustive. Building on earlier work that uncovered the evolutionary descent of the prion founder gene from an ancestral ZIP zinc transporter, we recently investigated a possible role of PrPC in a morphogenetic program referred to as epithelial-to-mesenchymal transition (EMT). By capitalizing on PrPC knockout cell clones in a mammalian cell model of EMT and using a comparative proteomics discovery strategy, neural cell adhesion molecule-1 emerged as a protein whose upregulation during EMT was perturbed in PrPC knockout cells. Follow-up work led us to observe that PrPC regulates the polysialylation of the neural cell adhesion molecule NCAM1 in cells undergoing morphogenetic reprogramming. In addition to governing cellular migration, polysialylation modulates several other cellular plasticity programs PrPC has been phenotypically linked to. These include neurogenesis in the subventricular zone, controlled mossy fiber sprouting and trimming in the hippocampal formation, hematopoietic stem cell renewal, myelin repair and maintenance, integrity of the circadian rhythm, and glutamatergic signaling. This review revisits this body of literature and attempts to present it in light of this novel contextual framework. When approached in this manner, a coherent model of PrPC acting as a regulator of polysialylation during specific cell and tissue morphogenesis events comes into focus.
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Affiliation(s)
- Mohadeseh Mehrabian
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Herbert Hildebrandt
- Institute for Cellular Chemistry, Hannover Medical School, Hannover, Germany
| | - Gerold Schmitt-Ulms
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada .,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Kritis AA, Stamoula EG, Paniskaki KA, Vavilis TD. Researching glutamate - induced cytotoxicity in different cell lines: a comparative/collective analysis/study. Front Cell Neurosci 2015; 9:91. [PMID: 25852482 PMCID: PMC4362409 DOI: 10.3389/fncel.2015.00091] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 02/26/2015] [Indexed: 12/21/2022] Open
Abstract
Although glutamate is one of the most important excitatory neurotransmitters of the central nervous system, its excessive extracellular concentration leads to uncontrolled continuous depolarization of neurons, a toxic process called, excitotoxicity. In excitotoxicity glutamate triggers the rise of intracellular Ca2+ levels, followed by up regulation of nNOS, dysfunction of mitochondria, ROS production, ER stress, and release of lysosomal enzymes. Excessive calcium concentration is the key mediator of glutamate toxicity through over activation of ionotropic and metabotropic receptors. In addition, glutamate accumulation can also inhibit cystine (CySS) uptake by reversing the action of the CySS/glutamate antiporter. Reversal of the antiporter action reinforces the aforementioned events by depleting neurons of cysteine and eventually glutathione’s reducing potential. Various cell lines have been employed in the pursuit to understand the mechanism(s) by which excitotoxicity affects the cells leading them ultimately to their demise. In some cell lines glutamate toxicity is exerted mainly through over activation of NMDA, AMPA, or kainate receptors whereas in other cell lines lacking such receptors, the toxicity is due to glutamate induced oxidative stress. However, in the greatest majority of the cell lines ionotropic glutamate receptors are present, co-existing to CySS/glutamate antiporters and metabotropic glutamate receptors, supporting the assumption that excitotoxicity effect in these cells is accumulative. Different cell lines differ in their responses when exposed to glutamate. In this review article the responses of PC12, SH-SY5Y, HT-22, NT-2, OLCs, C6, primary rat cortical neurons, RGC-5, and SCN2.2 cell systems are systematically collected and analyzed.
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Affiliation(s)
- Aristeidis A Kritis
- Laboratory of Physiology, Department of Physiology and Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki Greece
| | - Eleni G Stamoula
- Laboratory of Physiology, Department of Physiology and Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki Greece
| | - Krystallenia A Paniskaki
- Laboratory of Physiology, Department of Physiology and Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki Greece
| | - Theofanis D Vavilis
- Laboratory of Physiology, Department of Physiology and Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki Greece
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Barbosa DJ, Capela JP, de Lourdes Bastos M, Carvalho F. In vitro models for neurotoxicology research. Toxicol Res (Camb) 2015; 4:801-842. [DOI: 10.1039/c4tx00043a] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
The nervous system has a highly complex organization, including many cell types with multiple functions, with an intricate anatomy and unique structural and functional characteristics; the study of its (dys)functionality following exposure to xenobiotics, neurotoxicology, constitutes an important issue in neurosciences.
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Affiliation(s)
- Daniel José Barbosa
- REQUIMTE (Rede de Química e Tecnologia)
- Laboratório de Toxicologia
- Departamento de Ciências Biológicas
- Faculdade de Farmácia
- Universidade do Porto
| | - João Paulo Capela
- REQUIMTE (Rede de Química e Tecnologia)
- Laboratório de Toxicologia
- Departamento de Ciências Biológicas
- Faculdade de Farmácia
- Universidade do Porto
| | - Maria de Lourdes Bastos
- REQUIMTE (Rede de Química e Tecnologia)
- Laboratório de Toxicologia
- Departamento de Ciências Biológicas
- Faculdade de Farmácia
- Universidade do Porto
| | - Félix Carvalho
- REQUIMTE (Rede de Química e Tecnologia)
- Laboratório de Toxicologia
- Departamento de Ciências Biológicas
- Faculdade de Farmácia
- Universidade do Porto
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Cao N, Yao ZX. Oligodendrocyte N-methyl-D-aspartate receptor signaling: insights into its functions. Mol Neurobiol 2013; 47:845-56. [PMID: 23345133 DOI: 10.1007/s12035-013-8408-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 01/13/2013] [Indexed: 12/21/2022]
Abstract
Myelination by oligodendrocytes facilitates rapid nerve conduction. Loss of oligodendrocytes and failure of myelination lead to nerve degeneration and numerous demyelinating white matter diseases. N-methyl-D-aspartate (NMDA) receptors, which are key regulators on neuron survival and functions, have been recently identified to express in oligodendrocytes, especially in the myelin sheath. NMDA receptor signaling in oligodendrocytes plays crucial roles in energy metabolism and myelination. In the present review, we highlight the subcellular location-specific impairment of excessive NMDA receptor signaling on oligodendrocyte energy metabolism in soma and myelin, and the mechanisms including Ca(2+) overload, acidotoxicity, mitochondria dysfunction, and impairment of respiratory chains. Conversely, physiological NMDA receptor signaling regulates differentiation and migration of oligodendrocytes. How can we use above knowledge to treat excitotoxic oligodendrocyte loss, congenital myelination deficiency, or postnatal demyelination? A thorough understanding of NMDA receptor signaling-mediated cellular events in oligodendrocytes at the pathophysiological level will no doubt aid in exploring effective therapeutic strategies for demyelinating white matter diseases.
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Affiliation(s)
- Nian Cao
- Department of Physiology, Third Military Medical University, Chongqing 400038, China
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Kataria H, Wadhwa R, Kaul SC, Kaur G. Water extract from the leaves of Withania somnifera protect RA differentiated C6 and IMR-32 cells against glutamate-induced excitotoxicity. PLoS One 2012; 7:e37080. [PMID: 22606332 PMCID: PMC3351387 DOI: 10.1371/journal.pone.0037080] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 04/13/2012] [Indexed: 01/09/2023] Open
Abstract
Glutamate neurotoxicity has been implicated in stroke, head trauma, multiple sclerosis and neurodegenerative disorders. Search for herbal remedies that may possibly act as therapeutic agents is an active area of research to combat these diseases. The present study was designed to investigate the neuroprotective role of Withania somnifera (Ashwagandha), also known as Indian ginseng, against glutamate induced toxicity in the retinoic acid differentiated rat glioma (C6) and human neuroblastoma (IMR-32) cells. The neuroprotective activity of the Ashwagandha leaves derived water extract (ASH-WEX) was evaluated. Cell viability and the expression of glial and neuronal cell differentiation markers was examined in glutamate challenged differentiated cells with and without the presence of ASH-WEX. We demonstrate that RA-differentiated C6 and IMR-32 cells, when exposed to glutamate, undergo loss of neural network and cell death that was accompanied by increase in the stress protein HSP70. ASH-WEX pre-treatment inhibited glutamate-induced cell death and was able to revert glutamate-induced changes in HSP70 to a large extent. Furthermore, the analysis on the neuronal plasticity marker NCAM (Neural cell adhesion molecule) and its polysialylated form, PSA-NCAM revealed that ASH-WEX has therapeutic potential for prevention of neurodegeneration associated with glutamate-induced excitotoxicty.
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Affiliation(s)
- Hardeep Kataria
- Department of Biotechnology, Guru Nanak Dev University, Amritsar, India
| | - Renu Wadhwa
- National Institute of Advanced Industrial Science and Technology, Tsukuba, Japan
- * E-mail: (GK) (RW); (RW) (GK)
| | - Sunil C. Kaul
- National Institute of Advanced Industrial Science and Technology, Tsukuba, Japan
| | - Gurcharan Kaur
- Department of Biotechnology, Guru Nanak Dev University, Amritsar, India
- * E-mail: (GK) (RW); (RW) (GK)
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Neuhaus W, Freidl M, Szkokan P, Berger M, Wirth M, Winkler J, Gabor F, Pifl C, Noe CR. Effects of NMDA receptor modulators on a blood-brain barrier in vitro model. Brain Res 2011; 1394:49-61. [PMID: 21549356 DOI: 10.1016/j.brainres.2011.04.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 03/21/2011] [Accepted: 04/01/2011] [Indexed: 01/29/2023]
Abstract
Changes of the functionality of the blood-brain barrier (BBB) have been reported in the context of several brain related diseases such as multiple sclerosis, epilepsy, Alzheimer's disease and stroke. Several publications indicated the presence and functionality of the NMDA receptor (NMDAR) at the brain endothelium and a possible involvement of the NMDAR in the above-mentioned diseases. Recently, it was shown that the application of the NMDAR antagonist MK801 can block several adverse effects at the BBB in vitro, but also that MK801 can significantly change the proteome of brain endothelial cells without simultaneous stimulation of NMDAR by glutamate. Based on these reports we investigated if NMDAR antagonists MK801 and D-APV can affect the intracellular calcium level (Ca²⁺i) of an in vitro BBB model based on human cell line ECV304 on their own and compared these results to effects mediated by NMDAR agonists glutamate and NMDA. Treatment of ECV304 cells for 30 min with glutamate resulted in no significant change of Ca²⁺i. On the contrary, application of NMDA and NMDAR antagonists D-APV and MK801 led to a significant and concentration dependent decrease of Ca²⁺i. Further studies revealed that glutamate was able to decrease the transendothelial electrical resistance (TEER) of the BBB in vitro model, whereas NMDA and D-APV were able to increase TEER. Analysis of the protein expression levels of tight junctional molecules ZO-1 and occludin showed a complex regulation after application of NMDAR modulators. In summary, it was shown that NMDAR antagonists can alter BBB key properties in vitro on their own. Moreover, although qPCR results confirmed the presence of NMDA receptor subunits NR1, NR2A, NR2B and NR2C, membrane binding studies failed to prove the typical plasma membrane localization and functionality in human BBB cell line ECV304.
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Affiliation(s)
- Winfried Neuhaus
- Department of Anaesthesia and Critical Care, University Hospital Würzburg, Oberdürrbacherstrasse 6, 97080 Würzburg, Germany
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