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Sternstein C, Böhm TM, Fink J, Meyr J, Lüdemann M, Krug M, Kriukov K, Gurdap CO, Sezgin E, Ebert R, Seibel J. Development of an Effective Functional Lipid Anchor for Membranes (FLAME) for the Bioorthogonal Modification of the Lipid Bilayer of Mesenchymal Stromal Cells. Bioconjug Chem 2023; 34:1221-1233. [PMID: 37328799 DOI: 10.1021/acs.bioconjchem.3c00091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The glycosylation of cellular membranes is crucial for the survival and communication of cells. As our target is the engineering of the glycocalyx, we designed a functionalized lipid anchor for the introduction into cellular membranes called Functional Lipid Anchor for MEmbranes (FLAME). Since cholesterol incorporates very effectively into membranes, we developed a twice cholesterol-substituted anchor in a total synthesis by applying protecting group chemistry. We labeled the compound with a fluorescent dye, which allows cell visualization. FLAME was successfully incorporated in the membranes of living human mesenchymal stromal cells (hMSC), acting as a temporary, nontoxic marker. The availability of an azido function─a bioorthogonal reacting group within the compound─enables the convenient coupling of alkyne-functionalized molecules, such as fluorophores or saccharides. After the incorporation of FLAME into the plasma membrane of living hMSC, we were able to successfully couple our molecule with an alkyne-tagged fluorophore via click reaction. This suggests that FLAME is useful for the modification of the membrane surface. Coupling FLAME with a galactosamine derivative yielded FLAME-GalNAc, which was incorporated into U2OS cells as well as in giant unilamellar vesicles (GUVs) and cell-derived giant plasma membrane vesicles (GPMVs). With this, we have shown that FLAME-GalNAc is a useful tool for studying the partitioning in the liquid-ordered (Lo) and the liquid-disordered (Ld) phases. The molecular tool can also be used to analyze the diffusion behavior in the model and the cell membranes by fluorescence correlation spectroscopy (FCS).
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Affiliation(s)
- Christine Sternstein
- Institute of Organic Chemistry, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Theresa-Maria Böhm
- Department of Musculoskeletal Tissue Regeneration, Orthopedic Clinic König-Ludwig Haus, University of Würzburg, Friedrich-Bergius-Ring 15, 97076 Würzburg, Germany
| | - Julian Fink
- Institute of Organic Chemistry, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Jessica Meyr
- Institute of Organic Chemistry, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
| | - Martin Lüdemann
- Department of Orthopaedic Surgery, König-Ludwig-Haus, University of Würzburg, Brettreichstr. 11, 97074 Würzburg, Germany
| | - Melanie Krug
- Department of Musculoskeletal Tissue Regeneration, Orthopedic Clinic König-Ludwig Haus, University of Würzburg, Friedrich-Bergius-Ring 15, 97076 Würzburg, Germany
| | - Kirill Kriukov
- Department of Musculoskeletal Tissue Regeneration, Orthopedic Clinic König-Ludwig Haus, University of Würzburg, Friedrich-Bergius-Ring 15, 97076 Würzburg, Germany
| | - Cenk O Gurdap
- Science for Life Laboratory, Department of Women's and Children's Health, Karolinska Institutet, 17165 Solna, Sweden
| | - Erdinc Sezgin
- Science for Life Laboratory, Department of Women's and Children's Health, Karolinska Institutet, 17165 Solna, Sweden
| | - Regina Ebert
- Department of Musculoskeletal Tissue Regeneration, Orthopedic Clinic König-Ludwig Haus, University of Würzburg, Friedrich-Bergius-Ring 15, 97076 Würzburg, Germany
| | - Jürgen Seibel
- Institute of Organic Chemistry, University of Würzburg, Am Hubland, 97074 Würzburg, Germany
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2
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Wardzala CL, Clauss ZS, Kramer JR. Principles of glycocalyx engineering with hydrophobic-anchored synthetic mucins. Front Cell Dev Biol 2022; 10:952931. [PMID: 36325363 PMCID: PMC9621330 DOI: 10.3389/fcell.2022.952931] [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: 05/25/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022] Open
Abstract
The cellular glycocalyx is involved in diverse biological phenomena in health and disease. Yet, molecular level studies have been challenged by a lack of tools to precisely manipulate this heterogeneous structure. Engineering of the cell surface using insertion of hydrophobic-terminal materials has emerged as a simple and efficient method with great promise for glycocalyx studies. However, there is a dearth of information about how the structure of the material affects membrane insertion efficiency and resulting density, the residence time of the material, or what types of cells can be utilized. Here, we examine a panel of synthetic mucin structures terminated in highly efficient cholesterylamide membrane anchors for their ability to engineer the glycocalyx of five different cell lines. We examined surface density, residence time and half-life, cytotoxicity, and the ability be passed to daughter cells. We report that this method is robust for a variety of polymeric structures, long-lasting, and well-tolerated by a variety of cell lines.
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Abstract
Neuroprosthetic devices that record and modulate neural activities have demonstrated immense potential for bypassing or restoring lost neurological functions due to neural injuries and disorders. However, implantable electrical devices interfacing with brain tissue are susceptible to a series of inflammatory tissue responses along with mechanical or electrical failures which can affect the device performance over time. Several biomaterial strategies have been implemented to improve device-tissue integration for high quality and stable performance. Ranging from developing smaller, softer, and more flexible electrode designs to introducing bioactive coatings and drug-eluting layers on the electrode surface, such strategies have shown different degrees of success but with limitations. With their hydrophilic properties and specific bioactivities, carbohydrates offer a potential solution for addressing some of the limitations of the existing biomolecular approaches. In this review, we summarize the role of polysaccharides in the central nervous system, with a primary focus on glycoproteins and proteoglycans, to shed light on their untapped potential as biomaterials for neural implants. Utilization of glycosaminoglycans for neural interface and tissue regeneration applications is comprehensively reviewed to provide the current state of carbohydrate-based biomaterials for neural implants. Finally, we will discuss the challenges and opportunities of applying carbohydrate-based biomaterials for neural tissue interfaces.
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Affiliation(s)
- Vaishnavi Dhawan
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Xinyan Tracy Cui
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for Neural Basis of Cognition, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
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4
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Watson A, Simmermaker C, Aung E, Do S, Hackbusch S, Franz AH. NMR analysis and molecular dynamics conformation of α-1,6-linear and α-1,3-branched isomaltose oligomers as mimetics of α-1,6-linked dextran. Carbohydr Res 2021; 503:108296. [PMID: 33813322 DOI: 10.1016/j.carres.2021.108296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 01/01/2023]
Abstract
The conformational preferences of several α-1,6-linear and α-1,3-branched isomalto-oligosaccharides were investigated by NMR and MD-simulations. Right-handed helical structure contributed to the solution geometry in isomaltotriose and isomaltotetraose with one nearly complete helix turn and stabilizing intramolecular hydrogen bonds in the latter by MD-simulation. Decreased helix contribution was observed in α-1,3-glucopyranosyl- and α-1,3-isomaltosyl-branched saccharide chains. Especially the latter modification was predicted to cause a more compact structure consistent with literature rheology measurements as well as with published dextranase-resistant α-1,3-branched oligosaccharides. The findings presented here are significant because they shed further light on the conformational preference of isomalto-oligosaccharides and provide possible help for the design of dextran-based drug delivery systems or for the targeted degradation of capsular polysaccharides by dextranases in multi-drug resistant bacteria.
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Affiliation(s)
- Amelia Watson
- Department of Chemistry, University of the Pacific, 3601 Pacific Avenue, Stockton, CA, 95211, USA
| | - Cate Simmermaker
- Department of Chemistry, University of the Pacific, 3601 Pacific Avenue, Stockton, CA, 95211, USA
| | - Ei Aung
- Department of Chemistry, University of the Pacific, 3601 Pacific Avenue, Stockton, CA, 95211, USA
| | - Stephen Do
- Department of Chemistry, University of the Pacific, 3601 Pacific Avenue, Stockton, CA, 95211, USA
| | - Sven Hackbusch
- Department of Chemistry, University of the Pacific, 3601 Pacific Avenue, Stockton, CA, 95211, USA
| | - Andreas H Franz
- Department of Chemistry, University of the Pacific, 3601 Pacific Avenue, Stockton, CA, 95211, USA.
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5
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Garrudo FFF, Mikael PE, Xia K, Silva JC, Ouyang Y, Chapman CA, Hoffman PR, Yu Y, Han X, Rodrigues CAV, Cabral JMS, Morgado J, Ferreira FC, Linhardt RJ. The effect of electrospun scaffolds on the glycosaminoglycan profile of differentiating neural stem cells. Biochimie 2021; 182:61-72. [PMID: 33422570 PMCID: PMC7902476 DOI: 10.1016/j.biochi.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/03/2021] [Accepted: 01/03/2021] [Indexed: 12/20/2022]
Abstract
The use of electrospun scaffolds for neural tissue engineering applications allows a closer mimicry of the native tissue extracellular matrix (ECM), important for the transplantation of cells in vivo. Moreover, the role of the electrospun fiber mat topography on neural stem cell (NSC) differentiation remains to be completely understood. In this work REN-VM cells (NSC model) were differentiated on polycaprolactone (PCL) nanofibers, obtained by wet/wet electrospinning, and on flat glass lamellas. The obtained differentiation profile of NSCs was evaluated using immunofluorescence and qPCR analysis. Glycosaminoglycan (GAG) analysis was successfully emplyed to evaluate changes in the GAG profile of differentiating cells through the use of the highly sensitive liquid chromatography-tandem mass/mass spectrometry (LC-MS/MS) method. Our results show that both culture platforms allow the differentiation of REN-VM cells into neural cells (neurons and astrocytes) similarly. Moreover, LC-MS/MS analysis shows changes in the production of GAGs present both in cell cultures and conditioned media samples. In the media, hyaluronic acid (HA) was detected and correlated with cellular activity and the production of a more plastic extracellular matrix. The cell samples evidence changes in chondroitin sulfate (CS4S, CS6S, CS4S6S) and heparan sulfate (HS6S, HS0S), similar to those previously described in vivo studies and possibly associated with the creation of complex structures, such as perineural networks. The GAG profile of differentiating REN-VM cells on electrospun scaffolds was analyzed for the first time. Our results highlight the advantage of using platforms obtain more reliable and robust neural tissue-engineered transplants.
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Affiliation(s)
- Fábio F F Garrudo
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA; Department of Bioengineering and iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal; Department of Bioengineering and Instituto de Telecomunicações, Instituto Superior Técnico, Universidade de Lisboa, 1049-001, Lisboa, Portugal
| | - Paiyz E Mikael
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - Ke Xia
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - João C Silva
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA; Department of Bioengineering and iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal
| | - Yilan Ouyang
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - Caitlyn A Chapman
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - Pauline R Hoffman
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - Yanlei Yu
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - Xiaurui Han
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA
| | - Carlos A V Rodrigues
- Department of Bioengineering and iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal
| | - Joaquim M S Cabral
- Department of Bioengineering and iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal
| | - Jorge Morgado
- Department of Bioengineering and Instituto de Telecomunicações, Instituto Superior Técnico, Universidade de Lisboa, 1049-001, Lisboa, Portugal
| | - Frederico C Ferreira
- Department of Bioengineering and iBB - Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001, Lisboa, Portugal
| | - Robert J Linhardt
- Center for Biotechnology & Interdisciplinary Studies, Department of Chemistry & Chemical Biology, Rensselaer Polytechnic Institute, Biotechnology Center 4005, Troy, NY, 12180, USA.
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6
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Miura Y. Controlled polymerization for the development of bioconjugate polymers and materials. J Mater Chem B 2020; 8:2010-2019. [DOI: 10.1039/c9tb02418b] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Conjugates of various biopolymers with synthetic polymers were preparedvialiving radical polymerization. The conjugates have precise structures and potential for novel biofunctional materials.
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Affiliation(s)
- Yoshiko Miura
- Department of Chemical Engineering
- Graduate School of Engineering
- Kyushu University
- Fukuoka 819-0395
- Japan
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7
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Chaudhary PM, Toraskar S, Yadav R, Hande A, Yellin R, Kikkeri R. Multivalent Sialosides: A Tool to Explore the Role of Sialic Acids in Biological Processes. Chem Asian J 2019; 14:1344-1355. [PMID: 30839167 PMCID: PMC7159662 DOI: 10.1002/asia.201900031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/05/2019] [Indexed: 12/29/2022]
Abstract
Sialic acids (Sias) are fascinating nine-carbon monosaccharides that are primarily found on the terminus of the oligosaccharide chains of glycoproteins and glycolipids on cell surfaces. These Sias undergo a variety of structural modifications at their hydroxy and amine positions, thereby resulting in structural diversity and, hence, coordinating a variety of biological processes. However, deciphering the structural functions of such interactions is highly challenging, because the monovalent binding of Sias is extremely weak. Over the last decade, several multivalent Sia ligands have been synthesized to modulate their binding affinity with proteins/lectins. In this Minireview, we highlight recent developments in the synthesis of multivalent Sia probes and their potential applications. We will discuss four key multivalent families, that is, polymers, dendrimers, liposomes, and nanoparticles, and will emphasize the major parameters that are essential for the specific interactions of these molecules with proteins in biological systems.
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Affiliation(s)
- Preeti Madhukar Chaudhary
- Department of ChemistryIndian Institute of Science Education and ResearchDr. Homi Bhabha RoadPune411008MaharashtraIndia
| | - Suraj Toraskar
- Department of ChemistryIndian Institute of Science Education and ResearchDr. Homi Bhabha RoadPune411008MaharashtraIndia
| | - Rohan Yadav
- Department of ChemistryIndian Institute of Science Education and ResearchDr. Homi Bhabha RoadPune411008MaharashtraIndia
| | - Akshay Hande
- Department of ChemistryIndian Institute of Science Education and ResearchDr. Homi Bhabha RoadPune411008MaharashtraIndia
| | - Rina‐Arad Yellin
- Guangdong Technion Israel Institute of Technology241 Daxue RoadShantouGuangdong515063P. R. China
| | - Raghavendra Kikkeri
- Department of ChemistryIndian Institute of Science Education and ResearchDr. Homi Bhabha RoadPune411008MaharashtraIndia
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8
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NMR solution geometry of saccharides containing the 6-O-(α-D-glucopyranosyl)-α/β-D-glucopyranose (isomaltose) or 6-O-(α-D-galactopyranosyl)-α/β-D-glucopyranose (melibiose) core. Carbohydr Res 2019; 473:18-35. [DOI: 10.1016/j.carres.2018.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 12/26/2022]
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9
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Glycosaminoglycans (GAGs) and GAG mimetics regulate the behavior of stem cell differentiation. Colloids Surf B Biointerfaces 2017; 150:175-182. [DOI: 10.1016/j.colsurfb.2016.11.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/18/2016] [Indexed: 11/19/2022]
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10
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BODIPY-Conjugated Xyloside Primes Fluorescent Glycosaminoglycans in the Inner Ear of Opsanus tau. J Assoc Res Otolaryngol 2016; 17:525-540. [PMID: 27619213 DOI: 10.1007/s10162-016-0585-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 08/23/2016] [Indexed: 12/22/2022] Open
Abstract
We report on a new xyloside conjugated to BODIPY, BX and its utility to prime fluorescent glycosaminoglycans (BX-GAGs) within the inner ear in vivo. When BX is administered directly into the endolymphatic space of the oyster toadfish (Opsanus tau) inner ear, fluorescent BX-GAGs are primed and become visible in the sensory epithelia of the semicircular canals, utricle, and saccule. Confocal and 2-photon microscopy of vestibular organs fixed 4 h following BX treatment, reveal BX-GAGs constituting glycocalyces that envelop hair cell kinocilium, nerve fibers, and capillaries. In the presence of GAG-specific enzymes, the BX-GAG signals are diminished, suggesting that chondroitin sulfates are the primary GAGs primed by BX. Results are consistent with similar click-xylosides in CHO cell lines, where the xyloside enters the Golgi and preferentially initiates chondroitin sulfate B production. Introduction of BX produces a temporary block of hair cell mechanoelectrical transduction (MET) currents in the crista, reduction in background discharge rate of afferent neurons, and a reduction in sensitivity to physiological stimulation. A six-degree-of-freedom pharmacokinetic mathematical model has been applied to interpret the time course and spatial distribution of BX and BX-GAGs. Results demonstrate a new optical approach to study GAG biology in the inner ear, for tracking synthesis and localization in real time.
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Woods EC, Yee NA, Shen J, Bertozzi CR. Glycocalyx Engineering with a Recycling Glycopolymer that Increases Cell Survival In Vivo. Angew Chem Int Ed Engl 2015; 54:15782-8. [PMID: 26647316 PMCID: PMC4736730 DOI: 10.1002/anie.201508783] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Indexed: 11/10/2022]
Abstract
Synthetic glycopolymers that emulate cell-surface mucins have been used to elucidate the role of mucin overexpression in cancer. However, because they are internalized within hours, these glycopolymers could not be employed to probe processes that occur on longer time scales. In this work, we tested a panel of glycopolymers bearing a variety of lipids to identify those that persist on cell membranes. Strikingly, we found that cholesterylamine (CholA) anchored glycopolymers are internalized into vesicles that serve as depots for delivery back to the cell surface, allowing for the display of cell-surface glycopolymers for at least ten days, even while the cells are dividing. As with native mucins, the cell-surface display of CholA-anchored glycopolymers influenced the focal adhesion distribution. Furthermore, we show that these mimetics enhance the survival of nonmalignant cells in a zebrafish model of metastasis. CholA-anchored glycopolymers therefore expand the application of glycocalyx engineering in glycobiology.
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Affiliation(s)
- Elliot C Woods
- Department of Bioengineering, University of California, Berkeley, CA 94720 (USA)
| | - Nathan A Yee
- Department of Chemistry, Stanford University, Stanford, CA 94305-4401 (USA)
| | - Jeff Shen
- Department of Chemistry, Stanford University, Stanford, CA 94305-4401 (USA)
| | - Carolyn R Bertozzi
- Department of Chemistry, Stanford University, Stanford, CA 94305-4401 (USA).
- Howard Hughes Medical Institute (USA).
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12
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Woods EC, Yee NA, Shen J, Bertozzi CR. Glycocalyx Engineering with a Recycling Glycopolymer that Increases Cell Survival In Vivo. Angew Chem Int Ed Engl 2015. [DOI: 10.1002/ange.201508783] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Elliot C. Woods
- Department of Bioengineering, University of California, Berkeley, CA 94720 (USA)
| | - Nathan A. Yee
- Department of Chemistry, Stanford University, Stanford, CA 94305‐4401 (USA)
| | - Jeff Shen
- Department of Chemistry, Stanford University, Stanford, CA 94305‐4401 (USA)
| | - Carolyn R. Bertozzi
- Department of Chemistry, Stanford University, Stanford, CA 94305‐4401 (USA)
- Howard Hughes Medical Institute (USA)
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