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Esberg A, Kindstedt E, Isehed C, Lindquist S, Holmlund A, Lundberg P. LIGHT protein: A novel gingival crevicular fluid biomarker associated with increased probing depth after periodontal surgery. J Clin Periodontol 2024; 51:852-862. [PMID: 38390754 DOI: 10.1111/jcpe.13964] [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: 09/10/2023] [Revised: 01/27/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
AIM To evaluate the protein profiles in gingival crevicular fluid (GCF) in relation to clinical outcomes after periodontal surgery and examine if any selected proteins affect the mRNA expression of pro-inflammatory cytokines in human gingival fibroblasts. MATERIALS AND METHODS This exploratory study included 21 consecutive patients with periodontitis. GCF was collected, and the protein pattern (n = 92) and clinical parameters were evaluated prior to surgery and 3, 6 and 12 months after surgery. Fibroblastic gene expression was analysed by real-time quantitative polymerase chain reaction. RESULTS Surgical treatment reduced periodontal pocket depth (PPD) and changed the GCF protein pattern. Twelve months after surgery, 17% of the pockets showed an increase in PPD. Levels of a number of proteins in the GCF decreased after surgical treatment but increased with early signs of tissue destruction, with LIGHT being one of the proteins that showed the strongest association. Furthermore, LIGHT up-regulated the mRNA expression of pro-inflammatory cytokines interleukin (IL)-6, IL-8 and MMP9 in human gingival fibroblasts. CONCLUSIONS LIGHT can potentially detect subjects at high risk of periodontitis recurrence after surgical treatment. Moreover, LIGHT induces the expression of inflammatory cytokines and tissue-degrading enzymes in gingival fibroblasts.
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Affiliation(s)
- Anders Esberg
- Department of Odontology, Umeå University, Umeå, Sweden
| | - Elin Kindstedt
- Department of Molecular Periodontology, Umeå University, Umeå, Sweden
| | - Catrine Isehed
- Department of Molecular Periodontology, Umeå University, Umeå, Sweden
- Department of Periodontology, Public Dental Health County Council of Gävleborg, Gävle County Hospital, Gävle, Sweden
- Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Susanne Lindquist
- Department of Molecular Periodontology, Umeå University, Umeå, Sweden
| | - Anders Holmlund
- Department of Periodontology, Public Dental Health County Council of Gävleborg, Gävle County Hospital, Gävle, Sweden
- Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Pernilla Lundberg
- Department of Molecular Periodontology, Umeå University, Umeå, Sweden
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Skubica P, Husakova M, Dankova P. In vitro osteoclastogenesis in autoimmune diseases - Strengths and pitfalls of a tool for studying pathological bone resorption and other disease characteristics. Heliyon 2023; 9:e21925. [PMID: 38034780 PMCID: PMC10682642 DOI: 10.1016/j.heliyon.2023.e21925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Osteoclasts play a critical role in bone pathology frequently associated with autoimmune diseases. Studying the etiopathogenesis of these diseases and their clinical manifestations can involve in vitro osteoclastogenesis, an experimental technique that utilizes osteoclast precursors that are relatively easily accessible from peripheral blood or synovial fluid. However, the increasing number of methodical options to study osteoclastogenesis in vitro poses challenges in translating findings to clinical research and practice. This review compares and critically evaluates previous research work based on in vitro differentiation of human osteoclast precursors originating from patients, which aimed to explain autoimmune pathology in rheumatic and enteropathic diseases. The discussion focuses primarily on methodical differences between the studies, including the origin of osteoclast precursors, culture conditions, and methods for identifying osteoclasts and assessing their activity. Additionally, the review examines the clinical significance of the three most commonly used in vitro approaches: induced osteoclastogenesis, spontaneous osteoclastogenesis, and cell co-culture. By analyzing and integrating the gathered information, this review proposes general connections between different studies, even in cases where their results are seemingly contradictory. The derived conclusions and future directions aim to enhance our understanding of a potential and limitations of in vitro osteoclastogenesis and provide a foundation for discussing novel methods (such as osteoclastogenesis dynamic) and standardized approaches (such as spontaneous osteoclastogenesis) for future use in autoimmune disease research.
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Affiliation(s)
- Patrik Skubica
- Faculty of Science, Charles University, Prague, Czech Republic
| | - Marketa Husakova
- First Faculty of Medicine, Charles University, Prague and Institute of Rheumatology, Prague, Czech Republic
| | - Pavlina Dankova
- Faculty of Science, Charles University, Prague, Czech Republic
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Karimi A, Azar PS, Kadkhodayi M, Tandorost A, Vajdi M, Shoorei H, Farhangi MA. A comprehensive insight into effects of resveratrol on molecular mechanism in rheumatoid arthritis: A literature systematic review. Int J Rheum Dis 2022; 25:827-843. [PMID: 35754354 DOI: 10.1111/1756-185x.14356] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/29/2022] [Accepted: 05/15/2022] [Indexed: 02/01/2023]
Abstract
AIM Rheumatoid arthritis (RA) is an inflammatory autoimmune disease, which is characterized by massive pain and destruction of synovial joints, leads to bone erosion, damage to cartilage, and disability. Several studies suggested that resveratrol supplementation may be effective in the prevention and management of RA. Therefore, a systematic review was conducted to summarize published studies that assess the effect of resveratrol supplementation on the complications of RA. METHODS A comprehensive search to identify in vitro, animal, and human studies investigating the impact of resveratrol on the complications of RA was performed up to February 2022. Two independent reviewers evaluated studies based on inclusion/exclusion criteria and performed data extraction. RESULTS All studies examining the effects of resveratrol supplementation on the complications of RA were included. From a total of 571 retrieved articles, 32 studies were eligible for the current systematic review. The evidence reviewed here indicates that resveratrol supplementation may exert beneficial effects on the complications of RA by attenuating inflammation and oxidative stress, modulating the immune response, and down-regulating the messenger RNA expression of genes related to inflammatory pathways. CONCLUSION Due to the promising therapeutic effects of resveratrol on RA complications and limited number of human studies in this subject, further clinical trials are suggested.
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Affiliation(s)
- Arash Karimi
- Traditional Medicine and Hydrotherapy Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Pouria Sefidmooye Azar
- Department of Nutrition and Hospitality Management, School of Applied Sciences, The University of Mississippi, University Park, Mississippi, USA
| | - Mahtab Kadkhodayi
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arash Tandorost
- Traditional Medicine and Hydrotherapy Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mahdi Vajdi
- Student Research Committee, Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Shoorei
- Department of Anatomical Sciences, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
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Hulander E, Bärebring L, Turesson Wadell A, Gjertsson I, Calder PC, Winkvist A, Lindqvist HM. Proposed Anti-Inflammatory Diet Reduces Inflammation in Compliant, Weight-Stable Patients with Rheumatoid Arthritis in a Randomized Controlled Crossover Trial. J Nutr 2021; 151:3856-3864. [PMID: 34587253 PMCID: PMC8643575 DOI: 10.1093/jn/nxab313] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND It is unclear to what extent adjuvant dietary intervention can influence inflammation in rheumatoid arthritis (RA). OBJECTIVES The objective was to assess the effects of dietary manipulation on inflammation in patients with RA. METHODS In a crossover design, participants [n = 50, 78% females, median BMI (in kg/m2) 27, median age 63 y] were randomly assigned to begin with either a 10-wk portfolio diet of proposed anti-inflammatory foods (i.e., a high intake of fatty fish, whole grains, fruits, nuts, and berries) or a control diet resembling a Western diet with a 4-mo washout in between. This report evaluates the secondary outcome markers of inflammation among participants with stable medication. Analyses were performed using a linear mixed ANCOVA model. RESULTS There were no significant effects on CRP or ESR in the group as a whole. In those with high compliance (n = 29), changes in ESR within the intervention diet period differed significantly compared with changes within the control diet period (mean: -5.490; 95% CI: -10.310, -0.669; P = 0.027). During the intervention diet period, there were lowered serum concentrations of C-X-C motif ligand 1 (CXCL1) (mean: -0.268; 95% CI: -0.452, -0.084;P = 0.006), CXCL5 (mean: -0.278; 95% CI: -0.530, -0.026 P = 0.031), CXCL6 (mean: -0.251; 95% CI: -0.433, -0.069; P = 0.009), and tumor necrosis factor ligand superfamily member 14 (TNFSF14) (mean: -0.139; 95% CI: -0.275, -0.002; P = 0.047) compared with changes within the control diet period. CONCLUSION A proposed anti-inflammatory diet likely reduced systemic inflammation, as indicated by a decreased ESR in those who completed the study with high compliance (n = 29). These findings warrant further studies to validate our results, and to evaluate the clinical relevance of changes in CXCL1, CXCL5, CXCL6, and TNFSF14 in patients with RA.
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Affiliation(s)
- Erik Hulander
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Linnea Bärebring
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Turesson Wadell
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Inger Gjertsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Philip C Calder
- Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Anna Winkvist
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helen M Lindqvist
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Brunetti G, Belisario DC, Bortolotti S, Storlino G, Colaianni G, Faienza MF, Sanesi L, Alliod V, Buffoni L, Centini E, Voena C, Pulito R, Novello S, Ingravallo G, Rizzi R, Mori G, Reseland JE, Ware CF, Colucci S, Ferracini R, Grano M, Roato I. LIGHT/TNFSF14 Promotes Osteolytic Bone Metastases in Non-small Cell Lung Cancer Patients. J Bone Miner Res 2020; 35:671-680. [PMID: 31826304 DOI: 10.1002/jbmr.3942] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/03/2019] [Accepted: 12/08/2019] [Indexed: 12/24/2022]
Abstract
Tumor necrosis factor superfamily member 14 (TNFSF14), LIGHT, is a component of the cytokine network that regulates innate and adaptive immune responses, which promote homeostasis of lymphoid organs, liver, and bone. Metastatic tumors often disrupt the tissue microenvironment, thus altering the homeostasis of the invaded organ; however, the underlying mechanisms required further studies. We investigated the role of LIGHT in osteolytic bone disease induced by metastatic non-small cell lung cancer (NSCLC). Patients diagnosed with NSCLC bone metastasis show significantly higher levels of LIGHT expressed in monocytes compared with non-bone metastatic tumors and healthy controls. Serum LIGHT levels were also higher in patients with bone metastases than in controls, suggesting a role for LIGHT in stimulating osteoclast precursors. In bone metastatic patients, we also detected increased RNA expression and serum RANKL levels, thus by adding anti-LIGHT or RANK-fragment crystallizable region (RANK-Fc) in PBMC cultures, a significant inhibition of osteoclastogenesis was observed. To model this observation in mice, we used the mouse lung cancer cell line LLC-1. After intratibial implantation, wild-type mice showed an increased number of osteoclasts but reduced numbers of osteoblasts and decreased osteoid formation. In contrast, Tnfsf14-/- mice showed no significant bone loss or other changes in bone homeostasis associated with this model. These data indicate LIGHT is a key control mechanism for regulating bone homeostasis during metastatic invasion. Thus, LIGHT may be a novel therapeutic target in osteolytic bone metastases. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Giacomina Brunetti
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Dimas C Belisario
- Center for Experimental Research and Medical Studies (CeRMS), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sara Bortolotti
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Giuseppina Storlino
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Graziana Colaianni
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Maria F Faienza
- Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Lorenzo Sanesi
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Valentina Alliod
- Department of Oncological Sciences, University of Turin Medical School, Turin, Italy
| | - Lucio Buffoni
- Department of Oncological Sciences, University of Turin Medical School, Turin, Italy
| | - Elisa Centini
- Center for Experimental Research and Medical Studies (CeRMS), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Claudia Voena
- Center for Experimental Research and Medical Studies (CeRMS), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Roberta Pulito
- Center for Experimental Research and Medical Studies (CeRMS), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Silvia Novello
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Giuseppe Ingravallo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Rita Rizzi
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giorgio Mori
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Janne E Reseland
- Department of Biomaterials, Institute for Clinical Dentistry, University of Oslo Blindern, Oslo, Norway
| | - Carl F Ware
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Silvia Colucci
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Riccardo Ferracini
- Department of Surgical Sciences (DISC), Orthopaedic Clinic-IRCCS, A.O.U. San Martino, Genoa, Italy
| | - Maria Grano
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Ilaria Roato
- Center for Experimental Research and Medical Studies (CeRMS), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
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Ponzetti M, Rucci N. Updates on Osteoimmunology: What's New on the Cross-Talk Between Bone and Immune System. Front Endocrinol (Lausanne) 2019; 10:236. [PMID: 31057482 PMCID: PMC6482259 DOI: 10.3389/fendo.2019.00236] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/25/2019] [Indexed: 12/11/2022] Open
Abstract
The term osteoimmunology was coined many years ago to describe the research field that deals with the cross-regulation between bone cells and the immune system. As a matter of fact, many factors that are classically considered immune-related, such as InterLeukins (i.e., IL-6, -11, -17, and -23), Tumor Necrosis Factor (TNF)-α, Receptor-Activator of Nuclear factor Kappa B (RANK), and its Ligand (RANKL), Nuclear Factor of Activated T-cell, cytoplasmatic-1 (NFATc1), and others have all been found to be crucial in osteoclast and osteoblast biology. Conversely, bone cells, which we used to think would only regulate each other and take care of remodeling bone, actually regulate immune cells, by creating the so-called "endosteal niche." Both osteoblasts and osteoclasts participate to this niche, either by favoring engraftment, or mobilization of Hematopoietic Stem Cells (HSCs). In this review, we will describe the main milestones at the base of the osteoimmunology and present the key cellular players of the bone-immune system cross-talk, including HSCs, osteoblasts, osteoclasts, bone marrow macrophages, osteomacs, T- and B-lymphocytes, dendritic cells, and neutrophils. We will also briefly describe some pathological conditions in which the bone-immune system cross-talk plays a crucial role, with the final aim to portray the state of the art in the mechanisms regulating the bone-immune system interplay, and some of the latest molecular players in the field. This is important to encourage investigation in this field, to identify new targets in the treatment of bone and immune diseases.
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Brunetti G, Faienza MF, Colaianni G, Gigante I, Oranger A, Pignataro P, Ingravallo G, Di Benedetto A, Bortolotti S, Di Comite M, Storlino G, Lippo L, Ward-Kavanagh L, Mori G, Reseland JE, Passeri G, Schipani E, Tamada K, Ware CF, Colucci S, Grano M. Impairment of Bone Remodeling in LIGHT/TNFSF14-Deficient Mice. J Bone Miner Res 2018; 33:704-719. [PMID: 29178458 DOI: 10.1002/jbmr.3345] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/08/2017] [Accepted: 11/21/2017] [Indexed: 12/19/2022]
Abstract
Multiple cytokines produced by immune cells induce remodeling and aid in maintaining bone homeostasis through differentiation of bone-forming osteoblasts and bone-resorbing osteoclasts. Here, we investigate bone remodeling controlled by the tumor necrosis factor (TNF) superfamily cytokine LIGHT. LIGHT-deficient mice (Tnfsf14-/- ) exhibit spine deformity and reduced femoral cancellous bone mass associated with an increase in the osteoclast number and a slight decrease of osteoblasts compared with WT mice. The effect of LIGHT in bone cells can be direct or indirect, mediated by both the low expression of the anti-osteoclastogenic osteoprotegerin (OPG) in B and T cells and reduced levels of the pro-osteoblastogenic Wnt10b in CD8+ T cells in Tnfsf14-/- mice. LIGHT stimulation increases OPG levels in B, CD8+ T, and osteoblastic cells, as well as Wnt10b expression in CD8+ T cells. The high bone mass in Light and T- and B-cell-deficient mice (Rag- /Tnfsf14- ) supports the cooperative role of the immune system in bone homeostasis. These results implicate LIGHT as a potential target in bone disease. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Giacomina Brunetti
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Maria Felicia Faienza
- Department of Biomedical Science and Human Oncology, Paediatric Unit, University of Bari, Bari, Italy
| | - Graziana Colaianni
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Isabella Gigante
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Angela Oranger
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Paolo Pignataro
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Giuseppe Ingravallo
- Department of Emergency and Organ Transplantation, Pathology Section, University of Bari, Bari, Italy
| | - Adriana Di Benedetto
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Sara Bortolotti
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Mariasevera Di Comite
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Giuseppina Storlino
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Luciana Lippo
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Lindsay Ward-Kavanagh
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Giorgio Mori
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Janne E Reseland
- Department of Biomaterials, Institute for Clinical Dentistry, University of Oslo, Blindern, Oslo, Norway
| | - Giovanni Passeri
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ernestina Schipani
- Departments of Medicine and Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Koji Tamada
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carl F Ware
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Silvia Colucci
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Maria Grano
- Department of Emergency and Organ Transplantation, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
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Sabokbar A, Afrough S, Mahoney DJ, Uchihara Y, Swales C, Athanasou NA. Role of LIGHT in the pathogenesis of joint destruction in rheumatoid arthritis. World J Exp Med 2017; 7:49-57. [PMID: 28589079 PMCID: PMC5439172 DOI: 10.5493/wjem.v7.i2.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/01/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To characterise the role of substitutes for receptor-activator nuclear factor kappa-B ligand (RANKL) in rheumatoid arthritis (RA) joint destruction.
METHODS Synovial fluid (SF) macrophages isolated from the knee joint of RA patients were incubated with 25 ng/mL macrophage-colony stimulating factor (M-CSF) and 50 ng/mL LIGHT (lymphotoxin-like, exhibits inducible expression and competes with herpes simplex virus glycoprotein D for herpes virus entry mediator, a receptor expressed by T lymphocytes) in the presence and absence of 25 ng/mL RANKL and 100 ng/mL osteoprotegerin (OPG) on glass coverslips and dentine slices. Osteoclastogenesis was assessed by the formation of multinucleated cells (MNCs) expressing tartrate-resistant acid phosphatase (TRAP) on coverslips and the extent of lacunar resorption pit formation on dentine slices. The concentration of LIGHT in RA and osteoarthritis (OA) synovial fluid was measured by an enzyme-linked immunosorbent assay (ELISA) and the expression of LIGHT in RA and OA synovium was determined by immunohistochemistry using an indirect immunoperoxidase technique.
RESULTS In cultures of RA SF macrophages treated with LIGHT and M-CSF, there was significant formation of TRAP + MNCs on coverslips and extensive lacunar resorption pit formation on dentine slices. SF-macrophage-osteoclast differentiation was not inhibited by the addition of OPG, a decoy receptor for RANKL. Resorption pits were smaller and less confluent than in RANKL-treated cultures but the overall percentage area of the dentine slice resorbed was comparable in LIGHT- and RANKL-treated cultures. LIGHT significantly stimulated RANKL-induced lacunar resorption compared with RA SF macrophages treated with either RANKL or LIGHT alone. LIGHT was strongly expressed by synovial lining cells, subintimal macrophages and endothelial cells in RA synovium and the concentration of LIGHT was much higher in RA compared with OA SF.
CONCLUSION LIGHT is highly expressed in RA synovium and SF, stimulates RANKL-independent/dependent osteoclastogenesis from SF macrophages and may contribute to marginal erosion formation.
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Sabokbar A, Mahoney DJ, Hemingway F, Athanasou NA. Non-Canonical (RANKL-Independent) Pathways of Osteoclast Differentiation and Their Role in Musculoskeletal Diseases. Clin Rev Allergy Immunol 2017; 51:16-26. [PMID: 26578261 DOI: 10.1007/s12016-015-8523-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Osteoclasts are multinucleated cells derived from mononuclear phagocyte precursors (monocytes, macrophages); in the canonical pathway of osteoclastogenesis, these cells fuse and differentiate to form specialised bone-resorbing osteoclasts in the presence of receptor activator for nuclear factor kappa B ligand (RANKL). Non-canonical pathways of osteoclastogenesis have been described in which several cytokines and growth factors are able to substitute for RANKL. These humoral factors can generally be divided into those which, like RANKL, are tumour necrosis family (TNF) superfamily members and those which are not; the former include TNFα lymphotoxin exhibiting inducible expression and competing with herpes simplex virus glycoprotein D for herpesvirus entry mediator, a receptor expressed by T lymphocytes (LIGHT), a proliferation inducing ligand (APRIL) and B cell activating factor (BAFF); the latter include transforming growth factor beta (TGF-β), interleukin-6 (IL-6), IL-8, IL-11, nerve growth factor (NGF), insulin-like growth factor-I (IGF-I) and IGF-II. This review summarises the evidence for these RANKL substitutes in inducing osteoclast differentiation from tissue-derived and circulating mononuclear phagocytes. It also assesses the role these factors are likely to play in promoting the pathological bone resorption seen in many inflammatory and neoplastic lesions of bone and joint including rheumatoid arthritis, aseptic implant loosening and primary and secondary tumours of bone.
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Affiliation(s)
- A Sabokbar
- The Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services, Nuffield Orthopaedic Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - D J Mahoney
- The Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services, Nuffield Orthopaedic Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - F Hemingway
- The Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services, Nuffield Orthopaedic Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - N A Athanasou
- The Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services, Nuffield Orthopaedic Centre, University of Oxford, Oxford, OX3 7LD, UK.
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10
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Brunetti G, Rizzi R, Oranger A, Gigante I, Mori G, Taurino G, Mongelli T, Colaianni G, Di Benedetto A, Tamma R, Ingravallo G, Napoli A, Faienza MF, Mestice A, Curci P, Specchia G, Colucci S, Grano M. LIGHT/TNFSF14 increases osteoclastogenesis and decreases osteoblastogenesis in multiple myeloma-bone disease. Oncotarget 2015; 5:12950-67. [PMID: 25460501 PMCID: PMC4350341 DOI: 10.18632/oncotarget.2633] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/23/2014] [Indexed: 12/13/2022] Open
Abstract
LIGHT, a TNF superfamily member, is involved in T-cell homeostasis and erosive bone disease associated with rheumatoid arthritis. Herein, we investigated whether LIGHT has a role in Multiple Myeloma (MM)-bone disease. We found that LIGHT was overproduced by CD14+ monocytes, CD8+ T-cells and neutrophils of peripheral blood and bone marrow (BM) from MM-bone disease patients. We also found that LIGHT induced osteoclastogenesis and inhibited osteoblastogenesis. In cultures from healthy-donors, LIGHT induced osteoclastogenesis in RANKL-dependent and -independent manners. In the presence of a sub-optimal RANKL concentration, LIGHT and RANKL synergically stimulated osteoclast formation, through the phosphorylation of Akt, NFκB and JNK pathways. In cultures of BM samples from patients with bone disease, LIGHT inhibited the formation of CFU-F and CFU-OB as well as the expression of osteoblastic markers including collagen-I, osteocalcin and bone sialoprotein-II. LIGHT indirectly inhibited osteoblastogenesis in part through sclerostin expressed by monocytes. In conclusion, our findings for the first time provide evidence for a role of LIGHT in MM-bone disease development.
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Affiliation(s)
- Giacomina Brunetti
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Rita Rizzi
- Department of Emergency and Organ Transplantation, Section of Hematology with Transplantation, University of Bari, Bari, Italy
| | - Angela Oranger
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Isabella Gigante
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Giorgio Mori
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Grazia Taurino
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Teresa Mongelli
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Graziana Colaianni
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Adriana Di Benedetto
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Roberto Tamma
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Giuseppe Ingravallo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Anna Napoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Maria Felicia Faienza
- Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - Anna Mestice
- Department of Emergency and Organ Transplantation, Section of Hematology with Transplantation, University of Bari, Bari, Italy
| | - Paola Curci
- Department of Emergency and Organ Transplantation, Section of Hematology with Transplantation, University of Bari, Bari, Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation, Section of Hematology with Transplantation, University of Bari, Bari, Italy
| | - Silvia Colucci
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
| | - Maria Grano
- Department of Basic and Medical Sciences, Neurosciences and Sense Organs, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
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Pajarinen J, Kouri VP, Jämsen E, Li TF, Mandelin J, Konttinen YT. The response of macrophages to titanium particles is determined by macrophage polarization. Acta Biomater 2013; 9:9229-40. [PMID: 23827094 DOI: 10.1016/j.actbio.2013.06.027] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 05/24/2013] [Accepted: 06/18/2013] [Indexed: 02/06/2023]
Abstract
Aseptic loosening of total joint replacements is driven by the reaction of macrophages to foreign body particles released from the implant. It was hypothesized that the macrophages' response to these particles is dependent, in addition to particle characteristics and contaminating biomolecules, on the state of macrophage polarization as determined by the local cytokine microenvironment. To test this hypothesis we differentiated M1 and M2 macrophages from human peripheral blood monocytes and compared their responses to titanium particles using genome-wide microarray analysis and a multiplex cytokine assay. In comparison to non-activated M0 macrophages, the overall chemotactic and inflammatory responses to titanium particles were greatly enhanced in M1 macrophages and effectively suppressed in M2 macrophages. In addition, the genome-wide approach revealed several novel, potentially osteolytic, particle-induced mediators, and signaling pathway analysis suggested the involvement of toll-like and nod-like receptor signaling in particle recognition. It is concluded that the magnitude of foreign body reaction caused by titanium particles is dependent on the state of macrophage polarization. Thus, by limiting the action of M1 polarizing factors, e.g. bacterial biofilm formation, in peri-implant tissues and promoting M2 macrophage polarization by biomaterial solutions or pharmacologically, it might be possible to restrict wear-particle-induced inflammation and osteolysis.
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Affiliation(s)
- Jukka Pajarinen
- Institute of Biomedicine, Anatomy, University of Helsinki, Haartmaninkatu 8, P.O. Box 63, 00014 University of Helsinki, Finland; Department of Medicine, Institute of Clinical Medicine, University of Helsinki and Helsinki University Central Hospital, Haartmaninkatu 8, P.O. Box 20, 00029 HUS, Finland
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12
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A soft coral-derived compound, 11-epi-sinulariolide acetate suppresses inflammatory response and bone destruction in adjuvant-induced arthritis. PLoS One 2013; 8:e62926. [PMID: 23675440 PMCID: PMC3652811 DOI: 10.1371/journal.pone.0062926] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 03/27/2013] [Indexed: 12/02/2022] Open
Abstract
In recent years, a significant number of metabolites with potent anti-inflammatory properties have been discovered from marine organisms, and several of these compounds are now under clinical trials. In the present study, we isolated 11-epi-sinulariolide acetate (Ya-s11), a cembrane-type compound with anti-inflammatory effects, from the Formosa soft coral Sinularia querciformis. Preliminary screening revealed that Ya-s11 significantly inhibited the expression of the proinflammatory proteins induced nitric oxide synthase and cyclooxygenase-2 in lipopolysaccharide-stimulated murine macrophages. We also examined the therapeutic effects of Ya-s11 on adjuvant-induced arthritis (AIA) in female Lewis rats, which demonstrate features similar to human rheumatoid arthritis (RA). Animal experiments revealed that Ya-s11 (subcutaneously 9 mg/kg once every 2 days from day 7 to day 28 postimmunization) significantly inhibited AIA characteristics. Moreover, Ya-s11 also attenuated protein expression of cathepsin K, matrix metalloproteinases-9 (MMP-9), tartrate-resistant acid phosphatase (TRAP), and tumor necrosis factor-α (TNF-α) in ankle tissues of AIA-rats. Based on its attenuation of the expression of proinflammatory proteins and disease progression in AIA rats, the marine-derived compound Ya-s11 may serve as a useful therapeutic agent for the treatment of RA.
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Hemingway F, Kashima TG, Knowles HJ, Athanasou NA. Investigation of osteoclastogenic signalling of the RANKL substitute LIGHT. Exp Mol Pathol 2013; 94:380-5. [PMID: 23391709 DOI: 10.1016/j.yexmp.2013.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 01/28/2013] [Indexed: 01/07/2023]
Abstract
LIGHT (TNFSF14) is a member of the TNF superfamily and is known to substitute for RANKL to induce osteoclast differentiation. LIGHT binds HVEM and LTβR, but it is not known whether these receptors play a role in osteoclast formation or whether LIGHT acts via RANKL signalling pathways. We found that both RANKL and LIGHT strongly induced phosphorylation of Akt and NFκB but not JNK in mouse osteoclast precursor cells. The addition of an Akt inhibitor showed decreased osteoclast differentiation and resorption mediated by both RANKL and LIGHT. RT-PCR and FACS analysis showed that CD14(+) human osteoclast precursors expressed HVEM and LTβR; expression levels of HVEM increased in the course of osteoclastogenesis and a decrease in LIGHT expression was associated with an increase in HVEM suggesting that there is a feedback loop related to this receptor. Our findings show that LIGHT is not inhibited by the soluble RANKL receptor OPG and that LIGHT is a potent osteoclastogenesis factor that activates the Akt, NFκB and JNK pathways.
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Affiliation(s)
- F Hemingway
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford OX3 7HE, United Kingdom
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Wang D, Yuan F, Wang L, Wei W. Paeoniflorin inhibits function and down-regulates HLA-DR and CD80 expression of human peripheral blood monocytes stimulated by RhIL-1β. Int Immunopharmacol 2012; 14:172-8. [DOI: 10.1016/j.intimp.2012.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 06/13/2012] [Accepted: 07/10/2012] [Indexed: 12/21/2022]
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15
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Mabilleau G, Pascaretti-Grizon F, Baslé MF, Chappard D. Depth and volume of resorption induced by osteoclasts generated in the presence of RANKL, TNF-alpha/IL-1 or LIGHT. Cytokine 2011; 57:294-9. [PMID: 22172512 DOI: 10.1016/j.cyto.2011.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 11/18/2011] [Accepted: 11/20/2011] [Indexed: 01/07/2023]
Abstract
Rheumatoid arthritis (RA) is associated with pathological bone destruction mediated by osteoclasts. Although RANKL has been reported as a crucial factor for osteoclastogenesis, several other factors increased in RA support osteoclast formation and resorption in the absence of RANKL such as TNF-alpha and LIGHT. To date, in vitro bone resorption experiments are reported as the mean area of bone resorption per cortical or dentine slices and do not provide any information about depth and volume of resorption. The aims of this study were to assess these parameters by light microscopy and vertical scanning profilometry (VSP). Peripheral blood mononuclear cells were used as a source of osteoclast precursors and were cultured for up to 21 days in the presence of RANKL, TNF-alpha/IL-1 or LIGHT. Mean area, depth and volume of resorption were assessed by light microscopy and vertical scanning profilometry. As expected, RANKL induced large resorption pits (10,876 ± 2190μm(2)) whereas TNF-alpha/IL-1 and LIGHT generated smaller pits (respectively 1328 ± 210 and 1267 ± 173μm(2)) with no noticeable differences between these two cytokines. Depth and volume of resorption measured by VSP showed that RANKL promoted deep resorption pits resulting in large volume of resorption. Interestingly, although mean area of resorption was similar between TNF-alpha/IL-1 and LIGHT, the depth and volume of resorption of these lacunae were significantly increased by 2-fold with TNF-alpha/IL-1. These results provide evidence that although LIGHT appeared elevated in the synovial fluid of RA patients, its role in bone resorption is less than TNF-alpha/IL-1 or RANKL.
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Affiliation(s)
- Guillaume Mabilleau
- INSERM, U922 - LHEA "Remodelage osseux et Biomatériaux", IRIS-IBS, Institut de Biologie en Santé, CHU d'Angers, 49933 Angers, France.
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16
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Huang CC, Lloyd-Jones DM, Guo X, Rajamannan NM, Lin S, Du P, Huang Q, Hou L, Liu K. Gene expression variation between African Americans and whites is associated with coronary artery calcification: the multiethnic study of atherosclerosis. Physiol Genomics 2011; 43:836-43. [PMID: 21521779 DOI: 10.1152/physiolgenomics.00243.2010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Coronary artery calcium (CAC) is a strong indicator of total atherosclerosis burden. Epidemiological data have shown substantial differences in CAC prevalence and severity between African Americans and whites. However, little is known about the molecular mechanisms underlying initiation and progression of CAC. Microarray gene expression profiling of peripheral blood leucocytes was performed from 119 healthy women aged 50 yr or above in the Multi-Ethnic Study of Atherosclerosis cohort; 48 women had CAC score >100 and carotid intima-media thickness (IMT) >1 mm, while 71 had CAC <10 and IMT <0.65 mm. When 17 African Americans were compared with 41 whites in the low-CAC group, 409 differentially expressed genes (false discovery rate <5%) were identified. In addition, 316 differentially expressed genes were identified between the high- and low-CAC groups. A substantial overlap between these two gene lists was observed (148 genes, P < 10(-6)). Furthermore, genes expressed lower in African Americans also tend to express lower in individuals with low CAC (correlation 0.69, P = 0.002). Ontology analysis of the 409 race-associated genes revealed significant enrichment in mobilization of calcium and immune/inflammatory response (P < 10(-9)). Of note, 25 of 30 calcium mobilization genes were involved in immune/inflammatory response (P < 10(-10)). Our data suggest a connection between immune response and vascular calcification and the result provides a potential mechanistic explanation for the lower prevalence and severity of CAC in African Americans compared with whites.
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Affiliation(s)
- Chiang-Ching Huang
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA.
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Vaillancourt F, Silva P, Shi Q, Fahmi H, Fernandes JC, Benderdour M. Elucidation of molecular mechanisms underlying the protective effects of thymoquinone against rheumatoid arthritis. J Cell Biochem 2011; 112:107-17. [DOI: 10.1002/jcb.22884] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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18
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Grcevic D, Jajic Z, Kovacic N, Lukic IK, Velagic V, Grubisic F, Ivcevic S, Marusic A. Peripheral blood expression profiles of bone morphogenetic proteins, tumor necrosis factor-superfamily molecules, and transcription factor Runx2 could be used as markers of the form of arthritis, disease activity, and therapeutic responsiveness. J Rheumatol 2009; 37:246-56. [PMID: 20008919 DOI: 10.3899/jrheum.090167] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess whether different forms of arthritis and disease activity could be distinguished by peripheral blood expression profiles of bone-regulatory factors including tumor necrosis factor (TNF)-superfamily [TNF-related apoptosis-inducing ligand (TRAIL), the Fas ligand (FasL), and the ligand for herpesvirus entry mediator (LIGHT)] and bone morphogenetic protein (BMP)-family members (BMP-2, BMP-4, BMP-6) as well as osteoblast differentiation gene Runx2. METHODS Blood cells from healthy controls (n = 25) and patients at different disease stages with rheumatoid arthritis (RA; n = 49), osteoarthritis (OA; n = 17), or spondyloarthritis, including ankylosing spondylitis (AS; n = 27) or psoriatic arthritis (PsA; n = 23), were processed for quantitative polymerase chain reaction. Gene expression was assessed in comparison with control samples, correlated with clinical data of different forms of arthritis, and analyzed for discriminative efficacy between groups by receiver-operation characteristic (ROC) curves. Results were confirmed on diagnostic RA (n = 5) and AS (n = 8) samples. RESULTS BMP-4, BMP-6, and Runx2 expressions were significantly decreased in patients with RA and OA versus controls. Patients with RA also had decreased FasL and LIGHT expression, while patients with AS had increased Runx2 expression. Negative correlation with disease activity was found for BMP-4, FasL, and Runx2 in RA and for Runx2 in PsA, while positive correlation was found for BMP-4 in PsA. Gene expression was higher in the therapy-resistant form of AS (for BMP-4, LIGHT, and Runx2) and in methotrexate-treated patients in RA (for BMP-2 and LIGHT). ROC curve analysis confirmed discrimination between groups, particularly decreased LIGHT and Runx2 for RA and increased Runx2 for AS. CONCLUSION Our study identified BMP and Runx2 as possible biomarkers of bone metabolism in several forms of arthritis, while lower FasL and LIGHT were associated with RA. Correlation between gene expression and disease activity may be clinically useful in assessing therapeutic effectiveness and disease monitoring.
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Affiliation(s)
- Danka Grcevic
- Department of Physiology and Immunology, University of Zagreb School of Medicine, Zagreb, Croatia.
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