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Mondal M, Bala J, Mondal KR, Afrin S, Saha P, Saha M, Jamaddar S, Roy UK, Sarkar C. The protective effects of nerol to prevent the toxicity of carbon tetrachloride to the liver in Sprague-Dawley rats. Heliyon 2023; 9:e23065. [PMID: 38125544 PMCID: PMC10731234 DOI: 10.1016/j.heliyon.2023.e23065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/21/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Carbon-tetrachloride (CCl4) is well-known to cause liver damage due to severe oxidative stress. Nerol, on the other hand, is a monoterpene that is antioxidant, antiviral, antibacterial, anti-inflammatory, and anxiolytic. This study set out to determine if nerol may be used as a prophylactic measure against the oxidative stress mediated hepatic injury caused by CCl4. Materials and methods For the aim of this experiment, 35 male Sprague-Dawley rats ranging in body weight (BW) from 140 to 180 g were split into five separate groups. With the exception of vehicle control group 1, all experimental rats were subjected to carbon tetrachloride exposure through intra-peritoneal injection at a 0.7 mL/kg body weight dose once a week for 4 weeks (28 days). The treatment groups 3 and 4 received oral administration of nerol at 50 and 100 mg/kg BW for 28 days. In the same time period, the standard control group received 100 mg/kg BW silymarin. Results Serum hepatic markers, lipid profiles, albumin, globulin, bilirubin, and total protein were all substantially improved in nerol-treated rats in a dose-dependent manner that had been exposed to CCl4 compared to the only CCl4-treated group. Carbon tetrachloride-exposed rats had lower glutathione, superoxide dismutase, and catalase levels and higher thio-barbituric acid reactive substances (TBARS) levels than normal rats. In contrast, administration of nerol shown a significant augmentation in the concentrations of these antioxidant compounds, while concurrently inducing a decline in the levels of TBARS in the hepatic tissue. In a similar vein, the histo-pathological examination yielded further evidence indicating that nerol offered protection to the hepatocyte against damage generated by CCl4. Conclusion According to the findings of our investigation, nerol has potential as a functional element to shield the liver from harm brought on by ROS that are caused by CCL4.
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Affiliation(s)
- Milon Mondal
- Department of Pharmacy, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, 8100, Bangladesh
| | - Jibanananda Bala
- Department of Pharmacy, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, 8100, Bangladesh
| | | | - Sadia Afrin
- Department of Pharmacy, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, 8100, Bangladesh
| | - Protyaee Saha
- Department of Pharmaceutical Sciences, North South University, Dhaka, 1229, Bangladesh
| | - Moumita Saha
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka, 1342, Bangladesh
| | - Sarmin Jamaddar
- Department of Pharmacy, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, 8100, Bangladesh
| | - Uttam Kumar Roy
- Department of Pharmacy, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, 8100, Bangladesh
| | - Chandan Sarkar
- Department of Pharmacy, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, 8100, Bangladesh
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Badawy A, Hassanean H, Ibrahim AK, Habib ES, El-Magd MA, Ahmed SA. Isolates From Thymelaea Hirsuta Inhibit Progression Of Hepatocellular Carcinoma In Vitro And In Vivo. Nat Prod Res 2019; 35:1799-1807. [PMID: 31315443 DOI: 10.1080/14786419.2019.1643859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Herein, we investigated effect of Thymelaea hirsuta isolates on hepatocellular carcinoma. Methanolic extract of T. hirsuta led to isolation of two new compounds [6` hydroxyDaphnoretin (9) and Mithnin (15)], seven compounds reported for the first time from genus Thymelaea [Dotriacontanol (1), and 3-ketopentatriacontanoic (2), Docosylcoumarate (5), Docosylcaffeate (6), Daphnodorin B (11), 3`` -epi-dihydrodaphnodorin B (12) and Wikstaiwanone B (14)], and six known compounds. Eight compounds (5, 6, 9, 10, 11, 12, 14, and 15) showed significant anti-proliferative activity on HepG2 cells. These compounds caused significant reduction (p < 0.05) in serum levels of AST, ALT, ALP, total bilirubin, GGT, and AFP, a significant increase in Bax and p53 expression, and a significant decrease in Bcl2 gene in liver as compared to the HCC group. These results indicate that T. hirsuta isolates inhibited HCC progression, possibly through induction of apoptosis and therefore they could be used as a beneficial source for treating HCC.
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Affiliation(s)
- Ahmed Badawy
- Department of Pharmacognosy, Faculty of Pharmacy, Sinai University, El-Arish, Egypt
| | - Hashim Hassanean
- Department of Pharmacognosy, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Amany K Ibrahim
- Department of Pharmacognosy, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Eman S Habib
- Department of Pharmacognosy, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Mohammed A El-Magd
- Department of Anatomy, Faculty of Veterinary Medicine, Kafrelsheikh University, Egypt
| | - Safwat A Ahmed
- Department of Pharmacognosy, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
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Selvaraj S, Oh JH, Spanel R, Länger F, Han HY, Lee EH, Yoon S, Borlak J. The pathogenesis of diclofenac induced immunoallergic hepatitis in a canine model of liver injury. Oncotarget 2017; 8:107763-107824. [PMID: 29296203 PMCID: PMC5746105 DOI: 10.18632/oncotarget.21201] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/31/2017] [Indexed: 12/19/2022] Open
Abstract
Hypersensitivity to non-steroidal anti-inflammatory drugs is a common adverse drug reaction and may result in serious inflammatory reactions of the liver. To investigate mechanism of immunoallergic hepatitis beagle dogs were given 1 or 3 mg/kg/day (HD) oral diclofenac for 28 days. HD diclofenac treatment caused liver function test abnormalities, reduced haematocrit and haemoglobin but induced reticulocyte, WBC, platelet, neutrophil and eosinophil counts. Histopathology evidenced hepatic steatosis and glycogen depletion, apoptosis, acute lobular hepatitis, granulomas and mastocytosis. Whole genome scans revealed 663 significantly regulated genes of which 82, 47 and 25 code for stress, immune response and inflammation. Immunopathology confirmed strong induction of IgM, the complement factors C3&B, SAA, SERPING1 and others of the classical and alternate pathway. Alike, marked expression of CD205 and CD74 in Kupffer cells and lymphocytes facilitate antigen presentation and B-cell differentiation. The highly induced HIF1A and KLF6 protein expression in mast cells and macrophages sustain inflammation. Furthermore, immunogenomics discovered 24, 17, 6 and 11 significantly regulated marker genes to hallmark M1/M2 polarized macrophages, lymphocytic and granulocytic infiltrates; note, the latter was confirmed by CAE staining. Other highly regulated genes included alpha-2-macroglobulin, CRP, hepcidin, IL1R1, S100A8 and CCL20. Diclofenac treatment caused unprecedented induction of myeloperoxidase in macrophages and oxidative stress as shown by SOD1/SOD2 immunohistochemistry. Lastly, bioinformatics defined molecular circuits of inflammation and consisted of 161 regulated genes. Altogether, the mechanism of diclofenac induced liver hypersensitivity reactions involved oxidative stress, macrophage polarization, mastocytosis, complement activation and an erroneous programming of the innate and adaptive immune system.
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Affiliation(s)
- Saravanakumar Selvaraj
- Centre for Pharmacology and Toxicology, Hannover Medical School, 30625 Hannover, Germany
| | - Jung-Hwa Oh
- Department of Predictive Toxicology, Korea Institute of Toxicology, 34114 Gajeong-ro, Yuseong, Daejeon, Republic of Korea
| | - Reinhard Spanel
- Centre for Pharmacology and Toxicology, Hannover Medical School, 30625 Hannover, Germany.,Institute of Pathology, 41747 Viersen, Germany
| | - Florian Länger
- Institute of Pathology, Hannover Medical School, 30625 Hannover, Germany
| | - Hyoung-Yun Han
- Department of Predictive Toxicology, Korea Institute of Toxicology, 34114 Gajeong-ro, Yuseong, Daejeon, Republic of Korea
| | - Eun-Hee Lee
- Department of Predictive Toxicology, Korea Institute of Toxicology, 34114 Gajeong-ro, Yuseong, Daejeon, Republic of Korea
| | - Seokjoo Yoon
- Department of Predictive Toxicology, Korea Institute of Toxicology, 34114 Gajeong-ro, Yuseong, Daejeon, Republic of Korea
| | - Jürgen Borlak
- Centre for Pharmacology and Toxicology, Hannover Medical School, 30625 Hannover, Germany
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Identification of consensus biomarkers for predicting non-genotoxic hepatocarcinogens. Sci Rep 2017; 7:41176. [PMID: 28117354 PMCID: PMC5259716 DOI: 10.1038/srep41176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/16/2016] [Indexed: 12/31/2022] Open
Abstract
The assessment of non-genotoxic hepatocarcinogens (NGHCs) is currently relying on two-year rodent bioassays. Toxicogenomics biomarkers provide a potential alternative method for the prioritization of NGHCs that could be useful for risk assessment. However, previous studies using inconsistently classified chemicals as the training set and a single microarray dataset concluded no consensus biomarkers. In this study, 4 consensus biomarkers of A2m, Ca3, Cxcl1, and Cyp8b1 were identified from four large-scale microarray datasets of the one-day single maximum tolerated dose and a large set of chemicals without inconsistent classifications. Machine learning techniques were subsequently applied to develop prediction models for NGHCs. The final bagging decision tree models were constructed with an average AUC performance of 0.803 for an independent test. A set of 16 chemicals with controversial classifications were reclassified according to the consensus biomarkers. The developed prediction models and identified consensus biomarkers are expected to be potential alternative methods for prioritization of NGHCs for further experimental validation.
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Carter WG, Vigneswara V, Newlaczyl A, Wayne D, Ahmed B, Saddington S, Brewer C, Raut N, Gerdes HK, Erdozain AM, Tooth D, Bolt EL, Osna NA, Tuma DJ, Kharbanda KK. Isoaspartate, carbamoyl phosphate synthase-1, and carbonic anhydrase-III as biomarkers of liver injury. Biochem Biophys Res Commun 2015; 458:626-631. [PMID: 25684186 PMCID: PMC4355035 DOI: 10.1016/j.bbrc.2015.01.158] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 01/28/2015] [Indexed: 02/08/2023]
Abstract
We had previously shown that alcohol consumption can induce cellular isoaspartate protein damage via an impairment of the activity of protein isoaspartyl methyltransferase (PIMT), an enzyme that triggers repair of isoaspartate protein damage. To further investigate the mechanism of isoaspartate accumulation, hepatocytes cultured from control or 4-week ethanol-fed rats were incubated in vitro with tubercidin or adenosine. Both these agents, known to elevate intracellular S-adenosylhomocysteine levels, increased cellular isoaspartate damage over that recorded following ethanol consumption in vivo. Increased isoaspartate damage was attenuated by treatment with betaine. To characterize isoaspartate-damaged proteins that accumulate after ethanol administration, rat liver cytosolic proteins were methylated using exogenous PIMT and (3)H-S-adenosylmethionine and proteins resolved by gel electrophoresis. Three major protein bands of ∼ 75-80 kDa, ∼ 95-100 kDa, and ∼ 155-160 kDa were identified by autoradiography. Column chromatography used to enrich isoaspartate-damaged proteins indicated that damaged proteins from ethanol-fed rats were similar to those that accrued in the livers of PIMT knockout (KO) mice. Carbamoyl phosphate synthase-1 (CPS-1) was partially purified and identified as the ∼ 160 kDa protein target of PIMT in ethanol-fed rats and in PIMT KO mice. Analysis of the liver proteome of 4-week ethanol-fed rats and PIMT KO mice demonstrated elevated cytosolic CPS-1 and betaine homocysteine S-methyltransferase-1 when compared to their respective controls, and a significant reduction of carbonic anhydrase-III (CA-III) evident only in ethanol-fed rats. Ethanol feeding of rats for 8 weeks resulted in a larger (∼ 2.3-fold) increase in CPS-1 levels compared to 4-week ethanol feeding indicating that CPS-1 accumulation correlated with the duration of ethanol consumption. Collectively, our results suggest that elevated isoaspartate and CPS-1, and reduced CA-III levels could serve as biomarkers of hepatocellular injury.
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Affiliation(s)
- Wayne G Carter
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK.
| | - Vasanthy Vigneswara
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Anna Newlaczyl
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Declan Wayne
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Bilal Ahmed
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Stephen Saddington
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Charlotte Brewer
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Nikhilesh Raut
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Henry K Gerdes
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK
| | - Amaia M Erdozain
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby, DE22 3DT, UK; Department of Pharmacology, University of the Basque Country, and Centro de Investigación Biomédica en Red de Salud Mental, Spain
| | - David Tooth
- School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Edward L Bolt
- School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Natalie A Osna
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Biochemistry, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dean J Tuma
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Biochemistry, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kusum K Kharbanda
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Biochemistry, University of Nebraska Medical Center, Omaha, NE, USA
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van Swelm RPL, Kramers C, Masereeuw R, Russel FGM. Application of urine proteomics for biomarker discovery in drug-induced liver injury. Crit Rev Toxicol 2014; 44:823-41. [DOI: 10.3109/10408444.2014.931341] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Li X, Zhang F, Wang D, Li Z, Qin X, Du G. NMR-based metabonomic and quantitative real-time PCR in the profiling of metabolic changes in carbon tetrachloride-induced rat liver injury. J Pharm Biomed Anal 2014; 89:42-9. [DOI: 10.1016/j.jpba.2013.10.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/08/2013] [Accepted: 10/12/2013] [Indexed: 01/11/2023]
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Tanca A, Pisanu S, Biosa G, Pagnozzi D, Antuofermo E, Burrai GP, Canzonieri V, Cossu-Rocca P, De Re V, Eccher A, Fanciulli G, Rocca S, Uzzau S, Addis MF. Application of 2D-DIGE to formalin-fixed diseased tissue samples from hospital repositories: results from four case studies. Proteomics Clin Appl 2013; 7:252-63. [PMID: 23090899 DOI: 10.1002/prca.201200054] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 08/01/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE In the recent past, the potential suitability of fixed samples to 2D-DIGE studies has been demonstrated on model tissues, but not on "real-world" archival tissues. Therefore, this study was aimed to assess the quality of the results delivered by 2D-DIGE on samples retrieved from hospital tissue repositories. EXPERIMENTAL DESIGN Diseased and normal tissue samples (namely, human gastric adenocarcinoma and normal gastric tissue, human lung neuroendocrine tumors, canine mammary tubulo-papillary carcinoma and normal mammary tissue, sheep liver with cloudy swelling degeneration and normal liver tissue) were retrieved from human and veterinary biorepositories and subjected to full-length protein extraction, cyanine labeling, 2D-DIGE separation, image analysis, MS analysis, and protein identification. RESULTS Archival samples could be successfully subjected to 2D-DIGE, providing maps of satisfactory resolution, although with varying pattern complexity (possibly influenced by preanalytical variables). Moreover, differentially expressed protein identities were consistent with the disease biology. CONCLUSIONS AND CLINICAL RELEVANCE 2D-DIGE can support biomarker discovery and validation studies on large sample cohorts. In fact, although some information complexity is lost when compared to fresh-frozen tissues, their vast availability and the associated patient information can considerably boost studies suffering limited sample availability or involving long-distance exchange of samples.
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Zira A, Kostidis S, Theocharis S, Sigala F, Engelsen SB, Andreadou I, Mikros E. 1H NMR-based metabonomics approach in a rat model of acute liver injury and regeneration induced by CCl4 administration. Toxicology 2012; 303:115-24. [PMID: 23146765 DOI: 10.1016/j.tox.2012.10.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 10/12/2012] [Accepted: 10/13/2012] [Indexed: 11/28/2022]
Abstract
The administration of carbon tetrachloride (CCl(4)) has been established as a model of toxin-induced acute and chronic liver injury. In the present study, we investigate the progression of the biochemical response to acute CCl(4)-induced liver injury, capturing metabolic variations during both toxic insult and regeneration using NMR-based metabonomic analysis of liver tissue and plasma. A single dose of CCl(4) (1 mL/kg BW) was intraperitoneally administered to male Wister rats sacrificed every 12h up to 72 h post treatment, while healthy animals served as controls. Acquired (1)H NMR spectra of liver tissue extracts and plasma samples were explored with multivariate analysis and the resulted models were correlated with conventional biochemical and histopathological indices of toxicity for monitoring the progression of experimental injury. The metabonomic analysis resulted in discrimination between the subjects under toxic insult (up to 36 h) and those at the regenerative phase (peaked at 48 h). At 72 h normalization of liver's pathology similar to the controls group was apparent. Principal component analysis (PCA) trajectories highlighted the time points of the greater degree of toxic insult and the regenerative state. A number of metabolites such as glucose, lactate, choline, formate exhibited variations suggesting CCl(4) induced impairment in essential biochemical pathways as energy metabolism, lipid biosynthesis and transmethylation reactions. The latter provides new evidence of B12 and folate pathways deficiency, indicative of new mechanistic implications possibly by direct inhibition of B12 dependent enzymes by the chlorinated radicals of CCl(4) metabolism.
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Affiliation(s)
- Athina Zira
- Department of Pharmaceutical Chemistry, School of Pharmacy, University of Athens, Panepistimioupolis Zografou, 15771 Athens, Greece
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Laurindo FRM, Pescatore LA, Fernandes DDC. Protein disulfide isomerase in redox cell signaling and homeostasis. Free Radic Biol Med 2012; 52:1954-69. [PMID: 22401853 DOI: 10.1016/j.freeradbiomed.2012.02.037] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 02/23/2012] [Accepted: 02/24/2012] [Indexed: 12/16/2022]
Abstract
Thiol proteins may potentially act as redox signaling adaptor proteins, adjusting reactive oxygen species intermediates to specific signals and redox signals to cell homeostasis. In this review, we discuss redox effects of protein disulfide isomerase (PDI), a thioredoxin superfamily oxidoreductase from the endoplasmic reticulum (ER). Abundantly expressed PDI displays ubiquity, interactions with redox and nonredox proteins, versatile effects, and several posttranslational modifications. The PDI family contains >20 members with at least some apparent complementary actions. PDI has oxidoreductase, isomerase, and chaperone effects, the last not directly dependent on its thiols. PDI is a converging hub for pathways of disulfide bond introduction into ER-processed proteins, via hydrogen peroxide-generating mechanisms involving the oxidase Ero1α, as well as hydrogen peroxide-consuming reactions involving peroxiredoxin IV and the novel peroxidases Gpx7/8. PDI is a candidate pathway for coupling ER stress to oxidant generation. Emerging information suggests a convergence between PDI and Nox family NADPH oxidases. PDI silencing prevents Nox responses to angiotensin II and inhibits Akt phosphorylation in vascular cells and parasite phagocytosis in macrophages. PDI overexpression spontaneously enhances Nox activation and expression. In neutrophils, PDI redox-dependently associates with p47phox and supports the respiratory burst. At the cell surface, PDI exerts transnitrosation, thiol reductase, and apparent isomerase activities toward targets including adhesion and matrix proteins and proteases. Such effects mediate redox-dependent adhesion, coagulation/thrombosis, immune functions, and virus internalization. The route of PDI externalization remains elusive. Such multiple redox effects of PDI may contribute to its conspicuous expression and functional role in disease, rendering PDI family members putative redox cell signaling adaptors.
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Affiliation(s)
- Francisco R M Laurindo
- Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo School of Medicine, 05403-000 São Paulo, Brazil.
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