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Lockett J, Inder WJ, Clifton VL. The Glucocorticoid Receptor: Isoforms, Functions, and Contribution to Glucocorticoid Sensitivity. Endocr Rev 2024; 45:593-624. [PMID: 38551091 PMCID: PMC11244253 DOI: 10.1210/endrev/bnae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Indexed: 07/13/2024]
Abstract
Glucocorticoids exert pleiotropic effects on all tissues to regulate cellular and metabolic homeostasis. Synthetic forms are used therapeutically in a wide range of conditions for their anti-inflammatory benefits, at the cost of dose and duration-dependent side effects. Significant variability occurs between tissues, disease states, and individuals with regard to both the beneficial and deleterious effects. The glucocorticoid receptor (GR) is the site of action for these hormones and a vast body of work has been conducted understanding its function. Traditionally, it was thought that the anti-inflammatory benefits of glucocorticoids were mediated by transrepression of pro-inflammatory transcription factors, while the adverse metabolic effects resulted from direct transactivation. This canonical understanding of the GR function has been brought into question over the past 2 decades with advances in the resolution of scientific techniques, and the discovery of multiple isoforms of the receptor present in most tissues. Here we review the structure and function of the GR, the nature of the receptor isoforms, and the contribution of the receptor to glucocorticoid sensitivity, or resistance in health and disease.
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Affiliation(s)
- Jack Lockett
- Mater Research Institute, The University of Queensland, Translational Research Institute, Woolloongabba, QLD 4101, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD 4006, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Metro South Health, Woolloongabba, QLD 4102, Australia
| | - Warrick J Inder
- Faculty of Medicine, The University of Queensland, Herston, QLD 4006, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Metro South Health, Woolloongabba, QLD 4102, Australia
| | - Vicki L Clifton
- Mater Research Institute, The University of Queensland, Translational Research Institute, Woolloongabba, QLD 4101, Australia
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2
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Prabakaran AD, Chung HJ, McFarland K, Govindarajan T, El Abdellaoui Soussi F, Durumutla HB, Villa C, Piczer K, Latimer H, Werbrich C, Akinborewa O, Horning R, Quattrocelli M. The human genetic variant rs6190 unveils Foxc1 and Arid5a as novel pro-metabolic targets of the glucocorticoid receptor in muscle. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.28.586997. [PMID: 38585940 PMCID: PMC10996618 DOI: 10.1101/2024.03.28.586997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Genetic variations in the glucocorticoid receptor (GR) gene NR3C1 can impact metabolism. The single nucleotide polymorphism (SNP) rs6190 (p.R23K) has been associated in humans with enhanced metabolic health, but the SNP mechanism of action remains completely unknown. We generated a transgenic knock-in mice genocopying this polymorphism to elucidate how the mutant GR impacts metabolism. Compared to non-mutant littermates, mutant mice showed increased muscle insulin sensitivity and strength on regular chow and high-fat diet, blunting the diet-induced adverse effects on weight gain and exercise intolerance. Overlay of RNA-seq and ChIP-seq profiling in skeletal muscle revealed increased transactivation of Foxc1 and Arid5A genes by the mutant GR. Using adeno-associated viruses for in vivo overexpression in muscle, we found that Foxc1 was sufficient to transcriptionally activate the insulin response pathway genes Insr and Irs1. In parallel, Arid5a was sufficient to transcriptionally repress the lipid uptake genes Cd36 and Fabp4, reducing muscle triacylglycerol accumulation. Collectively, our findings identify a muscle-autonomous epigenetic mechanism of action for the rs6190 SNP effect on metabolic homeostasis, while leveraging a human nuclear receptor coding variant to unveil Foxc1 and Arid5a as novel epigenetic regulators of muscle metabolism.
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Affiliation(s)
- Ashok Daniel Prabakaran
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hyun-Jy Chung
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kevin McFarland
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Thirupugal Govindarajan
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Fadoua El Abdellaoui Soussi
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hima Bindu Durumutla
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chiara Villa
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Stem Cell Laboratory, Department of Pathophysiology and Transplantation, Dino Ferrari Centre, University of Milan, Italy
| | - Kevin Piczer
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hannah Latimer
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Cole Werbrich
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olukunle Akinborewa
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Systems Biology and Physiology Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Robert Horning
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mattia Quattrocelli
- Molecular Cardiovascular Biology, Heart Institute, Cincinnati Children’s Hospital Medical Center and Dept. Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Zhu T, Li Y, Zhu L, Xu J, Feng Z, Chen H, Shi S, Liu C, Ou Q, Gao F, Zhang J, Jin C, Xu J, Li J, Zhang J, Bi Y, Xu GT, Wang J, Tian H, Lu L. GMFB/AKT/TGF-β3 in Müller cells mediated early retinal degeneration in a streptozotocin-induced rat diabetes model. Glia 2024; 72:504-528. [PMID: 37904673 DOI: 10.1002/glia.24486] [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: 01/16/2023] [Revised: 09/14/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023]
Abstract
Retinal degeneration, characterized by Müller cell gliosis and photoreceptor apoptosis, is considered an early event in diabetic retinopathy (DR). Our previous study proposed that GMFB may mediate diabetic retinal degeneration. This study identified GMFB as a sensitive and functional gliosis marker for DR. Compared to the wild type (WT) group, Gmfb knockout (KO) significantly improved visual function, attenuated gliosis, reduced the apoptosis of neurons, and decreased the mRNA levels of tumor necrosis factor α (Tnf-α) and interleukin-1β (Il-1β) in diabetic retinas. Tgf-β3 was enriched by hub genes using RNA sequencing in primary WT and KO Müller cells. Gmfb KO significantly upregulated the transforming growth factor (TGF)-β3 protein level via the AKT pathway. The protective effect of TGF-β3 in the vitreous resulted in significantly improved visual function and decreased the number of apoptotic cells in the diabetic retina. The protection of Gmfb KO in primary Müller cells against high glucose (HG)-induced photoreceptor apoptosis was partially counteracted by TGF-β3 antibody and administration of TGFBR1/2 inhibitors. Nuclear receptor subfamily 3 group C member 1 (NR3C1) binds to the promoter region of Gmfb and regulates Gmfb mRNA at the transcriptional level. NR3C1 was increased in the retinas of early diabetic rats but decreased in the retinas of late diabetic rats. N'-[(1E)-(3-Methoxyphenyl)Methylene]-3-Methyl-1H-Pyrazole-5-Carbohydrazide (DS-5) was identified as an inhibitor of GMFB, having a protective role in DR. We demonstrated that GMFB/AKT/TGF-β3 mediated early diabetic retinal degeneration in diabetic rats. This study provides a novel therapeutic strategy for treating retinal degeneration in patients with DR.
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Affiliation(s)
- Tong Zhu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Yingao Li
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Lilin Zhu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Jinyuan Xu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Zijun Feng
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Hao Chen
- Department of Ophthalmology of Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Si Shi
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Caiying Liu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Qingjian Ou
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Pharmacology, Tongji University School of Medicine, Shanghai, China
| | - Furong Gao
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Jieping Zhang
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Pharmacology, Tongji University School of Medicine, Shanghai, China
| | - Caixia Jin
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Jingying Xu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Jiao Li
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Jingfa Zhang
- Department of Ophthalmology of Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yanlong Bi
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
| | - Guo-Tong Xu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Pharmacology, Tongji University School of Medicine, Shanghai, China
| | - Juan Wang
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Human Genetics, Tongji University School of Medicine, Shanghai, China
| | - Haibin Tian
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
| | - Lixia Lu
- Department of Ophthalmology of Shanghai Tongji Hospital, Laboratory of Clinical Visual Science of Tongji Eye Institute, School of Medicine, Tongji University, Shanghai, China
- Department of Biochemistry and Molecular Biology, Tongji University School of Medicine, Shanghai, China
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4
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Gråberg T, Bergman EA, Strömmer L, Sjöholm LK, Wikström AC, Winqvist O, Winerdal M. Genetic variability in exon 1 of the glucocorticoid receptor gene NR3C1 is associated with postoperative complications. Mol Med Rep 2022; 25:198. [PMID: 35445734 PMCID: PMC9052000 DOI: 10.3892/mmr.2022.12714] [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: 05/11/2021] [Accepted: 12/31/2021] [Indexed: 11/06/2022] Open
Abstract
Patients undergoing major surgery experience postoperative inflammation, which may contribute to postoperative morbidity. Endogenous glucocorticoids (GCs) are an essential part of the stress response, but this response varies between individuals, which may in turn affect clinical outcome and specifically postoperative inflammation. Exon 1 of the NR3C1 gene, encoding the GC receptor (GR), contains an established region of differential regulation. DNA methylation patterns in this region have been found to differ between individuals. The present study investigated the methylation status and genotype in the cytosine‑phosphate‑guanine (CpG) island in exon 1 of NR3C1 in 24 patients [Median age 65.5 (range 42‑81) years, 11 male, 13 female] who underwent major abdominal (12 pancreatic, 12 hepatic) surgery and explored its association with postoperative complications. DNA was extracted from peripheral blood leukocytes and underwent targeted bisulfite sequencing of the CpG island. Complications were graded according to the Clavien‑Dindo classification and 14 out of 24 patients had postoperative complications. Multifactorial and partial least square analyses were used to analyse the data. A homogenous demethylated pattern was observed in all patients and no single CpG methylation was associated with postoperative complications. Four SNPs were significantly associated with higher Clavien‑Dindo scores. Genetic variability in the chromosome 5:143,402,505‑143,405,805 region of exon 1 of the GR gene NR3C1, but not DNA methylation, was associated with more severe postoperative complications in patients having major abdominal surgery. These results indicated that the patients' response to GCs may be of clinical importance for inflammatory conditions.
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Affiliation(s)
- Truls Gråberg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, 14186 Stockholm, Sweden
| | - Emma Ahlén Bergman
- Department of Medicine, Immunology and Allergy Unit, Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital Solna, 17176 Stockholm, Sweden
| | - Lovisa Strömmer
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Karolinska University Hospital Huddinge, 14186 Stockholm, Sweden
| | - Louise K Sjöholm
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital Solna, 17176 Stockholm, Sweden
| | - Ann-Charlotte Wikström
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Laboratory, Karolinska Institute, Karolinska University Hospital Huddinge, 14186 Stockholm, Sweden
| | | | - Max Winerdal
- Department of Medicine, Immunology and Allergy Unit, Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital Solna, 17176 Stockholm, Sweden
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5
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Bondos SE, Dunker AK, Uversky VN. Intrinsically disordered proteins play diverse roles in cell signaling. Cell Commun Signal 2022; 20:20. [PMID: 35177069 PMCID: PMC8851865 DOI: 10.1186/s12964-022-00821-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/11/2021] [Indexed: 11/29/2022] Open
Abstract
Signaling pathways allow cells to detect and respond to a wide variety of chemical (e.g. Ca2+ or chemokine proteins) and physical stimuli (e.g., sheer stress, light). Together, these pathways form an extensive communication network that regulates basic cell activities and coordinates the function of multiple cells or tissues. The process of cell signaling imposes many demands on the proteins that comprise these pathways, including the abilities to form active and inactive states, and to engage in multiple protein interactions. Furthermore, successful signaling often requires amplifying the signal, regulating or tuning the response to the signal, combining information sourced from multiple pathways, all while ensuring fidelity of the process. This sensitivity, adaptability, and tunability are possible, in part, due to the inclusion of intrinsically disordered regions in many proteins involved in cell signaling. The goal of this collection is to highlight the many roles of intrinsic disorder in cell signaling. Following an overview of resources that can be used to study intrinsically disordered proteins, this review highlights the critical role of intrinsically disordered proteins for signaling in widely diverse organisms (animals, plants, bacteria, fungi), in every category of cell signaling pathway (autocrine, juxtacrine, intracrine, paracrine, and endocrine) and at each stage (ligand, receptor, transducer, effector, terminator) in the cell signaling process. Thus, a cell signaling pathway cannot be fully described without understanding how intrinsically disordered protein regions contribute to its function. The ubiquitous presence of intrinsic disorder in different stages of diverse cell signaling pathways suggest that more mechanisms by which disorder modulates intra- and inter-cell signals remain to be discovered.
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Affiliation(s)
- Sarah E. Bondos
- Department of Molecular and Cellular Medicine, Texas A&M Health Science Center, College Station, TX 77843 USA
| | - A. Keith Dunker
- Center for Computational Biology and Bioinformatics, Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202 USA
| | - Vladimir N. Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer’s Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612 USA
- Institute for Biological Instrumentation of the Russian Academy of Sciences, Federal Research Center “Pushchino Scientific Center for Biological Research of the Russian Academy of Sciences”, Pushchino, Moscow Region, Russia 142290
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6
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Restrained expression of canine glucocorticoid receptor splice variants α and P prognosticates fatal disease outcome in SIRS. Sci Rep 2021; 11:24505. [PMID: 34969952 PMCID: PMC8718537 DOI: 10.1038/s41598-021-03451-0] [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: 06/18/2021] [Accepted: 11/22/2021] [Indexed: 11/24/2022] Open
Abstract
Glucocorticoids play a central role in the inflammatory response and alleviate the symptoms in critically ill patients. The glucocorticoid action relies on the glucocorticoid receptor (GR) which translocates into the nucleus upon ligand-binding and regulates transcription of a battery of genes. Although the GR is encoded by a single gene, dozens of its splice variants have been described in diverse species. The GRα isoform encodes the full, functionally active protein that is composed of a transactivation, a DNA-binding, and a C-terminal ligand-binding domain. The second most highly expressed receptor variant, the GR-P, is formed by an intron retention that introduces an early stop codon and results in a probably dysfunctional protein with truncated ligand-binding domain. We described the canine ortholog of GR-P and showed that this splice variant is highly abundant in the peripheral blood of dogs. The level of cGRα and cGR-P transcripts are elevated in patients of SIRS and the survival rate is increased with elevated cGRα and cGR-P expression. The ratio of cGRα and cGR-P mRNA did not differ between the survivor and non-survivor patients; thus, the total GR expression is more pertinent than the relative expression of GR isoforms in assessment of the disease outcome.
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Kerkvliet CP, Truong TH, Ostrander JH, Lange CA. Stress sensing within the breast tumor microenvironment: how glucocorticoid receptors live in the moment. Essays Biochem 2021; 65:971-983. [PMID: 34132331 PMCID: PMC8627466 DOI: 10.1042/ebc20200165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/18/2022]
Abstract
The classification and treatment of breast cancer is largely defined by the expression of steroid hormone receptors (HRs), namely estrogen receptor (ER) and progesterone receptor (PR), and gene amplification/overexpression of human epidermal growth factor receptor 2 (HER2). More recently, studies of androgen receptor (AR), glucocorticoid receptor (GR), and mineralocorticoid receptor (MR) have revealed that targeting these related HRs may be a promising strategy for a more personalized approach to the treatment of specific subtypes of HR+ breast cancer. For example, GR expression is associated with a good prognosis in ER+ breast cancer, but predicts poor prognosis in triple-negative breast cancer (TNBC). GR, like ER, PRs, and AR, is a ligand-activated transcription factor, but also has significant ligand-independent signaling activities. GR transcriptional activity is classically regulated by circulating glucocorticoids (GCs; ligand-dependent). Recent studies demonstrate that GR transcriptional activity is also regulated by a variety of cellular stress stimuli that input to GR Ser134 phosphorylation via rapid activation of the p38 mitogen activated protein kinase (MAPK) signaling pathway (ligand-independent). Furthermore, ligand-independent GR activation promotes feedforward signaling loops that mediate sustained activation of stress signaling pathways to drive advanced cancer biology (i.e. migration, invasion, chemoresistance, survival, and cellular growth). In this review, we will focus on the role of GR as a key sensor and mediator of physiologic and tumor microenvironment (TME)-derived cellular stress signaling in TNBC and discuss how targeting GR and/or associated signaling pathways may provide a strategy to inhibit deadly TNBC progression.
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Affiliation(s)
| | - Thu H. Truong
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, U.S.A
| | - Julie Hanson Ostrander
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, U.S.A
- Department of Medicine (Division of Hematology, Oncology, and Transplantation), University of Minnesota, Minneapolis, MN 55455, U.S.A
| | - Carol A. Lange
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, U.S.A
- Department of Medicine (Division of Hematology, Oncology, and Transplantation), University of Minnesota, Minneapolis, MN 55455, U.S.A
- Department of Pharmacology, University of Minnesota, Minneapolis, MN 55455, U.S.A
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Motavalli R, Majidi T, Pourlak T, Abediazar S, Shoja MM, Zununi Vahed S, Etemadi J. The clinical significance of the glucocorticoid receptors: Genetics and epigenetics. J Steroid Biochem Mol Biol 2021; 213:105952. [PMID: 34274458 DOI: 10.1016/j.jsbmb.2021.105952] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/04/2021] [Accepted: 07/11/2021] [Indexed: 12/14/2022]
Abstract
The impacts of glucocorticoids (GCs) are mainly mediated by a nuclear receptor (GR) existing in almost every tissue. The GR regulates a wide range of physiological functions, including inflammation, cell metabolism, and differentiation playing a major role in cellular responses to GCs and stress. Therefore, the dysregulation or disruption of GR can cause deficiencies in the adaptation to stress and the preservation of homeostasis. The number of GR polymorphisms associated with different diseases has been mounting per year. Tackling these clinical complications obliges a comprehensive understanding of the molecular network action of GCs at the level of the GR structure and its signaling pathways. Beyond genetic variation in the GR gene, epigenetic changes can enhance our understanding of causal factors involved in the development of diseases and identifying biomarkers. In this review, we highlight the relationships of GC receptor gene polymorphisms and epigenetics with different diseases.
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Affiliation(s)
- Roza Motavalli
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taraneh Majidi
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Tala Pourlak
- Department of Pathology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sima Abediazar
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammadali M Shoja
- Clinical Academy of Teaching and Learning, Ross University School of Medicine, Miramar, FL, USA
| | | | - Jalal Etemadi
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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9
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Martins CS, de Castro M. Generalized and tissue specific glucocorticoid resistance. Mol Cell Endocrinol 2021; 530:111277. [PMID: 33864884 DOI: 10.1016/j.mce.2021.111277] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022]
Abstract
Glucocorticoids (GCs) are steroid hormones that influence several physiologic functions and are among the most frequently prescribed drugs worldwide. Resistance to GCs has been observed in the context of the familial generalized GC resistance (Chrousos' syndrome) or tissue specific GC resistance in chronic inflammatory states. In this review, we have summarized the major factors that influence individual glucocorticoid sensitivity/resistance. The fine-tuning of GC action is determined in a tissue-specific fashion that includes the combination of different GC receptor promoters, translation initiation sites, splice isoforms, interacting proteins, post-translational modifications, and alternative mechanisms of signal transduction.
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Affiliation(s)
- Clarissa Silva Martins
- Department of Internal Medicine - Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, SP, Brazil; School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Margaret de Castro
- Department of Internal Medicine - Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, SP, Brazil.
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10
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Awasthi S, Wagner T, Venkatakrishnan AJ, Puranik A, Hurchik M, Agarwal V, Conrad I, Kirkup C, Arunachalam R, O'Horo J, Kremers W, Kashyap R, Morice W, Halamka J, Williams AW, Faubion WA, Badley AD, Gores GJ, Soundararajan V. Plasma IL-6 levels following corticosteroid therapy as an indicator of ICU length of stay in critically ill COVID-19 patients. Cell Death Discov 2021; 7:55. [PMID: 33723251 PMCID: PMC7958587 DOI: 10.1038/s41420-021-00429-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/14/2020] [Accepted: 12/04/2020] [Indexed: 12/13/2022] Open
Abstract
Intensive care unit (ICU) admissions and mortality in severe COVID-19 patients are driven by "cytokine storms" and acute respiratory distress syndrome (ARDS). Interim clinical trial results suggest that the corticosteroid dexamethasone displays better 28-day survival in severe COVID-19 patients requiring ventilation or oxygen. In this study, 10 out of 16 patients (62.5%) that had an average plasma IL-6 value over 10 pg/mL post administration of corticosteroids also had worse outcomes (i.e., ICU stay >15 days or death), compared to 8 out of 41 patients (19.5%) who did not receive corticosteroids (p-value = 0.0024). Given this potential association between post-corticosteroid IL-6 levels and COVID-19 severity, we hypothesized that the glucocorticoid receptor (GR or NR3C1) may be coupled to IL-6 expression in specific cell types that govern cytokine release syndrome (CRS). Examining single-cell RNA-seq data from BALF of severe COVID-19 patients and nearly 2 million cells from a pan-tissue scan shows that alveolar macrophages, smooth muscle cells, and endothelial cells co-express NR3C1 and IL-6, motivating future studies on the links between the regulation of NR3C1 function and IL-6 levels.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - William Morice
- Mayo Clinic, Rochester, MN, 55905, USA
- Mayo Clinic Laboratories, Rochester, MN, 55905, USA
| | - John Halamka
- Mayo Clinic, Rochester, MN, 55905, USA
- Mayo Clinic Platform, Rochester, MN, 55905, USA
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He YJ, Xu JQ, Sun MM, Fang XZ, Peng ZK, Pan SW, Zhou T, Wang YX, Shang Y. Glucocorticoid-Induced Leucine Zipper: A Promising Marker for Monitoring and Treating Sepsis. Front Immunol 2020; 11:606649. [PMID: 33424852 PMCID: PMC7793647 DOI: 10.3389/fimmu.2020.606649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/13/2020] [Indexed: 12/16/2022] Open
Abstract
Sepsis is a clinical syndrome that resulting from a dysregulated inflammatory response to infection that leads to organ dysfunction. The dysregulated inflammatory response transitions from a hyper-inflammatory phase to a hypo-inflammatory or immunosuppressive phase. Currently, no phase-specific molecular-based therapies are available for monitoring the complex immune response and treating sepsis due to individual variations in the timing and overlap of the dysregulated immune response in most patients. Glucocorticoid-induced leucine zipper (GILZ), is broadly present in multiple tissues and circumvent glucocorticoid resistance (GCR) or unwanted side effects. Recently, the characteristics of GILZ downregulation during acute hyperinflammation and GILZ upregulation during the immunosuppressive phase in various inflammatory diseases have been well documented, and the protective effects of GILZ have gained attention in the field of sepsis. However, whether GILZ could be a promising candidate biomarker for monitoring and treating septic patients remains unknown. Here, we discuss the effect of GILZ in sepsis and sepsis-induced immunosuppression.
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Affiliation(s)
- Ya-Jun He
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ji-Qian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Miao-Miao Sun
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiang-Zhi Fang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhe-Kang Peng
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shang-Wen Pan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Zhou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ya-Xin Wang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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12
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Cazzola M, Rogliani P, Calzetta L, Matera MG. Pharmacogenomic Response of Inhaled Corticosteroids for the Treatment of Asthma: Considerations for Therapy. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:261-271. [PMID: 32801837 PMCID: PMC7414974 DOI: 10.2147/pgpm.s231471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/27/2020] [Indexed: 12/14/2022]
Abstract
There is a large interindividual variability in response to ICSs in asthma. About 70% of the variance in ICS response is likely due at least partially to genetically determined characteristics of target genes. In this article, we examine the effects on the ICS response of gene variations in the corticosteroid pathway, and in the pharmacokinetics of corticosteroids, and also those outside the corticosteroid pathway, which have the potential to influence corticosteroid activity. Although the available evidence indicates that responses to ICSs in asthma are influenced by different genetic variants, there are still deep uncertainties as to whether a real association between these genetic variants and corticosteroid response could also possibly exist because there are difficulties in reproducing pharmacogenetic findings. This explains at least partly the insufficient use of pharmacogenomic data when treating asthmatic patients, which creates a real limitation to the proper use of ICSs in an era of precision medicine that links the right patient to the right treatment. Knowing and dealing with the genetic factors that influence the therapeutic ICS response is a fundamental condition for prescribing the right dose of ICS to the right patient at the right time.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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13
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The Glucocorticoid Receptor NR3C1 in Testicular Peritubular Cells is Developmentally Regulated and Linked to the Smooth Muscle-Like Cellular Phenotype. J Clin Med 2020; 9:jcm9040961. [PMID: 32244354 PMCID: PMC7230580 DOI: 10.3390/jcm9040961] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/24/2020] [Accepted: 03/27/2020] [Indexed: 12/16/2022] Open
Abstract
Whether glucocorticoids (GC) can directly affect human testicular functions is not well understood. A predominant site of GC receptor (GR; NR3C1) expression in the adult testis are peritubular smooth muscle-like cells, which express smooth muscle actin (ACTA2), contract and thereby are involved in sperm transport. In contrast to the adult, neither GR nor ACTA2, or elastin (ELN) were detected in the peritubular compartment before puberty in non-human primate testes. In isolated human testicular peritubular cells (HTPCs), activation of GR by dexamethasone (Dex) caused the translocation of GR to the nucleus and stimulated expression of ACTA2 and ELN, without affecting the expression of collagens. Cytoskeletal ACTA2-rearrangements were observed and were associated with an increased ability to contract. Our results indicate post-pubertal testicular roles of GC in the maintenance of the contractile, smooth muscle-like phenotype of peritubular cells.
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14
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González Ramírez C, Villavicencio Queijeiro A, Jiménez Morales S, Bárcenas López D, Hidalgo Miranda A, Ruiz Chow A, Tellez Cárdenas L, Guardado Estrada M. The NR3C1 gene expression is a potential surrogate biomarker for risk and diagnosis of posttraumatic stress disorder. Psychiatry Res 2020; 284:112797. [PMID: 31982660 DOI: 10.1016/j.psychres.2020.112797] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/07/2020] [Accepted: 01/16/2020] [Indexed: 12/19/2022]
Abstract
Posttraumatic Stress Disorder (PTSD) is an anxiety disorder which occurs after a traumatic event. The NR3C1 gene codes for the Glucocorticoid Receptor, which participate in the Hypothalamic-Pituitary-Adrenal (HPA) axis and is altered in PTSD patients. To evaluate whether the NR3C1 gene expression in peripheral blood could be useful as a diagnosis biomarker, a total of 32 PTSD patients and 59 healthy controls were analyzed with quantitative RT-PCR. Also, to assess if NR3C1 dysregulation is associated with hypocortisolism in PTSD patients, serum cortisol was quantified by ELISA in a subset of these samples. Significant NR3C1 over-expression was found in PTSD patients compared with controls, and this was higher in patients with acute PTSD. The Area Under the Curve (AUC) of NR3C1 gene expression was 0.797. The sensibility and specificity of NRC1 gene expression to diagnose PTSD was 62.5% and 89.8%, respectively. We also found that an up-regulation of NR3C1 increased the risk for being diagnosed with PTSD (OR= 12.8, 95%, CI 4-41.4). Finally, the NR3C1 gene expression was inversely related with serum cortisol in PTSD patients. The present results suggest that NR3C1 gene expression could be a promising biomarker for PTSD diagnosis and estimate the risk for disease development.
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Affiliation(s)
- Claudia González Ramírez
- Laboratorio de Genética de la Licenciatura en Ciencia Forense, Facultad de Medicina, Universidad Nacional Autónoma de México, México
| | - Alexa Villavicencio Queijeiro
- Laboratorio de Genética de la Licenciatura en Ciencia Forense, Facultad de Medicina, Universidad Nacional Autónoma de México, México
| | | | - Diego Bárcenas López
- Laboratorio Genómica del Cáncer, Instituto Nacional de Medicina Genómica, Mexico
| | | | - Angel Ruiz Chow
- Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez", Mexico
| | | | - Mariano Guardado Estrada
- Laboratorio de Genética de la Licenciatura en Ciencia Forense, Facultad de Medicina, Universidad Nacional Autónoma de México, México.
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15
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Kraemer WJ, Ratamess NA, Hymer WC, Nindl BC, Fragala MS. Growth Hormone(s), Testosterone, Insulin-Like Growth Factors, and Cortisol: Roles and Integration for Cellular Development and Growth With Exercise. Front Endocrinol (Lausanne) 2020; 11:33. [PMID: 32158429 PMCID: PMC7052063 DOI: 10.3389/fendo.2020.00033] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/16/2020] [Indexed: 12/16/2022] Open
Abstract
Hormones are largely responsible for the integrated communication of several physiological systems responsible for modulating cellular growth and development. Although the specific hormonal influence must be considered within the context of the entire endocrine system and its relationship with other physiological systems, three key hormones are considered the "anabolic giants" in cellular growth and repair: testosterone, the growth hormone superfamily, and the insulin-like growth factor (IGF) superfamily. In addition to these anabolic hormones, glucocorticoids, mainly cortisol must also be considered because of their profound opposing influence on human skeletal muscle anabolism in many instances. This review presents emerging research on: (1) Testosterone signaling pathways, responses, and adaptations to resistance training; (2) Growth hormone: presents new complexity with exercise stress; (3) Current perspectives on IGF-I and physiological adaptations and complexity these hormones as related to training; and (4) Glucocorticoid roles in integrated communication for anabolic/catabolic signaling. Specifically, the review describes (1) Testosterone as the primary anabolic hormone, with an anabolic influence largely dictated primarily by genomic and possible non-genomic signaling, satellite cell activation, interaction with other anabolic signaling pathways, upregulation or downregulation of the androgen receptor, and potential roles in co-activators and transcriptional activity; (2) Differential influences of growth hormones depending on the "type" of the hormone being assayed and the magnitude of the physiological stress; (3) The exquisite regulation of IGF-1 by a family of binding proteins (IGFBPs 1-6), which can either stimulate or inhibit biological action depending on binding; and (4) Circadian patterning and newly discovered variants of glucocorticoid isoforms largely dictating glucocorticoid sensitivity and catabolic, muscle sparing, or pathological influence. The downstream integrated anabolic and catabolic mechanisms of these hormones not only affect the ability of skeletal muscle to generate force; they also have implications for pharmaceutical treatments, aging, and prevalent chronic conditions such as metabolic syndrome, insulin resistance, and hypertension. Thus, advances in our understanding of hormones that impact anabolic: catabolic processes have relevance for athletes and the general population, alike.
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Affiliation(s)
- William J. Kraemer
- Department of Human Sciences, The Ohio State University, Columbus, OH, United States
- *Correspondence: William J. Kraemer
| | - Nicholas A. Ratamess
- Department of Health and Exercise Science, The College of New Jersey, Ewing, NJ, United States
| | - Wesley C. Hymer
- Biochemistry and Molecular Biology, The Pennsylvania State University, University Park, PA, United States
| | - Bradley C. Nindl
- Department of Sports Medicine, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, United States
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16
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Flynn JK, Dankers W, Morand EF. Could GILZ Be the Answer to Glucocorticoid Toxicity in Lupus? Front Immunol 2019; 10:1684. [PMID: 31379872 PMCID: PMC6652235 DOI: 10.3389/fimmu.2019.01684] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022] Open
Abstract
Glucocorticoids (GC) are used globally to treat autoimmune and inflammatory disorders. Their anti-inflammatory actions are mainly mediated via binding to the glucocorticoid receptor (GR), creating a GC/GR complex, which acts in both the cytoplasm and nucleus to regulate the transcription of a host of target genes. As a result, signaling pathways such as NF-κB and AP-1 are inhibited, and cell activation, differentiation and survival and cytokine and chemokine production are suppressed. However, the gene regulation by GC can also cause severe side effects in patients. Systemic lupus erythematosus (SLE or lupus) is a multisystem autoimmune disease, characterized by a poorly regulated immune response leading to chronic inflammation and dysfunction of multiple organs, for which GC is the major current therapy. Long-term GC use, however, can cause debilitating adverse consequences for patients including diabetes, cardiovascular disease and osteoporosis and contributes to irreversible organ damage. To date, there is no alternative treatment which can replicate the rapid effects of GC across multiple immune cell functions, effecting disease control during disease flares. Research efforts have focused on finding alternatives to GC, which display similar immunoregulatory actions, without the devastating adverse metabolic effects. One potential candidate is the glucocorticoid-induced leucine zipper (GILZ). GILZ is induced by low concentrations of GC and is shown to mimic the action of GC in several inflammatory processes, reducing immunity and inflammation in in vitro and in vivo studies. Additionally, GILZ has, similar to the GC-GR complex, the ability to bind to both NF-κB and AP-1 as well as DNA directly, to regulate immune cell function, while potentially lacking the GC-related side effects. Importantly, in SLE patients GILZ is under-expressed and correlates negatively with disease activity, suggesting an important regulatory role of GILZ in SLE. Here we provide an overview of the actions and use of GC in lupus, and discuss whether the regulatory mechanisms of GILZ could lead to the development of a novel therapeutic for lupus. Increased understanding of the mechanisms of action of GILZ, and its ability to regulate immune events leading to lupus disease activity has important clinical implications for the development of safer anti-inflammatory therapies.
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Affiliation(s)
- Jacqueline K Flynn
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Wendy Dankers
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
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