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Park JY, Kim JH, Park CH, Kim SH, Kim IH, Cho WG. Polyhexamethylene guanidine phosphate induces pyroptosis via reactive oxygen species-regulated mitochondrial dysfunction in bronchial epithelial cells. Toxicology 2024; 505:153827. [PMID: 38729513 DOI: 10.1016/j.tox.2024.153827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/24/2024] [Accepted: 05/04/2024] [Indexed: 05/12/2024]
Abstract
Pyroptosis is a form of programmed cell death characterized by gasdermin (GSDM)-mediated pore formation in the cell membrane, resulting in the release of pro-inflammatory cytokines and cellular lysis. Increasing evidence has shown that pyroptosis is responsible for the progression of various pulmonary disorders. The inhalation of polyhexamethylene guanidine (PHMG) causes severe lung inflammation and pulmonary toxicity; however, the underlying mechanisms are unknown. Therefore, in this study, we investigate the role of pyroptosis in PHMG-induced pulmonary toxicity. We exposed bronchial epithelial cells, BEAS-2B, to PHMG phosphate (PHMG-p) and evaluated cell death type, reactive oxygen species (ROS) levels, and relative expression levels of pyroptosis-related proteins. Our data revealed that PHMG-p reduced viability and induced morphological alterations in BEAS-2B cells. Exposure to PHMG-p induced excessive accumulation of mitochondrial ROS (mtROS) in BEAS-2B cells. PHMG-p activated caspase-dependent apoptosis as well as NLRP3/caspase-1/GSDMD-mediated- and caspase-3/GSDME-mediated pyroptosis through mitochondrial oxidative stress in BEAS-2B cells. Notably, PHMG-p reduced mitochondrial respiratory function and induced the translocation of Bax and cleaved GSDM into the mitochondria, leading to mitochondrial dysfunction. Our results enhanced our understanding of PHMG-p-induced lung toxicity by demonstrating that PHMG-p induces pyroptosis via mtROS-induced mitochondrial dysfunction in bronchial epithelial cells.
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Affiliation(s)
- Jun Young Park
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Ji-Hee Kim
- Department of Occupational Therapy, Soonchunhyang University, 22 Soonchunhyang-ro, Asan-si 35138, Republic of Korea
| | - Chan Ho Park
- Department of Anatomy, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju-si, Gangwon-do 26426, Republic of Korea
| | - Sung-Hwan Kim
- Jeonbuk Branch Institute, Korea Institute of Toxicology, 56212, Republic of Korea
| | - In-Hyeon Kim
- Jeonbuk Branch Institute, Korea Institute of Toxicology, 56212, Republic of Korea
| | - Won Gil Cho
- Department of Anatomy, Yonsei University Wonju College of Medicine, 20, Ilsan-ro, Wonju-si, Gangwon-do 26426, Republic of Korea.
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Zhang J, Jiang X, Li X, Sun H, Wang M, Zhang W, Li H, Wang H, Zhuang M, Zhang L, Lu L, Tang J. Pulmonary Toxicity Assessment after a Single Intratracheal Inhalation of Chlorhexidine Aerosol in Mice. TOXICS 2023; 11:910. [PMID: 37999562 PMCID: PMC10675078 DOI: 10.3390/toxics11110910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023]
Abstract
Guanidine disinfectants are important chemical agents with a broad spectrum of activity that are effective against most microorganisms. Chlorhexidine, one of the most used guanidine disinfectants, is added to shampoo and mouthwash and applied in medical device sterilization. During the use of chlorhexidine, aerosols with micron particle size may be formed, which may cause inhalation toxicity. To assess the toxicity of inhaled chlorhexidine aerosol, mice underwent the intratracheal instillation of different concentrations of chlorhexidine (0, 0.125%, 0.25%, 0.5%, and 1%) using a MicroSprayer Aerosolizer. The mice were exposed for eight weeks and then sacrificed to obtain lung tissue for subsequent experiments. Histopathology staining revealed damaged lung tissues and increased collagen exudation. At the same time, pulmonary function tests showed that chlorhexidine exposure could cause restrictive ventilatory dysfunction, consistent with pulmonary fibrosis. The results of transcriptome analyses suggest that chlorhexidine may trigger an inflammatory response and promote the activation of pathways related to extracellular matrix deposition. Further, we identified that chlorhexidine exposure might enhance mucus secretion by up-regulating Muc5b and Muc5ac genes, thereby inducing fibrosis-like injury. These findings underscore the need for standardized use of disinfectants and the assessment of their inhalation toxicity.
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Affiliation(s)
- Jianzhong Zhang
- Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan 250001, China; (J.Z.); (X.J.); (L.Z.)
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Xinmin Jiang
- Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan 250001, China; (J.Z.); (X.J.); (L.Z.)
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Xin Li
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - He Sun
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Mingyue Wang
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Wanjun Zhang
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Haonan Li
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Hongmei Wang
- Department of Respiratory Medicine, Affiliated Hospital of Medical College of Qingdao University, Qingdao 266021, China; (H.W.); (M.Z.)
| | - Min Zhuang
- Department of Respiratory Medicine, Affiliated Hospital of Medical College of Qingdao University, Qingdao 266021, China; (H.W.); (M.Z.)
| | - Lin Zhang
- Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan 250001, China; (J.Z.); (X.J.); (L.Z.)
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Lin Lu
- Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan 250001, China; (J.Z.); (X.J.); (L.Z.)
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
| | - Jinglong Tang
- Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan 250001, China; (J.Z.); (X.J.); (L.Z.)
- Department of Environmental and Occupational Health, School of Public Health, Qingdao University, Qingdao 266071, China; (X.L.); (H.S.); (M.W.); (W.Z.); (H.L.)
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Krüger M. Remove, Refine, Reduce: Cell Death in Biological Systems. Int J Mol Sci 2023; 24:ijms24087028. [PMID: 37108191 PMCID: PMC10138335 DOI: 10.3390/ijms24087028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Cell death is an important biological phenomenon [...].
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Affiliation(s)
- Marcus Krüger
- Environmental Cell Biology Group, Department of Microgravity and Translational Regenerative Medicine, Otto von Guericke University, 39106 Magdeburg, Germany
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Yang HS, Yang M, Kang M, Kim B, Lee K. Inhalation toxicity of polyhexamethylene guanidine-phosphate in rats: A 4-week inhalation exposure and 24-week recovery period study. CHEMOSPHERE 2023; 312:137232. [PMID: 36379427 DOI: 10.1016/j.chemosphere.2022.137232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 06/16/2023]
Abstract
Humidifier disinfectant (HD) is a causative agent of atypical lung injury reported in 2011 in South Korea, and various diseases caused by HD after exposure cessation have been reported to date. However, there is limited research on most of the reported diseases in terms of their association with HD exposure, and information on the progression of diseases caused by HD exposure is also limited. Therefore, we investigated the effects of HD inhalation on the body in rats. Rats were exposed to 0.15, 0.50, and 1.60 mg/m3 polyhexamethylene guanidine-phosphate (PHMG-p), which is the major component of HDs and most closely related to HD-associated lung injury. We conducted necropsy four times during the recovery period (0, 4, 12, and 24 weeks) and evaluated general systemic toxicities. There were significant changes in the mortality rate, body weight, and food consumption in the PHMG-p-exposed groups. Hematology revealed changes in hemoglobin level, hematocrit, red blood cell, reticulocyte, and white blood cell counts until 12 weeks of the recovery period. PHMG-p induced a delay in prothrombin time until 12 weeks of the recovery period. The aspartate aminotransferase, alanine aminotransferase, total bilirubin, and triglyceride levels were higher in the PHMG-p-exposed groups than in the control group at week 4 of the recovery period, and these parameters normalized after 12 weeks of the recovery period. Histopathological examination in PHMG-p exposed groups revealed several changes in the lungs, including the presence of alveolar macrophages, chronic inflammation, squamous metaplasia, alveolar emphysema, and pulmonary fibrosis. The severity of these symptoms was maintained or exacerbated till 24 weeks. Overall, PHMG-p inhalation can induce irreversible histological changes in the lungs and cause various types of damage throughout the body, even after exposure ends.
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Affiliation(s)
- Hyo-Seon Yang
- Inhalation Toxicology Center for Airborne Risk Factors, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea; Biosafety Research Institute and Laboratory of Pathology, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Jeollabuk do, Republic of Korea.
| | - Mijin Yang
- Jeonbuk Pathology Research Group, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea.
| | - Mihyun Kang
- Inhalation Toxicology Center for Airborne Risk Factors, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea.
| | - Bumseok Kim
- Biosafety Research Institute and Laboratory of Pathology, College of Veterinary Medicine, Jeonbuk National University, Iksan-si, Jeollabuk do, Republic of Korea.
| | - Kyuhong Lee
- Inhalation Toxicology Center for Airborne Risk Factors, Korea Institute of Toxicology, Jeongeup, Jeollabuk-do 56212, Republic of Korea; Department of Human and Environmental Toxicology, University of Science and Technology, Daejeon 34113, Republic of Korea.
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Kim J, Baek YW, Kim C, Nam YJ, Lee YS, Lee H, Kang JY, Lee H, Choi JY, Park YH, Park SA, Park EK, Jeong SH, Lee JH. Evaluating the comparative MT1B, MT1F, MT1G, and MT1H expression in human pulmonary alveolar epithelial cells treated with polyhexamethylene guanidine-phosphate, chloromethylisothiazolinone/methylisothiazolinone, oligo(2-(2-ethoxy)ethoxyethyl guanidinium chloride, benzalkonium chloride, and sodium dichloroisocyanurate. Mol Cell Toxicol 2022. [DOI: 10.1007/s13273-022-00311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lee J, Choi SJ, Jeong JS, Kim SY, Lee SJ, Baek SK, Kwon N, Lee SH, Kim W, Cho JW, Koh EM, Lee K, Jeong EJ, Nam SY, Yu WJ. Adverse postnatal developmental effects in offspring from humidifier disinfectant biocide inhaled pregnant rats. CHEMOSPHERE 2022; 286:131636. [PMID: 34358894 DOI: 10.1016/j.chemosphere.2021.131636] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 06/13/2023]
Abstract
Inhalation exposure to polyhexamethylene guanidine phosphate (PHMG-P), one of the primary biocides used in humidifier disinfectants, caused a fatal pulmonary disease in Korea. Pregnant women were also exposed to PHMG-P, and subsequent studies showed that PHMG-P inhalation during pregnancy adversely affects their health and embryo-fetal development. However, the postnatal developmental effects after birth on prenatally PHMG-P-exposed offspring have not yet been investigated. Therefore, in this study, we aimed to examine the postnatal development of prenatally PHMG-P-exposed offspring. Pregnant rats (22 or 24 females per group) were exposed to PHMG-P during pregnancy in a whole-body inhalation chamber at the target concentrations of 0, 0.14, 1.60, and 3.20 mg/m3. After parturition, the prenatally exposed offspring were transferred to non-exposed surrogate mothers to minimize the secondary effects of severe maternal toxicities. Postnatal development of offspring was then examined with a modified extended one-generation reproductive toxicity study design. At 3.20 mg/m3 PHMG-P, increased perinatal death rates and decreased viability index (postnatal survival of offspring between birth and postnatal day 4) were observed. In addition, F1 offspring had lower body weight at birth that persisted throughout the study. PHMG-P-exposed pregnant rats also had severe systemic toxicities and increased gestation period. At 1.60 mg/m3 PHMG-P, a decreased viability index was also observed with systemic toxicities of PHMG-P-exposed pregnant rats. These results indicate that prenatal PHMG-P exposure adversely affects the offspring's future health and could be used for human risk assessment.
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Affiliation(s)
- Jinsoo Lee
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea; College of Veterinary Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Seong-Jin Choi
- Department of Chemical Assessment, Korea Environment Corporation, Incheon, Republic of Korea
| | - Ji-Seong Jeong
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang Yun Kim
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Seung-Jin Lee
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang-Ki Baek
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Nayun Kwon
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang-Hyub Lee
- Department of Chemical Assessment, Korea Environment Corporation, Incheon, Republic of Korea
| | - Woojin Kim
- Toxicologic Pathology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Jae-Woo Cho
- Toxicologic Pathology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Eun Mi Koh
- Bioanalytical and Immunoanalytical Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Kyuhong Lee
- Inhalation Toxicology Research Group, Korea Institute of Toxicology, Jeongeup, Republic of Korea; Department of Human and Environmental Toxicology, University of Science & Technology, Daejeon, Republic of Korea
| | - Eun Ju Jeong
- Chemical Risk Assessment Research Committee, Korea Institute of Toxicology, Daejeon, Republic of Korea
| | - Sang-Yoon Nam
- College of Veterinary Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Wook-Joon Yu
- Developmental and Reproductive Toxicology Research Group, Korea Institute of Toxicology, Daejeon, Republic of Korea.
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Choi S, Choi S, Choi Y, Cho N, Kim SY, Lee CH, Park HJ, Oh WK, Kim KK, Kim EM. Polyhexamethylene guanidine phosphate increases stress granule formation in human 3D lung organoids under respiratory syncytial virus infection. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2022; 229:113094. [PMID: 34942421 DOI: 10.1016/j.ecoenv.2021.113094] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
Polyhexamethylene guanidine phosphate (PHMG-p), a humidifier disinfectant, is known to cause lung toxicity, including inflammation and pulmonary fibrosis. In this study, we aimed to investigate the effect of PHMG-p on human lung tissue models (2D epithelial cells and 3D organoids) under conditions of oxidative stress and viral infection. The effect of PHMG-p was studied by evaluating the formation of stress granules (SGs), which play a pivotal role in cellular adaptation to various stress conditions. Under oxidative stress and respiratory syncytial virus (RSV) infection, exposure to PHMG-p remarkably increased eIF2α phosphorylation, which is essential for SG-related signalling, and significantly increased SG formation. Furthermore, PHMG-p induced fibrotic gene expression and caused cell death due to severe DNA damage, which was further increased under oxidative stress and RSV infection, indicating that PHMG-p induces severe lung toxicity under stress conditions. Taken together, toxicity evaluation under various stressful conditions is necessary to accurately predict potential lung toxicity of chemicals affecting the respiratory tract.
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Affiliation(s)
- Seri Choi
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea; Korea Bioactive Natural Material Bank, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul 08826, South Korea
| | - Sunkyung Choi
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Yeongsoo Choi
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Namjoon Cho
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Seung-Yeon Kim
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea; Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea
| | - Chang Hyun Lee
- Institute of Radiation Medicine, Seoul National University Hospital and College of Medicine, Seoul National University, Seoul 08826, South Korea; Department of Radiology, Seoul National University College of Medicine and Hospital, Seoul National University, Seoul 03080, South Korea
| | - Han-Jin Park
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea
| | - Won Keun Oh
- Korea Bioactive Natural Material Bank, Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul 08826, South Korea
| | - Kee K Kim
- Department of Biochemistry, Chungnam National University, Daejeon 34134, South Korea.
| | - Eun-Mi Kim
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea.
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Wu MH, Hui SC, Chen YS, Chiou HL, Lin CY, Lee CH, Hsieh YH. Norcantharidin combined with paclitaxel induces endoplasmic reticulum stress mediated apoptotic effect in prostate cancer cells by targeting SIRT7 expression. ENVIRONMENTAL TOXICOLOGY 2021; 36:2206-2216. [PMID: 34272796 DOI: 10.1002/tox.23334] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 06/13/2023]
Abstract
Prostate cancer (PCa), an extremely common malignancy in males, is the most prevalent disease in several countries. Norcantharidin (NCTD) has antiproliferation, antimetastasis, apoptosis, and autophagy effects in various tumor cells. Nevertheless, the antitumor effect of NCTD combined with paclitaxel (PTX), a chemotherapeutic drug, in PCa remains unknown. The cell growth, proliferative rate, cell cycle distribution, and cell death were determined by 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyltetrazolium bromide, colony formation assay, PI staining, and Annexin V/PI staining by flow cytomertry, whereas the mitochondrial membrane potential (MMP) and endoplasmic reticulum (ER) stress was evaluated using the MitoPotential assay and ER-ID red assay. We also evaluated the protein and mRNA expression of SIRTs by Western blotting and qRTPCR assay. Overexpression effectivity was measured by DNA transfection assay. Our study showed that cell viability and proliferative PC3 and DU145 rates were effectively inhibited after NCTD-PTX combination. We also found that NCTD-PTX combination treatment significantly enhance G2/M phase arrest, induction of cell death and ER stress, loss of MMP, and ER- or apoptotic-related protein expression. Furthermore, NCTD-PTX combination treatment was significantly decreasing the protein and mRNA expression of SIRT7 in PCa cells. Combination therapy effectively reduced cell viability, ER stress-mediated apoptosis and p-eIF2α/ATF4/CHOP/cleaved-PARP expression inhibition in SIRT7 overexpression of PCa cells. These results indicate that NCTD combined with PTX induces ER stress-mediated apoptosis of PCa cells by regulating the SIRT7 expression axis. Moreover, combination therapy may become a potential therapeutic strategy against human PCa.
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Affiliation(s)
- Min-Hua Wu
- Laboratory Department, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan
- Department of Medicinal Botanicals and Health Applications, Da-Yeh University, Chunghua, Taiwan
| | - Su-Chun Hui
- Laboratory Department, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan
| | - Yong-Syuan Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hui-Ling Chiou
- School of Medical Laboratory and Biotechnology, Chung Shan Medical University, Taichung, Taiwan
| | - Ching-Yi Lin
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chien-Hsing Lee
- Division of Pediatric Surgery, Department of Surgery, China Medical University Children's Hospital, Taichung, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Yi-Hsien Hsieh
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
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