Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Influence of grapefruit juice on the pharmacokinetics of diltiazem in Wistar rats upon single and multiple dosage regimens

Drug efflux by intestinal P-glycoprotein (P-gp) is recognized as a significant biochemical barrier affecting oral absorption for a number of drugs apart from the cytochrome P450 3A enzyme. Various conflicting reports have been published regarding the effects of grapefruit juice (GFJ) on P-gp mediated drug efflux, in which GFJ has been shown to have no effect, as an inhibitor effect or activation of the enzyme. Therefore the present study's objective was to provide clarification of previous findings, adopting a two-way approach, involving both single dose and multiple dosage regimens. Diltiazem (DTZ) 15 mg/kg was administered concomitantly with 5 ml/kg of GFJ to one group (n = 6) of male Wistar rats and another group (n = 6) of animals were provided distilled water with DTZ (the control). A third group of rats was administered GFJ orally for six days and on seventh day GFJ and DTZ were administered concomitantly. The Cmax and AUC of DTZ were decreased significantly in the presence of multiple dose treatment of GFJ. These data were also decreased in presence of simultaneous treatment of single dose GFJ. In vitro metabolism studies and gut sac experiments were conducted in order to understand the mechanism involved. In the liver S9 fraction prepared from the rats treated with multiple doses of GFJ, DTZ metabolism was significantly increased compared to the control. Furthermore, the amount of drug transported from the duodenum was reduced in GFJ treated rats compared to that of the control (1581.0 +/- 7.8 nM vs 1084.81 +/- 6.1 nM, respectively). Grapefruit juice was also reported to inhibit the organic anion transporting polypeptide (OATP), an influx transporter thus reducing the blood levels of OATP substrates which was evident from the in vitro studies. The amount of drug transported from the duodenum was reduced in the presence of pravastatin, a specific OATP inhibitor (1581.0 +/- 7.8 nM to 1265.0 +/- 5.5 nM). Oral single dose exposure to GFJ showed no effect on P-gp, whereas multiple dose administration of GFJ resulted in increased levels of P-gp expression and decreased levels of OATP, thus showing a varied effect on intestinal absorption, and therefore overcoming the inhibition of DTZ metabolism in rats.

Effect of pentoxifylline on the pharmacokinetics of rosiglitazone in Wistar rats

The aim of this study was to investigate the effect of pentoxifylline (PTX), an antiplatelet agent, on the pharmacokinetics of rosiglitazone (RSG) in rats. Pharmacokinetic parameters of RSG were determined in rats after oral administration (3 mg/kg/day) in the presence and absence of PTX (10 mg/kg) 3 times daily. Compared to control animals, rats pretreated with PTX for 7 days had a decrease in RSG peak plasma concentration (Cmax) of 19% with no change in the values of the area under the concentration-time curve (AUC). Alternatively, rats coadministered single-dose PTX did not show any differences from control with regard to RSG Cmax and AUC parameters. The time to peak concentration (tmax) of RSG was significantly increased in rats pretreated with PTX under both single- and multiple-dose conditions, whereas the elimination half-life (t1/2) of RSG was increased only with multiple-dose PTX pretreatment. In conclusion, the presence of PTX was found to cause a slight decrease in the oral exposure of RSG in rats. Concurrent use of PTX with RSG therefore needs to be appropriately evaluated for proper dose adjustments in humans.

Genetics of pulmonary fibrosis

Identifying genetic determinants of pulmonary fibrosis is at an early stage of evolution. It is now well recognized that "pulmonary fibrosis" covers a broad range of lung diseases including most topically the idiopathic interstitial pneumonias that have been classified recently. Additionally, it is recognized that the diffuse lung diseases of children that may progress to fibrosis are quite different from those of adults. Defining clinical phenotype is an absolute prerequisite to precise identification of genetic determinants, and this is at least part of the reason why we understand relatively little of these genetic determinants to date. In children, a number of mutations have been identified, particularly with regard to surfactant protein. In adults, families with idiopathic pulmonary fibrosis are being collected but there are no genetic data on these at this point. In sporadic disease, associations have been reported in early phase genes with disease predisposition and also, importantly, with disease severity: future studies will inevitably incorporate issues of severity of disease in analyses.

Mapping of the immunodominant T cell epitopes of the protein topoisomerase I

OBJECTIVES

To identify the immunodominant T cell epitopes of the topoisomerase I protein in patients with systemic sclerosis (SSc) and control subjects, using computational analysis software (TEPITOPE) and T cell proliferation assays.

METHODS

Six oligopeptides, predicted by TEPITOPE software as potential topoisomerase protein epitopes, were used to perform T cell proliferation assays in 21 patients with SSc and 15 healthy controls.

RESULTS

A positive response to at least one of the peptides was seen in 10/21 patients and 7/15 healthy controls. Among responders, the proliferative response was limited to a single peptide in 6/7 healthy controls, whereas 5/10 patients responded to more than one peptide. In responding patients a significant correlation was found between disease duration and number of peptides inducing a response (p = 0.007).

CONCLUSIONS

Several T cell epitopes of the topoisomerase I protein have been identified and evidence has been found to suggest epitope spreading in patients with SSc.

Inhibitor kappa B-alpha (IkappaB-alpha) promoter polymorphisms in UK and Dutch sarcoidosis

The aetiology of sarcoidosis is uncertain; current thinking implicates exposure of genetically susceptible hosts to environmental factors. The nuclear factor kappa B (NF-kappaB) family of transcription factors are critical regulators of immediate transcriptional responses in inflammatory situations and immune responses. Inhibitor kappa B-alpha (IkappaB-alpha) inhibits NF-kappaB and plays a major role in controlling its activity. We investigated IkappaB-alpha promoter polymorphisms using sequence-specific primer-polymerase chain reaction, at positions -881 (A/G), -826 (C/T), and -297 (C/T) in Caucasian sarcoidosis patients (UK and Dutch [NL]), each with their own controls. Disease severity at presentation was assigned using chest radiography and pulmonary function indices. In the combined populations, the -297T allele carriage was more prevalent in patients than in controls (P=0.008). Three common haplotypes were found, of which haplotype 2 (GTT) was significantly associated with sarcoidosis in comparison with control subjects (P=0.01). Subgroup analysis revealed that the -826T allelic carriage was most prevalent in stage II disease, and more prevalent in stage III than in stage IV (P=0.01). The -826T allelic carriage did not show any association with lung function. These results indicate that the NF-kappaB activation pathway might be associated with the inflammation of sarcoidosis.

BAL findings in idiopathic nonspecific interstitial pneumonia and usual interstitial pneumonia

Idiopathic pulmonary fibrosis (IPF), which has the histological pattern of usual interstitial pneumonia (UIP), is a progressive interstitial lung disease with a poor prognosis. Idiopathic interstitial pneumonias with a histological pattern of nonspecific interstitial pneumonia (NSIP) have a better prognosis than UIP, and may present with a clinical picture identical to IPF. The authors hypothesised that bronchoalveolar lavage (BAL) findings may distinguish between UIP and NSIP, and have prognostic value within disease subgroups. BAL findings were studied retrospectively in 54 patients with histologically proven (surgical biopsy) idiopathic UIP (n=35) or fibrotic NSIP (n=19), all presenting clinically as IPF. These findings were also compared with the BAL profile of patients with other categories of idiopathic interstitial pneumonias. BAL total and differential cell counts did not differ between the two groups. Survival was better in NSIP. In neither group were BAL findings predictive of survival or changes in lung function at 1 yr, even after adjustment for disease severity, smoking and treatment. BAL differential counts in fibrotic NSIP differed from respiratory bronchiolitis-associated interstitial lung disease, but not from desquamative interstitial pneumonia or cellular NSIP. The authors conclude that bronchoalveolar lavage findings do not discriminate between usual interstitial pneumonia and nonspecific interstitial pneumonia in patients presenting with clinical features of idiopathic pulmonary fibrosis, and have no prognostic value, once the distinction between the two has been made histologically.

Lung fibrosis: new classifications and therapy

The recent American Thoracic Society/European Respiratory Society consensus classification of idiopathic interstitial pneumonia is equally applicable to pulmonary fibrosis associated with connective tissue disease. The most frequent histopathologic entities are usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP), which is more prevalent than UIP in systemic sclerosis. The prognostic significance of NSIP is unknown in connective tissue disease, although NSIP has a better prognosis than UIP in idiopathic interstitial pneumonia. The use of computed tomography to distinguish between UIP and NSIP requires further refinement. Recent therapeutic studies have reinforced disenchantment amongst clinicians with corticosteroid and immunosuppressive regimens in UIP. UIP is increasingly regarded an "epithelial-fibrotic" disease rather than a primarily inflammatory disorder, accounting for recent widespread interest in antifibrotic agents. This conclusion should not be extrapolated to NSIP, especially in connective tissue disease. Strong circumstantial evidence of a therapeutic benefit justifies the continued use of cyclophosphamide in progressive lung fibrosis in systemic sclerosis.

Ace gene I/D polymorphism and sarcoidosis pulmonary disease severity

Previous studies of the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene in sarcoidosis have revealed both ethnic heterogeneity of I/D frequencies and controversy surrounding the association between the polymorphism and severity of disease. The objective of this study was, therefore, to clarify the role of the ACE I/D polymorphism in (1) disease susceptibility, (2) pulmonary disease severity (with particular reference to pulmonary fibrosis), and (3) pulmonary disease progression, in two distinct European sarcoidosis populations. Standard chest radiographic staging was performed on 118 UK and 56 Czech white patients with sarcoidosis at 2 yr from presentation. Pulmonary function data were analyzed, and patients were then categorized according to disease severity. A PCR-SSP assay was used to determine the ACE I/D genotype of each patient studied. The I/D allele frequencies from these patients were compared with frequencies from ethnically matched UK (n = 386) and Czech (n = 179) control subjects using a chi-square contingency table. No significant differences were seen in the distribution of the ACE I/D genotypes, allele frequencies or phenotype frequencies. Furthermore, no association was found between the ACE I/D polymorphism and pulmonary disease severity, fibrosis, and progression. We conclude that the ACE I/D polymorphism has no role in sarcoidosis susceptibility in European whites and that it is not a regulatory variant in this disease.

Integrin alpha(3)-subunit expression modulates alveolar epithelial cell monolayer formation

We investigated expression of the alpha(3)-integrin subunit by rat alveolar epithelial cells (AECs) grown in primary culture as well as the effects of monoclonal antibodies with blocking activity against the alpha(3)-integrin subunit on AEC monolayer formation. alpha(3)-Integrin subunit mRNA and protein were detectable in AECs on day 1 and increased with time in culture. alpha(3)- and beta(1)-integrin subunits coprecipitated in immunoprecipitation experiments with alpha(3)- and beta(1)-subunit-specific antibodies, consistent with their association as the alpha(3)beta(1)-integrin receptor at the cell membrane. Treatment with blocking anti-alpha(3) monoclonal antibody from day 0 delayed development of transepithelial resistance, reduced transepithelial resistance through day 5 compared with that in untreated AECs, and resulted in large subconfluent patches in monolayers viewed by scanning electron microscopy on day 3. These data indicate that alpha(3)- and beta(1)-integrin subunits are expressed in AEC monolayers where they form the heterodimeric alpha(3)beta(1)-integrin receptor at the cell membrane. Blockade of the alpha(3)-integrin subunit inhibits formation of confluent AEC monolayers. We conclude that the alpha(3)-integrin subunit modulates formation of AEC monolayers by virtue of the key role of the alpha(3)beta(1)-integrin receptor in AEC adhesion.

Structural correlates for enhanced stability in the E2 DNA-binding domain from bovine papillomavirus

Papillomaviral E2 proteins participate in viral DNA replication and transcriptional regulation. We have solved the solution structure of the DNA-binding domain of the E2 protein from bovine papillomavirus (BPV-1). The structure calculation used 2222 distance and 158 dihedral angle restraints for the homodimer (202 residues in total), which were derived from homonuclear and heteronuclear multidimensional nuclear magnetic resonance (NMR) spectroscopic data. The root-mean-square deviation for structured regions of the monomer when superimposed to the average is 0.73 +/- 0.10 A for backbone atoms and 1.42 +/- 0.16 A for heavy atoms. The 101 residue construct used in this study (residues 310-410) is about 4.5 kcal/mol more stable than a minimal domain comprising the C-terminal 85 amino acid residues (residues 326-410). The structure of the core domain contained within BPV-1 E2 is similar to the corresponding regions of other papilloma viral E2 proteins. Here, however, the extra N-terminal 16 residues form a flap that covers a cavity at the dimer interface and play a role in DNA binding. Interactions between residues in the N-terminal extension and the core domain correlate with the greater stability of the longer form of the protein relative to the minimal domain.

Lung transplantation for cystic fibrosis: an update and practical considerations for referring candidates

In this article, the authors provide an update to Maurer and Chaparro's 1995 review in this journal of lung transplantation for cystic fibrosis. Bilateral (sequential) cadaver donor transplantation is the usual procedure of choice. The four-year survival rate for adult, all-disease, double-bilateral lung transplantation has improved to 53%. Because of lower [corrected] survival rate among adults, living-donor lobar transplantation should be performed only when cadaver lungs are unlikely to become available. The International Society for Heart and Lung Transplantation and the Cystic Fibrosis Foundation have promulgated uniform guidelines for transplantation candidate selection. Issues of diabetes mellitus, mechanical ventilation, osteoporosis, malnutrition, fungi and drug-resistant bacteria, pleural fibrosis, and sinusitis in relation to transplantation candidacy are discussed. Some practical points regarding transplantation center referral are presented, and a list of cystic fibrosis transplantation centers in the United States is supplied.

Pulmonary veno-occlusive disease

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension that mainly affects children and young adults. Its cause is unknown, although viral infections and drugs have been implicated. Patients with PVOD present with symptoms of right-sided heart failure. Radiologic examination shows prominent pulmonary arteries with Kerley B lines, pleural effusion, and mediastinal adenopathy. The definite diagnosis is made by histologic examination. Eccentric intimal fibrosis and recanalized thrombi in pulmonary veins and venules, arterialized veins, alveolar edema, and medial hypertrophy of arteries are seen on lung biopsy. No effective treatment is available; lung transplantation has been tried. The prognosis associated with PVOD is poor.

Constrictive (obliterative) bronchiolitis: diagnosis, etiology, and a critical review of the literature

Constrictive bronchiolitis (CB) (or obliterative bronchiolitis) designates inflammation and fibrosis occurring predominantly in the walls and contiguous tissues of membranous and respiratory bronchioles, with resultant narrowing of their lumens. It differs from bronchiolitis obliterans-organizing pneumonia in its histopathology and clinical course. Most cases of CB occur in the setting of organ transplants, particularly lung and heart-lung transplants, but also in bone marrow transplants. Other bona fide cases are rare: infection, particularly viral infection, appears to be a well-documented precursor to CB in children, but not in immunocompetent adults. Constrictive bronchiolitis also has been reported in the course of rheumatoid arthritis, in certain other autoimmune diseases such as pemphigus vulgaris, after inhalation of toxic gases such as nitrogen oxide, after ingestion of certain drugs or medicinal agents such as Sauropus androgynous, and as a cryptogenic illness. Recent reports suggest that CB, as defined by clinical criteria (that is, bronchiolitis obliterans syndrome), is very common in lung allograft recipients who survive more than 5 years and, although it is associated with significant mortality, it also can be clinically stable. Furthermore, with the current practice of close monitoring of these patients, it appears that CB may now be diagnosed at an earlier stage, at which resolution, or at least stabilization of progression, is possible. A histopathologic diagnosis of CB in lung transplant and other patients may be difficult to make due to the patchy distribution of lesions, the technical difficulty in obtaining tissue in late lesions with extensive fibrosis, and the failure to recognize lesions. With regard to the last of these, in early stages of disease, CB may be subtle and easily missed in routine hematoxylin-eosin-stained specimens, while in advanced stages the disease may be equally difficult to diagnose if the patchy scarring in the lung is interpreted as nonspecific. The relative loss of bronchioles and the relationship of the scars to contiguous arteries should signal the need for elastic stains to look for the residual elastica of the bronchioles amidst the foci of fibrosis. Increasingly, clinical grounds, including pulmonary functions studies and high-resolution computed tomography findings, are proving to be relatively sensitive methods of detecting CB. Finally, the progressive airway destruction in chronic transplantation rejection appears to be a T-cell-mediated process. The "active" form of constrictive bronchiolitis, with attendant lymphocytic inflammation of the airways, likely precedes the "inactive" or scarred form of constrictive bronchiolitis.

Constrictive (obliterative) bronchiolitis

Constrictive bronchiolitis (CB), also termed in lung transplant patients obliterative bronchiolitis, is inflammation and fibrosis occurring predominantly in the walls and contiguous tissues of membranous and respiratory bronchioles with resultant narrowing of their lumens. CB is found in a variety of settings, most often as a complication of lung and heart-lung transplantation (affecting 34% to 39% of patients, usually in the first 2 years after transplantation) and bone marrow transplantation, but also in rheumatoid arthritis, after inhalation of toxic agents such as nitrogen dioxide, after ingestion of certain drugs such as penicillamine and ingestion of the East Asian vegetable Sauropus androgynous, and as a rare complication of adenovirus, influenza type A, measles, and Mycoplasma pneumoniae infections in children. In lung transplants, CB is the single most important factor leading to death thereafter. In one study, the overall mortality rate was 25%. However, at the same time, 87% of patients who were asymptomatic and diagnosed solely by transbronchial biopsy had resolution or stabilization of disease. Decreases in FEV1 from baseline can be used to clinically support CB in transplant patients; the term bronchiolitis obliterans syndrome is used to denote this clinical dysfunction, and a grading system has been established for it that is now widely used in the literature. Significant risk factors for the development of CB in lung transplants include alloantigen-dependent and -independent mechanisms. In the former group are late acute rejection and HLA mismatches at the A loci; in the latter are ischemia/reperfusion injuries to airways that result from the transplantation surgery and cytomegalovirus infection.

Progressive systemic sclerosis and the lung

Pulmonary manifestations of systemic sclerosis (scleroderma) are many. The mean survival in these patients is 78 +/- 17 months. Improved diagnostic techniques and better therapeutic options are essential to stem the tide of overwhelming mortality in patients with scleroderma lung disease.

Structure and topography of the membrane-binding C2 domain of factor VIII in the presence of dodecylphosphocholine micelles

A 21 residue peptide from the C2 domain of the antihaemophilic factor VIII competes with factor VIII for membrane-binding sites in vitro. Here, we provide the structure and topography of the peptide in solution, on dodecylphosphocholine (DPC) micelles, determined using 1H-NMR spectroscopy. The peptide assumes an amphipathic structure comprising an extended N-terminal region and a C-terminal helix. The average root-mean-square deviation is 0.7+/-0.2 A for the superimposition of the backbone atoms of Ile6 to Arg18 on the lowest energy structure. Whereas the backbone conformation is similar to that in SDS micelles, the Trp11 side-chain orientation is dramatically changed. The indole ring is nearly parallel to the peptide backbone in SDS micelles but perpendicular in DPC micelles. Further, pKa values of the two histidines change by more than 1 pH unit in SDS relative to DPC, which localizes the imidazole rings to the interfacial region. Line-broadening induced by spin-labelled phosphatidylcholine shows that most of the amino acid side-chains that penetrate the DPC micelle are hydrophobic. Thus, the long axis of the peptide lies parallel to the micelle surface and the hydrophobic face of the alpha-helix provides hydrophobic membrane interaction. The large chemical shift changes shown by Trp11 and N-terminal amino acid residues in SDS relative to DPC indicate that this region may be involved in membrane phospholipid recognition. 1H-NMR assignments, CD spectra, one-dimensional 1H-NMR spectra, chemical-shift analysis and nuclear Overhauser effect information are reported in Supplementary Publication SUP 50184 (11 pages), which has been deposited at the British Library Document Supply Centre, Boston Spa, Wetherby, West Yorkshire LS23 7BQ, U.K, from whom copies can be obtained according to the terms indicated in Biochem. J. (1997) 321, 8.

Parenteral triamcinolone acetonide: an alternative corticosteroid for the treatment of asthma

Corticosteroids are effective in reducing the airway inflammation and controlling the symptoms of asthma. Many patients with chronic, severe asthma are steroid-dependent, requiring daily oral corticosteroids. Although corticosteroids may be effective, many patients suffer from their intolerable side effects. Various medications have been used as steroid-sparing agents in patients who suffer from the side effects of long-term high-dose steroids. While drugs like methotrexate and cyclosporine are promising, none have clearly been shown to be beneficial in most patients with asthma. The long-acting parenteral steroid triamcinolone acetonide has been tested by various investigators in these patients for over 20 years. Intramuscular triamcinolone appears to beneficial, with no significant increase in adverse effects.

Diagnostic pitfalls in asthma

Asthma is a common disease, diagnosed and treated routinely, that still lacks a clear, universally accepted definition. The diagnosis, made mostly by history and physical diagnosis, is often supported by peak flow rate or spirometric measurements. This time-honored approach may prove to be unreliable, resulting in overdiagnosis of the disease. The literature is replete with reports about patients treated as if they had asthma in whom other pulmonary diseases were eventually diagnosed. The incidence of asthma is increasing; there seems to be a lower threshold now for making this diagnosis. Overdiagnosis can be avoided, however, by systematic evaluation and complete pulmonary function testing. This paper presents two examples of clinical carelessness resulting in diagnostic delay of underlying disorders mimicking bronchial asthma.

Effect of prolyl isomerase on the folding reactions of staphylococcal nuclease

The low-temperature fluorescence-detected refolding of staphylococcal nuclease (SNase) can be described by three slow kinetic phases. The slowest phase is absent in the P117G mutant of SNase. Peptidyl prolyl cis-trans isomerase (cyclophilin), which has been shown to catalyze the slow folding reactions of some proteins, was employed to determine which of the refolding reactions of SNase and P117G SNase involve proline isomerization. We report here that all three folding phases of the wild type and the slower phase of P117G SNase are catalyzed by prolyl isomerase, indicating that proline isomerization is involved in these fluorescence-detected phases in the refolding of SNase. Since the rates of these phases are denaturant-dependent, we conclude that the slow folding steps involve isomerization of non-native cis proline peptide bonds and are tightly coupled to denaturant-sensitive structural changes.

Autocatalyzed protein folding

Proline isomerization, an intrinsically slow process, kinetically traps intermediates in slow protein folding reactions. Thus, enzymes that catalyze proline isomerization (prolyl isomerases) often catalyze protein folding. We have investigated the folding kinetics of FKBP, a prolyl isomerase. The main conclusion is that FKBP catalyzes its own folding. Altogether, the FKBP refolding kinetics are resolved into three exponential phases: a fast phase, tau 3; an intermediate phase, tau 2; and a slow phase, tau 1. Unfolding occurs in a single phase, the unfolding branch of phase tau 2. In the presence of native FKBP, both the intermediate (tau 2) and slow (tau 1) phases are faster, suggesting that folding phases tau 1 and tau 2 involve proline cis-trans isomerization. In the absence of added native FKBP, autocatalytic folding of FKBP is detected. For refolding starting with all the FKBP unfolded initially, the slowest folding phase (tau 1) is almost 2-fold faster at a final concentration of 14 microM FKBP than at 2 microM FKBP, suggesting that catalytically active FKBP formed in the fast (tau 3) or intermediate (tau 2) folding phases catalyzes the slow folding phase (tau 1). Moreover, autocatalysis of folding is inhibited by FK506, an inhibitor of the FKBP prolyl isomerase activity. The results show that the slow phase in FKBP folding is an autocatalyzed formation of native FKBP from kinetically trapped species with non-native proline isomers. While the magnitude of the catalytic effects reported here are modest, FKBP folding may provide a prototype for autocatalysis of kinetically trapped macromolecular conformational changes in other systems.

Prolyl isomerase as a probe of stability of slow-folding intermediates

Catalysis of slow folding reactions by peptidyl prolyl cis-trans isomerase (PPI) provides estimates of stabilities of intermediates in folding of normal and mutational variants of yeast iso-2 cytochrome c. A two-state model postulating a rapid preequilibration of intermediates with the unfolded protein is employed to calculate the stabilization free energy of the intermediate from the catalytic efficiency (kcat/Km) of PPI toward slow folding species. Stability measurements have been made for two distinct slow-folding intermediates: the absorbance-detected (IIS) and fluorescence-detected (IIIS) intermediates. Mutation-induced changes in the stability of the intermediates and in the activation free energy for slow folding are compared to changes in equilibrium thermodynamic stability. The results show that (1) for iso-2 the absorbance-detected intermediates (IIS) are slightly more stable than the fluorescence-detected intermediates (IIIS), (2) most mutations have different effects on equilibrium stability and the stability of the IIS or IIIS intermediates, and (3) for both slow folding reactions the mutation-induced changes in the activation free energy are small compared to the magnitude of the activation free energy barrier. Differential effects of mutations on equilibrium stability and the stability of intermediates provides a means of assessing the sequence-encoded structural specificity for folding. Mutations with different effects on intermediate stability and equilibrium stability change the encoded folding information and may alter folding pathways and/or lead to different three-dimensional structures. Identification of mutations which stabilize a folding intermediate relative to the native conformation provides an empirical approach to the design of thermodynamically stable forms of folding intermediates.

Characterization of folding intermediates using prolyl isomerase

Structure-reactivity relationships of human peptidyl prolyl cis-trans isomerase (PPI) toward the two slow folding reactions of yeast iso-2 cytochrome c have been used to characterize the structure of folding intermediates in the vicinity of critical prolines. We propose that the relative catalytic efficiency of PPI for the protein substrate relative to a peptide substrate, (kcat/Km)rel, is a measure of structure in folding intermediates. The structural stability of slow-folding intermediates as detected by changes in (kcat/Km)rel was investigated using two structural perturbants: guanidine hydrochloride and site-directed mutagenesis. Neither of the two slow folding reactions for wild-type cytochrome c is catalyzed at low denaturant concentrations. However, both phases are catalyzed at moderate concentrations of guanidine hydrochloride. A mutation in cytochrome c enhances catalysis of the fluorescence-detected slow folding phase. For protein substrates destabilized by denaturants or mutation, we suggest that increases in (kcat/Km)rel result from a loosening of the substrate structure, providing better access of peptidyl prolyl isomerase to critical proline(s).

A form of protease nexin I is expressed on the platelet surface during platelet activation

A protein that has several similarities to protease nexin I, a fibroblast thrombin and urokinase inhibitor, has been detected on platelets (Gronke RS, Bergman BL, and Baker JB: J Biol Chem 262:3030, 1987). On incubation of platelets with 125I-thrombin, this platelet protein forms complexes with 125I-thrombin that are found both in the incubation medium and, as demonstrated here, associated with purified platelet plasma membranes. The present results indicate that interaction with the platelet surface may modulate the conformation and function of this platelet form of protease nexin I (PNIp) because: (a) an antibody against protease nexin I inhibited released PNIp, but not platelet-bound PNIp from complexing 125I-thrombin, and (b) whereas PNIp extracted from platelets bound both thrombin and urokinase, platelet-bound PNIp bound only thrombin. In experiments using several different platelet isolation methods, PNIp accounted for a large fraction of the rapid high affinity binding of 125I-thrombin to platelets. However, platelets isolated and maintained in the presence of metabolic inhibitors failed to take added thrombin into 125I-thrombin-PNIp complexes. This finding suggests that PNIp is released from inside platelets during activation, and thus does not function to transmit the primary activating signal that is generated by thrombin binding to platelets.