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Liang M, Dickel N, Györfi AH, SafakTümerdem B, Li YN, Rigau AR, Liang C, Hong X, Shen L, Matei AE, Trinh-Minh T, Tran-Manh C, Zhou X, Zehender A, Kreuter A, Zou H, Schett G, Kunz M, Distler JHW. Attenuation of fibroblast activation and fibrosis by adropin in systemic sclerosis. Sci Transl Med 2024; 16:eadd6570. [PMID: 38536934 DOI: 10.1126/scitranslmed.add6570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
Fibrotic diseases impose a major socioeconomic challenge on modern societies and have limited treatment options. Adropin, a peptide hormone encoded by the energy homeostasis-associated (ENHO) gene, is implicated in metabolism and vascular homeostasis, but its role in the pathogenesis of fibrosis remains enigmatic. Here, we used machine learning approaches in combination with functional in vitro and in vivo experiments to characterize adropin as a potential regulator involved in fibroblast activation and tissue fibrosis in systemic sclerosis (SSc). We demonstrated consistent down-regulation of adropin/ENHO in skin across multiple cohorts of patients with SSc. The prototypical profibrotic cytokine TGFβ reduced adropin/ENHO expression in a JNK-dependent manner. Restoration of adropin signaling by therapeutic application of bioactive adropin34-76 peptides in turn inhibited TGFβ-induced fibroblast activation and fibrotic tissue remodeling in primary human dermal fibroblasts, three-dimensional full-thickness skin equivalents, mouse models of bleomycin-induced pulmonary fibrosis and sclerodermatous chronic graft-versus-host-disease (sclGvHD), and precision-cut human skin slices. Knockdown of GPR19, an adropin receptor, abrogated the antifibrotic effects of adropin in fibroblasts. RNA-seq demonstrated that the antifibrotic effects of adropin34-76 were functionally linked to deactivation of GLI1-dependent profibrotic transcriptional networks, which was experimentally confirmed in vitro, in vivo, and ex vivo using cultured human dermal fibroblasts, a sclGvHD mouse model, and precision-cut human skin slices. ChIP-seq confirmed adropin34-76-induced changes in TGFβ/GLI1 signaling. Our study characterizes the TGFβ-induced down-regulation of adropin/ENHO expression as a potential pathomechanism of SSc as a prototypical systemic fibrotic disease that unleashes uncontrolled activation of profibrotic GLI1 signaling.
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Affiliation(s)
- Minrui Liang
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Division of Rheumatology, Huashan Rare Disease Center, Huashan Hospital, Fudan University, 200032 Shanghai, P. R. China
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Nicholas Dickel
- Chair of Medical Informatics, Friedrich-Alexander University (FAU), Erlangen-Nürnberg, 91058 Erlangen, Germany
| | - Andrea-Hermina Györfi
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Bilgesu SafakTümerdem
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Yi-Nan Li
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Aleix Rius Rigau
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Chunguang Liang
- Chair of Medical Informatics, Friedrich-Alexander University (FAU), Erlangen-Nürnberg, 91058 Erlangen, Germany
- Institute of Immunology, Jena University Hospital, 07743 Jena, Germany
| | - Xuezhi Hong
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Lichong Shen
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
- Division of Rheumatology, Renji Hospital, Shanghai Jiao Tong University, 200001 Shanghai, P. R. China
| | - Alexandru-Emil Matei
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Thuong Trinh-Minh
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Cuong Tran-Manh
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Xiang Zhou
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Ariella Zehender
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Alexander Kreuter
- Department of Dermatology and Allergology, HELIOS Sankt Elisabeth Klinik Oberhausen, 46045 Oberhausen, Nordrhein-Westfalen, Germany
| | - Hejian Zou
- Division of Rheumatology, Huashan Rare Disease Center, Huashan Hospital, Fudan University, 200032 Shanghai, P. R. China
| | - Georg Schett
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
| | - Meik Kunz
- Chair of Medical Informatics, Friedrich-Alexander University (FAU), Erlangen-Nürnberg, 91058 Erlangen, Germany
| | - Jörg H W Distler
- Department of Rheumatology, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Hiller Research Unit, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University; 40225 Düsseldorf, Germany
- Rheumatology and Clinical Immunology, Department of Internal Medicine 3, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nürnberg and University Hospital Erlangen, 91054 Erlangen, Germany
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Zehender A, Li YN, Lin NY, Stefanica A, Nüchel J, Chen CW, Hsu HH, Zhu H, Ding X, Huang J, Shen L, Györfi AH, Soare A, Rauber S, Bergmann C, Ramming A, Plomann M, Eckes B, Schett G, Distler JHW. TGFβ promotes fibrosis by MYST1-dependent epigenetic regulation of autophagy. Nat Commun 2021; 12:4404. [PMID: 34285225 PMCID: PMC8292318 DOI: 10.1038/s41467-021-24601-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/29/2021] [Indexed: 12/13/2022] Open
Abstract
Activation of fibroblasts is essential for physiological tissue repair. Uncontrolled activation of fibroblasts, however, may lead to tissue fibrosis with organ dysfunction. Although several pathways capable of promoting fibroblast activation and tissue repair have been identified, their interplay in the context of chronic fibrotic diseases remains incompletely understood. Here, we provide evidence that transforming growth factor-β (TGFβ) activates autophagy by an epigenetic mechanism to amplify its profibrotic effects. TGFβ induces autophagy in fibrotic diseases by SMAD3-dependent downregulation of the H4K16 histone acetyltransferase MYST1, which regulates the expression of core components of the autophagy machinery such as ATG7 and BECLIN1. Activation of autophagy in fibroblasts promotes collagen release and is both, sufficient and required, to induce tissue fibrosis. Forced expression of MYST1 abrogates the stimulatory effects of TGFβ on autophagy and re-establishes the epigenetic control of autophagy in fibrotic conditions. Interference with the aberrant activation of autophagy inhibits TGFβ-induced fibroblast activation and ameliorates experimental dermal and pulmonary fibrosis. These findings link uncontrolled TGFβ signaling to aberrant autophagy and deregulated epigenetics in fibrotic diseases and may contribute to the development of therapeutic interventions in fibrotic diseases.
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Affiliation(s)
- Ariella Zehender
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Yi-Nan Li
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Neng-Yu Lin
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
- Graduate Institute of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Adrian Stefanica
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Julian Nüchel
- Center for Biochemistry, University of Cologne, Faculty of Medicine, Cologne, Germany
| | - Chih-Wei Chen
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Hsiao-Han Hsu
- Graduate Institute of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Honglin Zhu
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiao Ding
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Jingang Huang
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Lichong Shen
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Andrea-Hermina Györfi
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Alina Soare
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Simon Rauber
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Christina Bergmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Andreas Ramming
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Markus Plomann
- Center for Biochemistry, University of Cologne, Faculty of Medicine, Cologne, Germany
| | - Beate Eckes
- Translational Matrix Biology, University of Cologne, Faculty of Medicine, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Jörg H W Distler
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany.
- Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany.
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Zehender A, Li YN, Lin NY, Györfi AH, Soare A, Bergmann C, Ramming A, Schett G, Distler JHW. AB0091 INHIBITION OF AUTOPHAGY PREVENTS PROGRESSION OF FIBROSIS IN MURINE MODELS OF SYSTEMIC SCLEROSIS. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Autophagy is catabolic process allowing cells to degrade unnecessary or dysfunctional cellular organelles. Failure of appropriate regulation of autophagy, however, can severely perturb tissue homeostasis. Recent studies demonstrate that autophagy is activated in several fibrotic diseases such as liver fibrosis, renal interstitial fibrosis, cardiac fibrosis.Objectives:The objective of this work was to characterize the activation of autophagy in systemic sclerosis (SSc) and to decipher its role in the pathogenesis of SSc.Methods:Activation of autophagy in skin samples of patients and murine models of SSc was assessed by co-staining of LC3B and P62 with the lysosomal marker LAMP2. The role of the autophagy was investigated in the model of bleomycin-induced dermal fibrosis. Beclin1 was overexpressed using adenovirus encoding for Beclin1. To knockdown Atg7 in vivo was achieved by subcutaneous injections of Atg7 siRNA or non-targeting siRNA. In vivo, 3-methyladenine (3-MA) was administered i.p. in a concentration of 15 mg/kg ones daily. Protein expression was measured by Western blot. Target genes were analyzed by qPCR. To monitor the autophagic flux, we generated adenoviral vectors encoding for tandem fluorescent-tagged LC3 (mRFP-EGFP-LC3).Results:In the present study, we demonstrate that autophagy is activated in fibroblasts in SSc skin and also in experimental fibrosis models as compared to respective non-fibrotic control tissue with enhanced activity in in vivo and in vitro autophagy reporter studies. The aberrant activation of autophagy had profound stimulatory effects on fibroblasts. Activation of autophagy by forced expression of BECLIN1 promoted fibroblast-to-myofibroblast transition and stimulated the collagen release by cultured human fibroblasts and induced fibrosis in murine model. Nevertheless, inhibition of autophagy can deactivate myofibroblasts and induce regression of tissue fibrosis. Knockdown of ATG7 or BECLIN1 in human fibroblasts reduced the expression of αSMA and the number of stress fibers in myofibroblasts, indicating re-differentiation of myofibroblasts into resting fibroblasts upon inhibition of autophagy. Similar results were obtained with the autophagy inhibitors CQ and 3-MA. In vivo, siRNA mediated knockdown of Atg7 effectively prevented progression of fibrosis in a model of established bleomycin-induced skin fibrosis. Inactivation of autophagy decreased dermal thickness, myofibroblast counts and hydroxyproline content to below pretreatment levels, indicating regression of bleomycin-induced skin fibrosis. In addition, treatment of mice with the autophagy inhibitor 3-MA ameliorated bleomycin-induced skin fibrosis.Conclusion:We demonstrate that autophagy activity is enhanced in fibroblasts of SSc patients and in murine models of SSc. The increased activation of autophagy induces fibroblast-to-myofibroblast transition and promotes fibrotic tissue remodeling. However, inhibition of autophagy can deactivate myofibroblasts and induce regression of tissue fibrosis.References:[1]Wynn, T. Cellular and molecular mechanisms of fibrosis. J Pathol 214, 199-210 (2008).[2]Klionsky DJ, Abeliovich H, Agostinis P, et al. Guidelines for the use and interpretation of assays for monitoring autophagy in higher eukaryotes. Autophagy 4, 151-175 (2008).[3]Wang, CW & Klionsky, DJ. The molecular mechanism of autophagy. Mol Med 9, 65-76 (2003).[4]Hernández-Gea V, Ghiassi-Nejad Z, Rozenfeld R, et al. Autophagy releases lipid that promotes fibrogenesis by activated hepatic stellate cells in mice and in human tissues. Gastroenterology 142, 938-946 (2012).Disclosure of Interests:Ariella Zehender: None declared, Yi-Nan Li: None declared, Neng-Yu Lin: None declared, Andrea-Hermina Györfi: None declared, Alina Soare: None declared, Christina Bergmann: None declared, Andreas Ramming: None declared, Georg Schett: None declared, Jörg H.W. Distler Consultant of: Actelion, Active Biotech, Anamar, ARXX, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, Medac, Pfizer, RuiYi and UCB., Grant/research support from: Anamar, Active Biotech, Array Biopharma, aTyr, BMS, Bayer Pharma, Boehringer Ingel-heim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB., Employee of: stock owner of 4D Science and Scientific head of FibroCure
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Bergmann C, Hallenberger L, Chenguiti Fakhouri S, Merlevede B, Brandt A, Dees C, Zhu H, Zehender A, Zhou X, Schwab A, Chen CW, Györfi AH, Matei AE, Chakraborty D, Trinh-Minh T, Rauber S, Coras R, Bozec A, Kreuter A, Ziemer M, Schett G, Distler JHW. X-linked inhibitor of apoptosis protein (XIAP) inhibition in systemic sclerosis (SSc). Ann Rheum Dis 2021; 80:1048-1056. [PMID: 33903093 DOI: 10.1136/annrheumdis-2020-219822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/05/2021] [Accepted: 03/22/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE X-linked inhibitor of apoptosis protein (XIAP) is a multifunctional protein with important functions in apoptosis, cellular differentiation and cytoskeletal organisation and is emerging as potential target for the treatment of various cancers. The aim of the current study was to investigate the role of XIAP in the pathogenesis of systemic sclerosis (SSc). METHODS The expression of XIAP in human skin samples of patients with SSc and chronic graft versus host disease (cGvHD) and healthy individuals was analysed by quantitative PCR, immunofluorescence (IF) and western blot. XIAP was inactivated by siRNA-mediated knockdown and pharmacological inhibition. The effects of XIAP inactivation were analysed in cultured fibroblasts and in the fibrosis models bleomycin-induced and topoisomerase-I-(topoI)-induced fibrosis and in Wnt10b-transgenic mice. RESULTS The expression of XIAP, but not of other inhibitor of apoptosis protein family members, was increased in fibroblasts in SSc and sclerodermatous cGvHD. Transforming growth factor beta (TGF-β) induced the expression of XIAP in a SMAD3-dependent manner. Inactivation of XIAP reduced WNT-induced fibroblast activation and collagen release. Inhibition of XIAP also ameliorated fibrosis induced by bleomycin, topoI and overexpression of Wnt10b in well-tolerated doses. The profibrotic effects of XIAP were mediated via WNT/β-catenin signalling. Inactivation of XIAP reduces binding of β-catenin to TCF to in a TLE-dependent manner to block WNT/β-catenin-dependent transcription. CONCLUSIONS Our data characterise XIAP as a novel link between two core pathways of fibrosis. XIAP is overexpressed in SSc and cGvHD in a TGF-β/SMAD3-dependent manner and in turn amplifies the profibrotic effects of WNT/β-catenin signalling on fibroblasts via transducin-like enhancer of split 3. Targeted inactivation of XIAP inhibits the aberrant activation of fibroblasts in murine models of SSc.
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Affiliation(s)
- Christina Bergmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Ludwig Hallenberger
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Sara Chenguiti Fakhouri
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Benita Merlevede
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Amelie Brandt
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Clara Dees
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Honglin Zhu
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany.,Department of Rheumatology and Immunology, Xiangya Hospital Central South University, Changsha, China
| | - Ariella Zehender
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Xiang Zhou
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Annemarie Schwab
- Interdisciplinary Centre for Clinical Research, University Hospital Erlangen, FAU-Erlangen-Nuremberg, Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Chih-Wei Chen
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Andrea Hermina Györfi
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Alexandru Emil Matei
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Debomita Chakraborty
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Thuong Trinh-Minh
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Simon Rauber
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Roland Coras
- Department of Neuropathology, Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Aline Bozec
- Institute for Clinical Immunology University of Erlangen-Nuremberg, Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Alexander Kreuter
- Department of Dermatology and Allergology, HELIOS Sankt Elisabeth Klinik Oberhausen, Oberhausen, Nordrhein-Westfalen, Germany
| | - Mirjana Ziemer
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Leipzig, Leipzig, Sachsen, Germany
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Jörg H W Distler
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
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Zehender A, Lin NY, LI YN, Györfi AH, Bergmann C, Ramming A, Schett G, Distler J. SAT0284 EPIGENETIC DEREGULATION OF AUTOPHAGY PROMOTES FIBROSIS IN SYSTEMIC SCLEROSIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Autophagy is catabolic process allowing cells to degrade unnecessary or dysfunctional cellular organelles. Failure of appropriate regulation of autophagy, however, can severely perturb tissue homeostasis. Several stimuli present in fibrosis such as pro-fibrotic cytokines are known to activate autophagy.Objectives:The objective of this work was to characterize the regulation of autophagy in systemic sclerosis (SSc) and to decipher its role in the pathogenesis of SSc.Methods:Activation of autophagy in SSc skin and matched tissue samples from healthy individuals was assessed by immunofluorescence staining for ATG7, BECLIN1 and P62. We generatedAtg7fl/flxCol1a2;CreER mice to selectively disable autophagy in fibroblasts. The role of the autophagy was investigated in the model of bleomycin- and TβRIact-induced dermal and pulmonary fibrosis. Overexpression of Myst1 was achieved by adenovirus encoding forMyst1. Collagen release and protein expression were measure by Western blot. Target genes were analyzed by RT-PCR. Co-immunoprecipitation and reporter assay were performed to study physical and functional interactions between MYST1 and SMAD3. To monitor the autophagic fluxin vitroandin vivowe generated adenoviral vectors encoding for tandem fluorescent-tagged LC3 (mRFP-EGFP-LC3).Results:Transforming growth factor-β (TGFβ) activates autophagy by an epigenetic mechanism to amplify its profibrotic effects. TGFβ induces autophagy in fibrotic diseases by SMAD3-dependent downregulation of the H4K16 histone acetyltransferase MYST1, which regulates the expression of core components of the autophagy machinery such as ATG7 and BECLIN1. Activation of autophagy in fibroblasts promotes collagen release and is both, sufficient and required, to induce tissue fibrosis. Forced expression of MYST1 abrogates the stimulatory effects of TGFβ on autophagy and re-establishes the epigenetic control of autophagy in fibrotic conditions. Interference with the aberrant activation of autophagy inhibits TGFβ-induced fibroblast activation and ameliorates experimental dermal and pulmonary fibrosis. These findings link uncontrolled TGFβ signaling to aberrant autophagy, deregulated epigenetics in fibrotic diseases and may open new avenues for therapeutic intervention in fibrotic diseases.Conclusion:We demonstrate that the epigenetic control of autophagy is disturbed by a TGFβ-dependent downregulation of the H4K16 histone acetyltransferase MYST1. The increased activation of autophagy induces fibroblast-to-myofibroblast transition and promotes fibrotic tissue remodeling. Re-expression of MYST1 prevents aberrant autophagy, limits the profibrotic effects of TGFβ and ameliorates experimental fibrosis. Restoration of the epigenetic control of autophagy might thus be a novel approach to ameliorate fibrotic tissue remodeling.References:[1]Wynn, T.A. Cellular and molecular mechanisms of fibrosis. J Pathol 214, 199-210 (2008).[2]Distler, J.H., et al. Review: Frontiers of Antifibrotic Therapy in Systemic Sclerosis. Arthritis & rheumatology (Hoboken, N.J.) 69, 257-267 (2017).[3]Gyorfi, A.H., Matei, A.E. & Distler, J.H.W. Targeting TGF-beta signaling for the treatment of fibrosis. Matrix biology: journal of the International Society for Matrix Biology 68-69, 8-27 (2018).[4]Wang, C.W. & Klionsky, D.J. The molecular mechanism of autophagy. Mol Med 9, 65-76 (2003).[5]Hernandez-Gea, V., et al. Autophagy releases lipid that promotes fibrogenesis by activated hepatic stellate cells in mice and in human tissues. Gastroenterology 142, 938-946 (2012).Disclosure of Interests:Ariella Zehender: None declared, Neng Yu Lin: None declared, Yi-Nan Li: None declared, Andrea-Hermina Györfi: None declared, Christina Bergmann: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim
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Liang R, Kagwiria R, Zehender A, Dees C, Bergmann C, Ramming A, Krasowska D, Michalska-Jakubus M, Kreuter A, Kraner ME, Schett G, Distler JHW. Acyltransferase skinny hedgehog regulates TGFβ-dependent fibroblast activation in SSc. Ann Rheum Dis 2019; 78:1269-1273. [PMID: 31177096 DOI: 10.1136/annrheumdis-2019-215066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/10/2019] [Accepted: 05/24/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is characterised by aberrant hedgehog signalling in fibrotic tissues. The hedgehog acyltransferase (HHAT) skinny hedgehog catalyses the attachment of palmitate onto sonic hedgehog (SHH). Palmitoylation of SHH is required for multimerisation of SHH proteins, which is thought to promote long-range, endocrine hedgehog signalling. The aim of this study was to evaluate the role of HHAT in the pathogenesis of SSc. METHODS Expression of HHAT was analysed by real-time polymerase chain reaction(RT-PCR), immunofluorescence and histomorphometry. The effects of HHAT knockdown were analysed by reporter assays, target gene studies and quantification of collagen release and myofibroblast differentiation in cultured human fibroblasts and in two mouse models. RESULTS The expression of HHAT was upregulated in dermal fibroblasts of patients with SSc in a transforming growth factor-β (TGFβ)/SMAD-dependent manner. Knockdown of HHAT reduced TGFβ-induced hedgehog signalling as well as myofibroblast differentiation and collagen release in human dermal fibroblasts. Knockdown of HHAT in the skin of mice ameliorated bleomycin-induced and topoisomerase-induced skin fibrosis. CONCLUSION HHAT is regulated in SSc in a TGFβ-dependent manner and in turn stimulates TGFβ-induced long-range hedgehog signalling to promote fibroblast activation and tissue fibrosis. Targeting of HHAT might be a novel approach to more selectively interfere with the profibrotic effects of long-range hedgehog signalling.
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Affiliation(s)
- Ruifang Liang
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Rosebeth Kagwiria
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Ariella Zehender
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Clara Dees
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Christina Bergmann
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Andreas Ramming
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Dorota Krasowska
- Department of Dermatology, Venereology and Pediatric Dermatology, Medical University of Lublin, Lublin, Poland
| | | | - Alexander Kreuter
- Department of Dermatology, Venereolog and Allergology, HELIOS St Elisabeth Hospital Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - Max E Kraner
- Department of Biology, Division of Biochemistry, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
| | - Jörg H W Distler
- Department of Internal Medicine 3- Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Bayern, Germany
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Zehender A, Huang J, Györfi AH, Matei AE, Trinh-Minh T, Xu X, Li YN, Chen CW, Lin J, Dees C, Beyer C, Gelse K, Zhang ZY, Bergmann C, Ramming A, Birchmeier W, Distler O, Schett G, Distler JHW. The tyrosine phosphatase SHP2 controls TGFβ-induced STAT3 signaling to regulate fibroblast activation and fibrosis. Nat Commun 2018; 9:3259. [PMID: 30108215 PMCID: PMC6092362 DOI: 10.1038/s41467-018-05768-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 07/25/2018] [Indexed: 12/31/2022] Open
Abstract
Uncontrolled activation of TGFβ signaling is a common denominator of fibrotic tissue remodeling. Here we characterize the tyrosine phosphatase SHP2 as a molecular checkpoint for TGFβ-induced JAK2/STAT3 signaling and as a potential target for the treatment of fibrosis. TGFβ stimulates the phosphatase activity of SHP2, although this effect is in part counterbalanced by inhibitory effects on SHP2 expression. Stimulation with TGFβ promotes recruitment of SHP2 to JAK2 in fibroblasts with subsequent dephosphorylation of JAK2 at Y570 and activation of STAT3. The effects of SHP2 on STAT3 activation translate into major regulatory effects of SHP2 on fibroblast activation and tissue fibrosis. Genetic or pharmacologic inactivation of SHP2 promotes accumulation of JAK2 phosphorylated at Y570, reduces JAK2/STAT3 signaling, inhibits TGFβ-induced fibroblast activation and ameliorates dermal and pulmonary fibrosis. Given the availability of potent SHP2 inhibitors, SHP2 might thus be a potential target for the treatment of fibrosis.
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Affiliation(s)
- Ariella Zehender
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Jingang Huang
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.
| | - Andrea-Hermina Györfi
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Alexandru-Emil Matei
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Thuong Trinh-Minh
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Xiaohan Xu
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Yi-Nan Li
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Chih-Wei Chen
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Jianping Lin
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, 575 Stadium Mall Drive Indiana, West Lafayette, 47907, USA
| | - Clara Dees
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Christian Beyer
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Kolja Gelse
- Department of Trauma Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Zhong-Yin Zhang
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, 575 Stadium Mall Drive Indiana, West Lafayette, 47907, USA
| | - Christina Bergmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Andreas Ramming
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Walter Birchmeier
- Max Delbrück Center for Molecular Medicine (MDC), Robert-Rössle-Str. 10, 13092, Berlin, Germany
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Gloriastrasse 25, 8091, Zurich, Switzerland
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Jörg H W Distler
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.
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