Background
Pulmonary artery hypertension (PAH) is a devastating disease with high mortality and morbidity, hemodynamically characterized by the mean pulmonary arterial pressure (mPAP) > 20 mmHg [
1]. Inappropriate vasoconstriction, abnormal pulmonary vascular remodeling and thrombosis in situ are identified as major pathogenesis in PAH [
2]. During the development of PAH, the irreversible pulmonary vascular remodeling results from changes of cells in arterial vessel walls, especially pulmonary artery smooth muscle cell (PASMC) excessive proliferation and migration [
3]. Current pharmacological therapies for PAH mostly focus on vasomotor pathways, which is inadequate to reach the therapeutic goal for many patients. Novel pathogenic mechanisms and targets of vascular remodeling may provide important insights into PAH treatment.
High-mobility group box 1 (HMGB1), a chromatin-associated protein, stabilizes nucleosomes, thus regulating transcription [
4]. Under certain stress conditions, HMGB1 is released from macrophages, monocytes, endothelial cells or various tumor cells. Once released, HMGB1 initiates inflammation and regulates autophagy by binding to toll-like receptor 4 (TLR4) and receptor for advanced glycation end products (RAGE) [
5,
6]. Previous studies indicate that HMGB1 and its downstream signaling are involved in PAH pathogenesis [
7,
8]. The extracellular or circulating HMGB1 in patients is elevated and used as a biomarker to identify PAH in patients with congenital heart disease [
9,
10]. Hypoxia-induced mitogenic factor (HIMF)/HMGB1 signaling axis acts as a pivotal mediator for the proliferation of smooth muscle cells [
11]. HMGB1 neutralization or inhibition of TLR4 and RAGE activity represent effective therapeutic strategies for the prevention of PAH [
12‐
14]. However, the specific mechanism by which HMGB1 acts on the progression of PAH is still unclear and needs to be investigated.
Endoplasmic reticulum (ER), as a cellular organelle in eukaryotes, participates in the synthesis, folding, modification and transportation of proteins, involved in the regulation of systemic metabolic, inflammatory, and endocrine processes [
15]. Diverse stimuli including hypoxia, nutrient deprivation, aberrant Ca
2+ regulation and oxidative stress perturb ER homeostasis, leading to accumulation of misfolded and unfolded proteins, and ultimately ER stress [
16]. Following ER stress, three sensors of ER homeostasis, inositol-requiring kinase 1 (IRE1), protein kinase RNA-like endoplasmic reticulum kinase (PERK) and activating transcription factor-6(ATF6), are activated to re-establish normal ER function, termed the unfolded protein response (UPR) [
17]. Study shows that the PERK-eIF2 signaling cascade is enhanced in the hypoxic bone morphogenetic protein receptor type 2 (BMPR2) heterozygous PASMCs and inhibition of PERK exerts potential antiproliferative effects on PASMCs [
18]. All three UPR pathways are activated in the PAH animal models [
18‐
20]. Furthermore, intervention of ER stress by 4-phenylbutyric acid (4-PBA) is beneficial for right ventricular function and prevents the occurrence of PAH [
21]. Despite advancement in research on the role of ER stress during PAH, the molecular mechanisms of PERK in PAH are largely undefined.
The mammalian seven-in-absentia homolog 2 (SIAH2) belongs to the RING finger ubiquitin ligase, which is part of a regulatory cascade in the ubiquitin–proteasome system [
22]. SIAH2 mediates efficient ubiquitination and degradation of substrates and exerts distinct functions in cellular processes including cell growth, differentiation, angiogenesis and the unfolded protein response [
23‐
25]. Under severe ER stress condition, SIAH2 is an integral component of the ER stress response. ATF4 or IRE1/sXBP1 may constitute the initial signal for SIAH2 transcription, which in turn augments ATF4 availability [
23]. In breast cancer cells, SIAH2 partially controls the overall hypoxia response through its effects on the stability of HIF1α, as by ubiquitylation and degradation of homeodomain-interacting protein kinase 2 (HIPK2) [
26]. In PAH animal model, SIAH2 promotes pulmonary vascular remodeling through inactivation of YAP [
27]. In this study, we assume that HMGB1 triggers ER stress, concomitant with upregulation of SIAH2 and downregulation of HIPK2, leading to PASMC proliferation/migration and pulmonary vascular remodeling.
Materials and methods
Cell culture
Primary PASMCs were isolated and cultured from pulmonary arteries of male Sprague–Dawley rats (120–180 g) as previously described [
28]. In brief, the main pulmonary arteries were obtained from anesthetized rats. After removing the adventitia and intima carefully, the isolated arteries were shred into small tissue blocks (0.5–1 mm3) and transferred into a culture flask. Then, cells were incubated with high glucose Dulbecco's modified Eagle's medium (DMEM, Gibco Laboratories, Invitrogen, USA) supplemented with 10% fetal bovine serum (FBS, Gemini Bio, Woodland, CA, USA) and 1% penicillin–streptomycin in a humidified incubator at 37 °C aerated with 5% CO2. When cells reached 80% confluency, cells were digested using 0.25% trypsin (Invitrogen, Carlsbad, CA, USA). For maintaining the PASMC phenotype, early-passage cells (passage 3 to 6) were used for all experiments and cell purity was determined by immunostaining for α-smooth muscle actin (α-SMA,1:200) (BM0002, Boster, CA, USA). Cells were starved overnight using a serum-free medium before each experiment. HMGB1 (0-300 ng/ml) (1690-HMB050, R&D systems, Minneapolis, USA) was used to stimulate PASMCs.
Small interfering RNA (siRNA) transfection
Cells were seeded into 6-well plates for 24 h at approximately 30–40% confluence. Then, cells were transfected with a mixture of Lipofectamine™ 3000 and siRNA. The subsequent experimentations were conducted after transfection for 48 h. The sequences of siRNA duplexes specific for rat PERK, ATF4, SIAH2 and negative control were:
PERK siRNA, sense 5′-GCAGGUCCUUAGUAAUCAUTT-3′, anti-sense 5′-AUGAUUACUAAGGACCUGCTT-3′; ATF4 siRNA, sense 5′-GUCUCUUAGAUGACUAUCUTT-3′, anti-sense 5′-AGAUAGUCAUCUAAGAGACTT′; SIAH2 siRNA: sense 5′-GCAGUUCUGUUUCCCUGUATT-3′, anti-sense 5′-UACAGGGAAACAGAACUGCTT′; negative control (NC) siRNA, sense 5′-UUCUCCGAACGUGUCACGUTT-3′, anti-sense 5′ -ACGUGACACGUUCGGAGAAT-3′. All siRNA was purchased from GenePharma (Shanghai, China).
Cell proliferation assay
Cell proliferation was determined using cell counting kit-8 (CCK-8) and EdU incorporation assay. Approximately 5 × 103 cells per well were plated into a 96-well culture plate. Three biological replicates of cells were incubated with CCK-8 solution (FD3788, Fudebio-tech, Hangzhou, China) for 2 h. Then, the optical density at 450 nm was measured using a microplate reader. For the EdU incorporation assay, cells were labeled with EdU (C0071S, Beyotime, Shanghai, China) for 4 h at 37 °C. The positive cells were observed under inverted fluorescence microscopy and calculated using Image J software (NIH, Bethesda, MD, USA).
Cell migration assay
After different treatments, cells (5 × 104 cells/well) in the serum-free medium were collected and seeded into the upper chamber of 24-well transwell chambers (Corning Inc, USA). The lower chamber was filled with 500 µl DMEM containing 10% FBS with or without HMGB1. Then, cells traversed the membrane were fixed with 4% (w/v) paraformaldehyde for 20 min and stained with 0.1% crystal violet for 10 min at room temperature. The number of migrated cells was counted under an inverted microscope.
Animal experiment
Male Sprague Dawley rats were purchased from Xi'an Jiaotong University Experimental Animal Center. All procedures involved in the experiment were approved by the Institutional Animal Ethics Committee of Xi'an Jiaotong University and under the Guide for the Care and Use of Laboratory Animals of Xi'an Jiaotong University Animal Experiment Center. Rats were kept in a temperature-controlled room (20 ± 2 °C) with a 12 h light/dark cycle and maintained on a standard diet. In this study, all rats weigh approximately 200–220 g. PAH rats were induced by a single intraperitoneal(ip) injection of 60 mg/kg MCT (Must Bio-Technology, Chengdu, China) on day 1, while control animals (n = 8) were administered 0.9% NaCl solution. Then MCT-injected rats were randomly divided into six groups (n = 8 per group) as follows: MCT group; MCT + DMSO group: received DMSO vehicle; MCT + Glycyrrhizin (GLY) group: received GLY (100 mg/kg, 53,956–04-0, Santa Cruz, CA, USA) by daily ip injection; MCT + 4-phenylbutyric acid (4-PBA) group: received 4-PBA (500 mg/kg, HY-A0281, MedChemExpress, Monmouth Junction, America) by daily gavage; MCT + Vitamin K3(VK3) group: received VK3 (3.5 mg/kg, HY-B0332, MedChemExpress, Monmouth Junction, America) by ip injection twice a week; MCT + Tetramethylpyrazine(TMP) group: received TMP(100 mg/kg, Lizhu Pharmaceutical Limited Company, Zhuhai, China) by daily gavage.
Hemodynamic measurements
For measurement of hemodynamic parameters, rats were anesthetized using 2% pentobarbital sodium (0.3 ml/100 g). A catheter was inserted into the right pulmonary artery through the right external jugular vein and then the right ventricle by closed-chest technique. Right ventricular systolic pressure (RVSP) and mPAP were assessed carefully. After that, we dissected the right ventricle (RV) and left ventricle (LV) plus interventricular septum (S). The right ventricular hypertrophy was assessed by the RV/LV + S ratio.
Histology, immunohistochemistry staining and double-labeling immunofluorescence staining
Lung and heart specimens were fixed in 4% formalin, embedded in paraffin and sectioned longitudinally at a thickness of 5 µm. Slides were stained with hematoxylin–eosin (HE) and Elastic van Gieson (EVG) using previous protocols [
29]. The percentage of medial wall thickness was measured n distal pulmonary arteries (20–70 μm diameters, n = 30 per rat). Images were captured using a light microscope (CellSens Imaging Software, Olympus, Tokyo, Japan). For immunohistochemistry staining, paraffin-embedded lung sections were incubated with α-SMA (#14395-1-AP, Proteintech, Wuhan, China) overnight at 4 °C. Semi-quantitative analysis for staining of α-SMA was conducted to categorize the degree of pulmonary arterial muscularization. The co-staining of α-SMA and ATF4 was conducted to determine the expression of ATF4 in the PASMCs. Lung sections were incubated with α-SMA (1:50 dilution) and ATF4 (1:100 dilution) at 4 °C overnight. Then, sections were incubated with the fluorescent secondary antibody (1:250) and DAPI. Afterward, sections were observed and photographed by an inverted fluorescence microscope (Leika Microsystems, Wetzlar, Germany).
Transmission electron microscopy
The left lower lobe of the lung was removed from rats and fixed in 2.5% (w/v) glutaraldehyde. Pulmonary arteries were isolated from lungs and postfixed with 1% (w/v) OsO4, dehydrated by alcohol and then embedded in araldite. Ultrathin sections were sliced from the specimens and mounted on copper grids. Then, sections were stained with 2% uranyl acetate and lead citrate. A transmission electron microscope (TEM) (H-7650, Hitachi, Japan) was used to observe and evaluate the ultrastructure of ER.
Western blotting
The lung tissues of rats were cut into pieces and homogenized using cold RIPA buffer (Beyotime, Shanghai, China). Total protein was obtained from the lysed tissue homogenate centrifuged at 10,000 rpm at 4 °C for 20 min. Total cellular proteins were also extracted using the RIPA lysis buffer. All protein concentrations were quantified with the bicinchoninic acid kit (Beyotime Shanghai, China). Then, proteins from each sample were separated by 10% SDS-PAGE and electro-blotted onto polyvinylidene fluoride membranes (Millipore, Billerica, MA). The membranes were blocked using 5% non-fat milk for 60 min at room and incubated with primary antibodies overnight at 4 °C while shaking. Rabbit monoclonal antibodies against PERK (#3192) and ATF4 (#11815) were purchased from Cell Signaling Technology (Beverly, MA, USA). Rabbit polyclonal antibody against SIAH2 (#YT4297) and mouse monoclonal antibody against β-actin (#YM3028) were from Immunoway (Plano, TX, USA). Rabbit monoclonal antibody against HIPK2 (#ab108543) was from Abcam (Boston, MA, USA). To detect the primary antibody, the membranes were incubated with a horseradish peroxidase-conjugated anti-rabbit or anti-mouse IgG antibody diluted 1:5000 to 1:10,000 for 1 h at room temperature. Chemiluminescence was performed using the ChemiDoc XRS system and analyzed with ImageJ software.
Statistical analysis
Results were presented as mean ± standard deviation (SD). All experiments were conducted for at least three independent replications. The data were applied to Shapiro–Wilk normality test and F test for normality and equal variance tests, respectively. The student’s t-test determined statistical differences between two groups. For comparisons within multiple groups, one-way ANOVA followed by Tukey’s multiple comparisons post-hoc test was used. Statistical analyses were performed using GraphPad Prism version 8.0 (GraphPad Software, La Jolla, CA, USA). The significant difference was assumed at P-value < 0.05.
Discussion
The biological functions of HMGB1 are dependent on its diverse cellular localization. When response to persistent tissue injury, HMGB1 is released into the extracellular environment as a key molecule of innate immunity, inflammation and tissue remodeling [
37]. In IPAH patients, extranuclear HMGB1 is observed in plexiform vascular lesions. Circulating HMGB1 levels increase and correlate with the severity of PAH [
38]. Our study investigated the role of extracellular HMGB1 in PASMCs and the pathogenesis of MCT-induced PAH rats. We found that HMGB1 promoted PASMC proliferation and migration. In vivo, the HMGB1 serum level was elevated, whereas inhibition of HMGB1 by GLY reduced the HMGB1 concentration in the serum and improved pulmonary hemodynamics and vascular remodeling.
Accumulated evidence indicates that ER stress participates in diverse PAH-triggering and PAH-facilitating processes such as inflammation, hypoxia and genetic mutation [
34,
39]. All branches of the UPR under ER stress are activated, accompanied by inflammatory responses in chronic hypoxia-induced PAH. In lung sections from IPAH patients, unfolded protein response triggered by ER stress is evident [
40]. Moreover, PERK mediates the C/EBP-homologous protein (CHOP) transcriptional activation and participates in hypoxia-induced dysfunction of HPAECs [
41]. In this study, we found that PERK/ATF4 expression was up-regulated by HMGB1 and inhibition of PERK/ATF4 suppressed proliferation and migration of PASMCs. 4-PBA, a chemical chaperone, has been identified as an inhibitor of ER stress[42; 43] and has reduced the expression of ER stress indicators, including GRP78, ATF6, IRE-1 and PERK [21; 44]. We showed that ER stress was obvious in the MCT-induced PAH rat model, indicated by the morphological change of ER and elevation of PERK/ATF4 expression. Moreover, 4-PBA application inhibited PERK/ATF4 expression and contributed to the reversal of pulmonary artery vascular remodeling.
SIAH2 is a member of the seven in absentia homolog family proteins, comprising a C-terminal substrate-binding domain, a catalytic RING domain, and two zinc fingers [
45]. SIAH2 is involved in different fundamental cellular processes and activated by various stress conditions and intracellular signaling pathways [
46]. It has been reported that ER stress induces the transcription of SIAH2 [
23]. In the present study, we found that HMGB1 promoted SIAH2 expression by PERK/ATF4 axis in PASMCs and PAH rats. Furthermore, VitaminK3 as a novel inhibitor suppressed SIAH2 expression, inhibited PASMC proliferation and migration, and ultimately reversed vascular remodeling in PAH.
HIPK2 is a conserved serine/threonine kinase that modulates several biological responses, including cell proliferation, apoptosis, and DNA damage response [
47,
48]. As a signal transduction element, HIPK2 regulates molecular pathways that contribute to diabetes, nephropathy, idiopathic pulmonary fibrosis, cardiac disease and several cancers [
49‐
53]. HIPK2 overexpression plays a crucial role in promoting apoptosis in diverse cell types [
54,
55]. In hepatocellular carcinoma, HMGBI promotes ubiquitination and degeneration of HIPK2, which results in autophagy induction and tumor progression [
56]. In myocardial infarction, exercise reduces HIPK2 protein level, leading to the prevention of cardiomyocytes apoptosis and elevation of cardiac function [
57]. Consistent with these studies, we observed that HIPK2 expression was down-regulated in HMGB1-treated PASMCs and in MCT-induced PAH rats through PERK/ATF4/SIAH2 pathway.
TMP, an amide alkaloid, is the main bioactive active component of a traditional Chinese herbal medicine, Chuanxiong [
58]. TMP exerts potent effects in anti-cancer, anti-oxidation, anti-inflammation and antithrombotic [
59,
60]. At present, TMP is widely used in the clinic for the treatment of cardiovascular [
61], cerebral ischemia [
62], cancer [
63] and pulmonary hypertension [
33]. The curative effects of TMP have been shown in PAH patients indicated by the increase of average 6-min walk distance and right heart function. In PAH rats, hypoxia is an important trigger for the increase in [Ca
2+]. TMP inhibits the intracellular Ca
2+ signaling in PASMCs and reverses established PH in rats [
35]. Several studies also show that TMP exerts protective effects on various diseases via inhibition of ER stress [
64‐
66]. In coronary endothelial cells, TMP prevents Ang-II-induced endothelial dysfunction by blocking the phosphorylation of PERK and upregulation of ATF4 [
65]. In the present study, we found that TMP treatment suppressed activation of ER stress, decreased SIAH2 expression and increased HIPK2 expression, ultimately prevented PASMC proliferation/migration and ameliorated pulmonary vascular remodeling in MCT-induced PAH rats. These results are consistent with the previous study and indicate that PERK/ATF4/SIAH2/HIPK2 might be the molecular mechanism of TMP to maintain the function of pulmonary artery vascular and to inhibit the development of PAH.
Conclusion
In the present study, our study evaluated the crucial role of ER stress in the development of PAH. First, we observed that HMGB1 induced activation of ER stress, upregulation of SIAH2 and downregulation of HIPK2 in PASMCs and MCT-induced PAH rat model. Furthermore, GLY, 4-PBA and VK3 administration attenuated the increases of RVSP, mPAP and RV/(LV+S), right ventricular hypertrophy, and pulmonary vascular remodeling by targeting on PERK/ATF4/SIAH2/HIPK2 pathway in PAH rats. Our results also demonstrated that TMP as a traditional Chinese medicine inhibited PASMCs proliferation and migration, and blocked the progression of PAH through inhibition of ER stress in PAH model. Based on the history of safe usage and high efficacy of TMP, it might be an ideal and potential drug for the treatment of PAH.
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