Association of Urinary Biomarkers of Inflammation, Injury, and Fibrosis with Renal Function Decline: The ACCORD Trial.

BACKGROUND AND OBJECTIVES: Current measures for predicting renal functional decline in patients with type 2 diabetes with preserved renal function are unsatisfactory, and multiple markers assessing various biologic axes may improve prediction. We examined the association of four biomarker-to-creatinine ratio levels (monocyte chemotactic protein-1, IL-18, kidney injury molecule-1, and YKL-40) with renal outcome. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a nested case-control design in the Action to Control Cardiovascular Disease Trial by matching 190 participants with ≥40% sustained eGFR decline over the 5-year follow-up period to 190 participants with ≤10% eGFR decline in a 1:1 fashion on key characteristics (age within 5 years, sex, race, baseline albumin-to-creatinine ratio within 20 µg/mg, and baseline eGFR within 10 ml/min per 1.73 m(2)), with ≤10% decline. We used a Mesoscale Multiplex Platform and measured biomarkers in baseline and 24-month specimens, and we examined biomarker associations with outcome using conditional logistic regression. RESULTS: Baseline and 24-month levels of monocyte chemotactic protein-1-to-creatinine ratio levels were higher for cases versus controls. The highest quartile of baseline monocyte chemotactic protein-1-to-creatinine ratio had fivefold greater odds, and each log increment had 2.27-fold higher odds for outcome (odds ratio, 5.27; 95% confidence interval, 2.19 to 12.71 and odds ratio, 2.27; 95% confidence interval, 1.44 to 3.58, respectively). IL-18-to-creatinine ratio, kidney injury molecule-1-to-creatinine ratio, and YKL-40-to-creatinine ratio were not consistently associated with outcome. C statistic for traditional predictors of eGFR decline was 0.70, which improved significantly to 0.74 with monocyte chemotactic protein-1-to-creatinine ratio. CONCLUSIONS: Urinary monocyte chemotactic protein-1-to-creatinine ratio concentrations were strongly associated with sustained renal decline in patients with type 2 diabetes with preserved renal function.

Urine neutrophil gelatinase-associated lipocalin levels do not improve risk prediction of progressive chronic kidney disease.

Novel biomarkers may improve our ability to predict which patients with chronic kidney disease (CKD) are at higher risk for progressive loss of renal function. Here, we assessed the performance of urine neutrophil gelatinase-associated lipocalin (NGAL) for outcome prediction in a diverse cohort of 3386 patients with CKD in the Chronic Renal Insufficiency Cohort study. In this cohort, the baseline mean estimated glomerular filtration rate (eGFR) was 42.4 ml/min per 1.73 m(2), the median 24-h urine protein was 0.2 g/day, and the median urine NGAL concentration was 17.2 ng/ml. Over an average follow-up of 3.2 years, there were 689 cases in which the eGFR was decreased by half or incident end-stage renal disease developed. Even after accounting for eGFR, proteinuria, and other known CKD progression risk factors, urine NGAL remained a significant independent risk factor (Cox model hazard ratio 1.70 highest to lowest quartile). The association between baseline urine NGAL levels and risk of CKD progression was strongest in the first 2 years of biomarker measurement. Within this time frame, adding urine NGAL to a model that included eGFR, proteinuria, and other CKD progression risk factors led to net reclassification improvement of 24.7%, but the C-statistic remained nearly identical. Thus, while urine NGAL was an independent risk factor of progression among patients with established CKD of diverse etiology, it did not substantially improve prediction of outcome events.

The renal transcriptome of db/db mice identifies putative urinary biomarker proteins in patients with type 2 diabetes: a pilot study.

We sought to identify novel urinary biomarkers of kidney function in type 2 diabetes. We screened the renal transcriptome of db/db and db/m mice for differentially expressed mRNA transcripts that encode secreted proteins with human orthologs. Whether elevated urine levels of the orthologous proteins correlated with diminished glomerular filtration rate was tested in a cross-sectional study of n = 56 patients with type 2 diabetes. We identified 36 putative biomarker genes in db/db kidneys: 31 upregulated and 5 downregulated. Urinary protein levels of six selected candidates (endothelin-1, lipocalin-2, transforming growth factor-ß, growth and differentiation factor-15, interleukin-6, and macrophage chemoattractant protein-1) were elevated in type 2 diabetic patients with subnormal glomerular filtration rate (i.e., <90 ml·min(-1)·1.73 m(-2)), independent of microalbuminuria, age, sex, race, and use of angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists. In contrast, urinary levels of fibroblast growth factor were not increased. A composite variable of urine albumin and any of the six candidate markers was associated with subnormal estimated glomerular filtration rate more closely than albumin alone. In addition, urinary endothelin-1, growth and differentiation factor-15, and interleukin-6 were associated with a marker of proximal tubule damage, N-acetyl-ß-d-glucosaminidase activity. These results suggest that gene expression profiling in diabetic mouse kidney can complement existing proteomic-based approaches for renal biomarker discovery in humans.

Endothelin-1 increases collagen accumulation in renal mesangial cells by stimulating a chemokine and cytokine autocrine signaling loop.

Endothelin-1 (ET-1), a potent vasoconstrictor, has been implicated in the pathogenesis of collagen accumulation, extracellular matrix remodeling, and renal and cardiac fibrosis in diabetes. However, the mechanism by which ET-1 promotes collagen accumulation remains unclear. Here, we analyzed the gene expression profile of ET-1-stimulated mesangial cells to identify determinants of collagen accumulation. In human mesangial cells (a microvascular pericyte that secretes excess collagen in diabetic glomerulosclerosis), ET-1 increased mRNA and protein for MCP-1 (macrophage chemoattractant protein-1) and IL-6. ET-1-induced MCP-1 and IL-6 mRNAs and proteins were blocked by an ET(A) (but not ET(B)) receptor antagonist. ET-1/ET(A) receptor signaling evoked a 7.4-fold increase in collagen accumulation. Exogenous addition of either recombinant MCP-1 or IL-6 increased collagen accumulation by 3.5-fold. Co-stimulation with both MCP-1 and IL-6 did not elevate collagen accumulation further. Neither an MCP-1-neutralizing antibody nor an MCP-1 receptor antagonist inhibited ET-1-induced collagen accumulation. Similarly, neutralizing antibodies against IL-6 or the gp130 subunit of the IL-6 receptor did not attenuate ET-1-induced collagen accumulation. However, co-incubation with MCP-1- and IL-6-neutralizing antibodies inhibited ET-1-induced collagen accumulation by 52%, suggesting a robust autocrine loop wherein MCP-1 and IL-6 are redundant. Taken together, these results demonstrate that an autocrine signaling loop involving MCP-1 and IL-6 contributes to ET-1-induced collagen accumulation.

AMP-activated protein kinase inhibits transforming growth factor-beta-induced Smad3-dependent transcription and myofibroblast transdifferentiation.

In wound healing, myofibroblast transdifferentiation (MFT) is a metaplastic change in phenotype producing profibrotic effector cells that secrete and remodel the extracellular matrix. Unlike pathways that induce MFT, the molecular mechanisms that negatively regulate MFT are poorly understood. Here, we report that AMP-activated protein kinase (AMPK) blocks MFT in response to transforming growth factor-beta (TGFbeta). Pharmacological activation of AMPK inhibited TGFbeta-induced secretion of extracellular matrix proteins collagen types I and IV and fibronectin. AMPK activation also prevented induction of the myofibroblast phenotype markers alpha-smooth muscle actin and the ED-A fibronectin splice variant. AMPK activators did not prevent MFT in cells transduced with an adenovirus expressing dominant negative, kinase-dead AMPKalpha2. Moreover, AMPK activators did not inhibit MFT induction in AMPK(alpha1,2)(-/-) fibroblasts, demonstrating a requirement for AMPK(alpha) expression. Adenoviral transduction of constitutively active AMPK(alpha2) was sufficient to prevent TGFbeta-induced collagen I, alpha-smooth muscle actin, and ED-A fibronectin. AMPK did not reduce TGFbeta-stimulated Smad3 COOH-terminal phosphorylation and nuclear translocation, which are necessary for MFT. However, AMPK activation inhibited TGFbeta-induced transcription driven by Smad3-binding cis-elements. Consistent with a role for AMPK in transcriptional regulation, nuclear translocation of AMPKalpha2 correlated with the appearance of active AMPKalpha in the nucleus. Collectively, these results demonstrate that AMPK inhibits TGFbeta-induced transcription downstream of Smad3 COOH-terminal phosphorylation and nuclear translocation. Furthermore, activation of AMPK is sufficient to negatively regulate MFT in vitro.

Oleate induces a myofibroblast-like phenotype in mesangial cells.

OBJECTIVE: High circulating free fatty acids, commonly associated with obesity and insulin resistance, impair structure and function of the microvasculature. However, the mechanisms by which fatty acids cause microvascular remodeling are unclear. Using the mesangial cell model of microvascular pericytes, we demonstrate that the monounsaturated free fatty acid oleate induces a myofibroblast phenotype, an important cell fate transition in fibrotic remodeling of the extracellular matrix. MATERIALS AND RESULTS: Oleate induced a time- and dose-dependent increase in secretion of collagen I and fibronectin. Oleate also induced the myofibroblast phenotype markers alpha smooth muscle actin and ED-A fibronectin, and the magnitude of marker protein expression was similar to that for transforming growth factor (TGF)-beta. Oleate raised TGF-beta secretion 2.2-fold, and processing of latent to bioactive TGF-beta was also elevated. Oleate rapidly stimulated extracellular signal-regulated kinase1/2, and a pharmacological MEK inhibitor blocked TGF-beta secretion and conversion to the myofibroblast phenotype. A neutralizing TGF-beta antibody and a TGF-beta receptor kinase inhibitor blocked oleate-induced collagen I, alpha smooth muscle actin, and ED-A fibronectin, suggesting that oleate-stimulated TGF-beta was necessary for inducing myofibroblasts. CONCLUSIONS: Collectively, these results demonstrate that oleate can induce a myofibroblast phenotype in mesangial cells, which suggests a mechanism whereby elevated free fatty acids might promote microvascular remodeling in vivo.

TGF-beta-regulated collagen type I accumulation: role of Src-based signals.

Transforming growth factor-beta (TGF-beta) stimulates myofibroblast transdifferentiation, leading to type I collagen accumulation and fibrosis. We investigated the function of Src in TGF-beta-induced collagen I accumulation. In human mesangial cells, PTyr416 Src (activated Src) was 3.3-fold higher in TGF-beta-treated cells than in controls. Src activation by TGF-beta was blocked by rottlerin and by a dominant negative mutant of protein kinase Cdelta (PKCdelta), showing that TGF-beta activates Src by a PKCdelta-based mechanism. Pharmacological inhibitors and a dominant negative Src mutant prevented the increase in collagen type I secretion in cells exposed to TGF-beta. Similarly, on-target Src small interference RNA (siRNA) prevented type I collagen secretion in response to TGF-beta, but off-target siRNA complexes had no effect. It is well established in mesangial cells that upregulation of type I collagen by TGF-beta requires extracellular signal-regulated kinase 1/2 (ERK1/2), and we found that activation of ERK1/2 by TGF-beta requires Src. In conclusion, these results suggest that stimulation of collagen type I secretion by TGF-beta requires a PKCdelta-Src-ERK1/2 signaling motif.

Association between endothelin-1 and collagen deposition in db/db diabetic mouse kidneys.

Endothelin-1 has been implicated in diabetic kidney injury, but there are few firm data establishing the temporal and spatial expression of kidney endothelin-1 in diabetes. We performed an immunohistochemical and histopathological analysis to determine endothelin-1 peptide expression in the kidneys of diabetic db/db mice and non-diabetic db/m controls. Diabetic mice were studied at 8 weeks, before histological damage is evident, and again at 16 weeks, when significant glomerular injury has occurred. Urinary endothelin-1 was 6.2- and 3.6-fold higher in 8- and 16-week diabetic mice compared to age-matched controls (P<0.01 db/db vs. db/m). Compared to non-diabetic kidneys, immunoreactive endothelin-1 was first elevated 2.5-fold (P=0.02) in the tubulointerstitial compartment at 8-week and remained high (3.8-fold, P<0.01) at 16 weeks. In contrast, glomerular endothelin-1 was elevated 3.2-fold (P=0.03) only in 16-week diabetic mice. Glomerular and tubulointerstitial endothelin-1 were unchanged in 8- and 16-week non-diabetic mice. Elevated endothelin-1 in diabetic mice associated temporally and spatially with collagen deposition, especially in the tubulointerstitial compartment. The localization of kidney endothelin-1 is consistent with a role for this peptide in renal fibrogenesis. These results also highlight the potential role of ET-1 in the pathogenesis of early tubulointerstitial changes in diabetes.

Cell cycle signaling by endothelin-1 requires Src nonreceptor protein tyrosine kinase.

Cross-talk between G protein-coupled receptors and protein tyrosine kinases is well established, but the phenotypic consequences of these signaling interactions are not completely understood. To investigate the role of Src family kinases in mitogenic signaling by G protein-coupled receptors, we used genetic and pharmacological inhibition of Src to study cell growth in response to endothelin-1. We found that dominant-negative Src and COOH-terminal Src kinase blocked mesangial cell growth in response to endothelin-1, whereas growth induced by v-Ras was unaffected. Endothelin-1-induced cell growth was blocked by the pharmacological Src antagonist 4-amino-5-(4-chlorophenyl)-7-(t-butyl)pyrazolo[3,4-d]pyrimidine (PP2) but not by the inactive analog 4-amino-7-phenylpyrazol[3,4-d]pyrimidine. RNA interference knockdown of Src with on-target but not with off-target small interfering RNAs also inhibited growth in cells treated with endothelin-1. Dominant-negative Src prevented growth in cells activated by platelet-derived growth factor alone or in combination with endothelin-1, which suggests that Src integrates mitogenic signals from diverse classes of cell surface receptors. To further explore the role of Src in mitogenic signaling by G protein-coupled receptors, we sought to determine whether endothelin-1 induced cyclin D1 by a Src-based mechanism. We found that endothelin-1 increased cyclin D1 protein, which was blocked by preincubation with the Src antagonist PP2 and with the protein kinase C antagonist bisindolylmaleimide I. These results provide evidence for a Src- and protein kinase C-based pathway of mitogenic signaling by endothelin-1 receptors that involves cyclin D1.

Saturated free fatty acids and apoptosis in microvascular mesangial cells: palmitate activates pro-apoptotic signaling involving caspase 9 and mitochondrial release of endonuclease G.

BACKGROUND: In type 2 diabetes, free fatty acids (FFA) accumulate in microvascular cells, but the phenotypic consequences of FFA accumulation in the microvasculature are incompletely understood. Here we investigated whether saturated FFA induce apoptosis in human microvascular mesangial cells and analyzed the signaling pathways involved. METHODS: Saturated and unsaturated FFA-albumin complexes were added to cultured human mesangial cells, after which the number of apoptotic cells were quantified and the signal transduction pathways involved were delineated. RESULTS: The saturated FFA palmitate and stearate were apoptotic unlike equivalent concentrations of the unsaturated FFA oleate and linoleate. Palmitate-induced apoptosis was potentiated by etomoxir, an inhibitor of mitochondrial beta-oxidation, but was prevented by an activator of AMP-kinase, which increases fatty acid beta-oxidation. Palmitate stimulated an intrinsic pathway of pro-apoptotic signaling as evidenced by increased mitochondrial release of cytochrome-c and activation of caspase 9. A caspase 9-selective inhibitor blocked caspase 3 activation but incompletely blocked apoptosis in response to palmitate, suggesting an additional caspase 9-independent pathway. Palmitate stimulated mitochondrial release of endonuclease G by a caspase 9-independent mechanism, thereby implicating endonuclease G in caspase 9-independent regulation of apoptosis by saturated FFA. We also observed that the unsaturated FFA oleate and linoleate prevented palmitate-induced mitochondrial release of both cytochrome-c and endonuclease G, which resulted in complete protection from palmitate-induced apoptosis. CONCLUSIONS: Taken together, these results demonstrate that palmitate stimulates apoptosis by evoking an intrinsic pathway of proapoptotic signaling and identify mitochondrial release of endonuclease G as a key step in proapoptotic signaling by saturated FFA and in the anti-apoptotic actions of unsaturated FFA.

High glucose evokes an intrinsic proapoptotic signaling pathway in mesangial cells.

BACKGROUND: In response to chronic hyperglycemia, microvascular cells undergo stress and injury, which can lead to cell death. We characterized a proapoptotic signaling pathway whereby high glucose evokes an intrinsic, caspase-9-dependent mechanism of cell death in human mesangial cells. METHODS: Biochemical (caspase activity, cytochrome-c release, etc.) and morphologic (chromatin condensation and nuclear segmentation) features of apoptotic cell death were assessed in cultured human mesangial cells exposed to high glucose, a risk factor for mesangial cell injury and diabetic glomerulosclerosis. Proapoptotic signaling was also analyzed in the db/db murine model of kidney injury in diabetes. RESULTS: Incubation in high glucose caused cytotoxicity and apoptosis in mesangial cells. High glucose stimulated mitochondrial release of cytochrome-c, cleavage of procaspase-9, and caspase-9 enzyme activity, suggesting an intrinsic pathway of proapoptotic signaling. In contrast, caspase-8 was unaffected by high glucose. A cell-permeable, caspase-9-selective inhibitor blocked caspase-3 activation and prevented chromatin condensation and nuclear segmentation in cells treated with high glucose. To determine whether an intrinsic signaling pathway occurs in the diabetic kidney in vivo, apoptosis was investigated in diabetic 8- and 16-week db/db murine kidneys. Effector caspases-3 and -7 were activated in diabetic db/db kidneys but not in age-matched nondiabetic db/m controls. At 16 weeks, apoptotic cells in db/db glomeruli were identified on the basis of nuclear segmentation and DNA fragmentation. Apoptosis of glomerular cells correlated with expansion of the mesangial matrix and with worsening of albuminuria. Consistent with an intrinsic signaling pathway, caspase-9 cleavage was elevated only in db/db kidneys, whereas activation of caspase-8 and caspase-12 was undetectable. CONCLUSION: These findings support the hypothesis that hyperglycemia evokes an intrinsic pathway of proapoptotic signaling in mesangial cells. In addition, these results point to an important role for the intrinsic pathway in microvascular injury in the diabetic kidney in vivo.

Adipose differentiation-related protein and regulators of lipid homeostasis identified by gene expression profiling in the murine db/db diabetic kidney.

We investigated the molecular basis of progressive diabetic renal injury in db/db mice by profiling kidney gene expression. Using high-density microarrays, we identified 482 RNA transcripts differentially expressed in 8-wk db/db vs. nondiabetic db/m kidneys, a time characterized by hyperglycemia but by little renal histopathology. By 16 wk significant mesangial expansion had developed. Sixteen-week db/db kidneys differentially expressed 639 RNA transcripts. Diabetic kidneys specifically expressed several genes normally found in adipocytes, including adipocyte differentiation-regulated protein (ADRP; or adipophilin in humans). ADRP mRNA was specifically upregulated 5.4-fold in 16-wk db/db kidneys. This finding was confirmed at the protein level by Western blotting, and immunohistochemistry localized ADRP diffusely to tubular epithelium throughout the cortex. ADRP is a perilipin family protein that forms lipid storage vesicles and controls triglyceride utilization; we showed that accumulation of lipid storage droplets correlated with the magnitude and localization of ADRP in db/db kidneys. Other genes involved in lipid transport, oxidation, and storage were differentially regulated in db/db kidneys, and peroxisome proliferator-activated receptor-alpha (PPAR alpha) has been shown to regulate their expression in adipocytes. In our experiments, PPAR alpha mRNA was elevated in db/db diabetic kidneys, and PPAR alpha protein was upregulated in glomeruli, cortical tubules, and renal arterial vessels of db/db mice. In conclusion, these studies furnish new RNA-based data for mechanistic investigation into renal injury in the diabetic kidney and identify a switch of kidney phenotype in favor of lipid accumulation in diabetic kidney.

Gene expression profile of endothelin-1-induced growth in glomerular mesangial cells.

Endothelin (ET)-1 is a vasoconstrictor and mitogen involved in vascular remodeling. Changes in gene expression that underlie control of cell growth by ET-1 remain poorly characterized. To identify pathways of growth control we used microarrays to analyze ET-1-regulated gene expression in human mesangial cells, an important ET-1 vascular target cell in vivo. Statistical assessment of differential expression (significance analysis of microarrays) revealed upregulated transcripts for growth factors [heparin-binding epidermal growth factor (EGF)-like growth factor (HB-EGF), fibroblast growth factor (FGF), interleukin (IL)-6] and downregulated transcripts for genes that inhibit growth (BAX, p27KIP1, DAD1). Consistent with the gene expression profile, quantitative RT-PCR and Western blotting confirmed induction of HB-EGF by ET-1. To test a functional role for HB-EGF in ET-1 signaling, we showed that exogenous HB-EGF stimulated phosphorylation of ErbB1 and growth of mesangial cells. ET-1-induced proliferation was blocked by an ErbB1 receptor-selective kinase inhibitor and by a specific ErbB1 receptor-neutralizing antibody. Proliferation in response to ET-1 was also inhibited by neutralizing antisera against human HB-EGF. Together, these results provide data for modeling ET-1 pathways for growth control and suggest a specific role for HB-EGF gene induction in mesangial cell growth in response to ET-1.

Ca2+/calmodulin-dependent protein kinase II stimulates c-fos transcription and DNA synthesis by a Src-based mechanism in glomerular mesangial cells.

Mesangial cell growth factors elevate intracellular free [Ca2+]i, but mechanisms linking [Ca2+]i to gene expression and DNA synthesis are unclear. This study investigated the hypothesis that Ca2+/calmodulin-dependent protein kinase II (CaMK II), which is activated by elevated [Ca2+]i, increases c-fos transcription and DNA synthesis via a Src-based mechanism. In cultured rat mesangial cells, dominant negative Src (SrcK-) blocked activation of the c-fos gene promoter by CaMK II 290, a constitutively active form of CaMK IIalpha. Activation of the c-fos promoter by CaMK II 290 was also blocked by COOH-terminal Src kinase, which phosphorylates and inactivates c-Src. A pharmacologic CaMK inhibitor, KN-93, did not block activation of the c-fos promoter by ectopically expressed v-Src. Stimulation of c-Src by endothelin-1 required CaMK II activity, further supporting the notion that CaMK II acts upstream of Src in a signaling cassette. Activation of the c-fos promoter by CaMKII290 and Src required the c-fos serum response element. Dominant negative SrcK- also blocked induction of DNA synthesis in mesangial cells by CaMK II 290. Collectively, these results suggest that in mesangial cells Src protein tyrosine kinases act downstream of CaMKII in a signaling pathway in which [Ca2+]i induces the c-fos promoter and increases DNA synthesis.

Gene expression profiling reveals role for EGF-family ligands in mesangial cell proliferation.

Control of mesangial cell growth and matrix accumulation is critical for normal development of the glomerular tuft and progression of glomerular injury, but the genes that control mesangial cell growth are not well understood. We used high-density oligonucleotide microarrays to analyze gene expression in well-differentiated human mesangial cells treated with serum to stimulate proliferation. Parallel measurement of >12,000 genes and expressed sequence tags identified 5,806 mRNA transcripts in quiescent, unstimulated cells and 609 genes significantly induced or repressed by serum. Functional classification of serum-regulated genes revealed many genes not directly related to cell cycle progression that, instead, might control renal hemodynamics and glomerular filtration or cause tissue injury, leukocyte exudation, matrix accumulation, and fibrosis. Hierarchical cluster analysis defined sets of coregulated genes with similar functions and identified networks of proinflammatory genes with similar expression patterns. Pathway analysis of the gene expression profile suggested an autocrine role in mesangial cell proliferation for three growth factors in the epidermal growth factor (EGF) family: heparin-binding EGF-like growth factor, amphiregulin, and epiregulin. A functional role for EGF receptor (EGFR) activation was confirmed by blocking serum-induced proliferation with an EGFR-selective kinase inhibitor and a specific EGFR-neutralizing antibody. Taken together, these results suggest a role for EGFR signaling in control of mesangial cell growth in response to serum.

Inhibition of endothelin-1 improves survival and vasculopathy in rat cardiac transplants treated with cyclosporine.

BACKGROUND: In animal models, endothelin-1 (ET-1) blockade attenuates transplant vasculopathy and chronic allograft dysfunction even in the absence of cyclosporine (CsA). As CsA has side effects and ET-1 antagonism alone has significant benefits, we postulated that allograft survival could be significantly improved by combining an endothelin-converting enzyme inhibitor with low-dose CsA. METHODS: Survival of Lewis to Fisher 344 rat heterotopic cardiac allografts was determined in untreated animals and compared with those treated with high-dose CsA (62 mg/kg i.m. on day 2), low-dose CsA (25 mg/kg), an endothelin-converting enzyme inhibitor, phosphoramidon (PA, 10 mg/kg/day), or low-dose CsA + PA. RESULTS: Untreated allografts had a median survival of 16 days compared with 20 days for low-dose CsA. Grafts treated with PA survived for 28 days, and combination of PA and low-dose CsA improved median survival to 47 days (P<0.01). Median survival with combination therapy was similar to that for high-dose CsA (42 days). To explore mechanisms underlying the benefits of combination therapy, cardiac allografts treated as above (n=4 each group) were explanted at 20 d and analyzed for parenchymal rejection, neointimal vasculopathy, myocardial fibrosis, and macrophage infiltration. Low-dose CsA alone but not PA improved parenchymal rejection; in contrast, PA alone but not low-dose CsA improved vasculopathy. Both parenchymal rejection and vasculopathy were improved by combination therapy with low-dose CsA and PA. Unlike CsA, inhibition of ET-1 biosynthesis significantly reduced myocardial fibrosis in allografts. CONCLUSIONS: These results suggest that the combination of low-dose CsA and endothelin-converting enzyme inhibition may prove useful to improve long-term graft survival while minimizing potential side effects of CsA.

Cyclic AMP-Independent Mechanisms of Nuclear Signal Transduction by PGE(2).

Arachidonic acid-derived mediators induce transcription of several immediate early genes, but the molecular mechanisms underlying these responses remain poorly characterized. We designed experiments to explore the mechanisms by which PGE(2) induces expression of transcription factor c-fos in glomerular mesangial cells. Binding of PGE(2) to prostaglandin receptors in mesangial cells stimulates both adenylate cyclase and phospholipase C-linked signaling pathways. Prostaglandin E(2) (PGE(2)) induced marked and transient accumulation of c-fos mRNA, but induction of the c-fos gene occurred independent of PGE(2)-stimulated adenylate cyclase activity. These results contrast with previous experiments in NIH 3T3 cells in which PGE(2) stimulated c-fos accumulation by a cAMP-dependent mechanism. We further showed that PGE(2) induces c-fos gene expression by increasing the transactivating capacity of the serum response element. Collectively, these results provide evidence of a cAMP-independent pathway linking PGE(2) receptors to transcriptional activation in the nucleus. Thus, activation of PGE(2) receptors in different cell types leads to both cAMP-independent and -dependent pathways for gene expression.