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From the Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| Abstract |
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| Introduction |
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The C5b-9 membrane attack complex induces injury in diverse renal glomerular diseases. For example, in the rat passive Heymann nephritis (PHN) model of membranous nephropathy, impairment of glomerular capillary wall permselectivity (proteinuria) is mediated by antibody and C5b-9.8,9 The primary target of C5b-9 is the visceral glomerular epithelial cell (GEC), which suffers noncytolytic injury.8,9 C5b-9 also stimulates production of glomerular eicosanoids, including prostaglandin E2 (PGE2) and thromboxane A2,10-12 and the latter may enhance proteinuria in certain models of membranous nephropathy.11-14 This effect of thromboxane A2 may be through an increase in glomerular transcapillary pressure, which appears to be responsible for a portion of the enhanced urine protein excretion.15,16
We have used well differentiated rat GEC
in culture to define biochemical pathways that are activated by
sublytic C5b-9. By analogy to GEC in vivo, in cultured GEC,
sublytic C5b-9 injures plasma membranes.17
Sublytic C5b-9
also increases cytosolic Ca2+
concentration,3,18
stimulates phospholipases C, including
phospholipase C-
1, which leads to production of inositol phosphates
and 1,2-diacylglycerol,3,19,20
stimulates activities of
protein kinase C (PKC) and extracellular signal-regulated kinase-2
(ERK2),20
activates cytosolic phospholipase
A2 (cPLA2), and releases
arachidonic acid (AA) and eicosanoids.18,20-22
Our
studies suggest that the functional consequences of
cPLA2 activation include production of
eicosanoids and exacerbation of complement-induced GEC
injury.22
The functional role of ERK2 activation remains
to be determined.
Although we and others have characterized multiple signaling pathways
that are activated by C5b-9, less is known about plasma
membrane-associated events triggered by C5b-9 assembly, or the
activation of very early steps in these pathways. There is no known
transmembrane receptor for C5b-9, however, in B cell lines, the C5b-9
complex is reported to couple to heterotrimeric G-proteins, which can
activate downstream effectors.5
The present study
addresses another mechanism by which assembly of C5b-9 may lead to the
activation of protein kinases and phospholipases, ie, the
transactivation of receptor tyrosine kinases (RTKs). Generally, RTKs
function as transmembrane receptors for peptide ligands such as growth
factors and contain an intrinsic tyrosine kinase as a part of their
cytoplasmic domains.23-25
It is believed that binding of
a peptide ligand to the extracellular domain of the corresponding RTK
leads to an increase in tyrosine kinase activity, in association with
phosphorylation of the receptor on multiple cytoplasmic tyrosine
residues, and phosphorylation of substrate proteins.23-25
The signal may then be transmitted to nuclear or cytoplasmic
effectors through a series of adaptor molecules and serine/threonine
protein kinases known collectively as the mitogen-activated protein
kinase pathway.24,25
Alternatively, enzymes, including
phospholipase C-
1, can associate with the phosphorylated RTK and
undergo activation.24,25
Recently, it has been reported
that the epidermal growth factor receptor (EGF-R) tyrosine kinase can
be activated not only by EGF, but also, in the absence of natural
ligand, via transactivation by G-protein-coupled
receptors.26-28
Using rat GEC in culture, we demonstrated
that early signals elicited by C5b-9 assembly in the plasma membrane
include tyrosine phosphorylation of various RTKs, including EGF-R.
Inhibition of the EGF-R tyrosine kinase, in part, abolishes
C5b-9-induced activation of ERK2 and cPLA2 and
production of PGE2. Furthermore, we extended
these results in cultured GEC to C5b-9-mediated injury in
vivo by demonstrating that ERK2 activity and
PGE2 synthesis are increased in glomeruli of rats
with PHN and that these increases are partially blocked after
inhibition of the EGF-R tyrosine kinase.
| Materials and Methods |
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Tissue culture reagents were obtained from Life Technologies (Burlington, ON). C8-deficient serum and purified C8 were purchased from Quidel (San Diego, CA). Lipids, phorbol myristate acetate (PMA), digitonin, AG1478, PGE2, and anti-PGE2 antiserum were purchased from Sigma Chemical Co. (St. Louis, MO). EGF, basic fibroblast growth factor (bFGF), and hepatocyte growth factor were from Collaborative Research (Bedford, MA). PP1 was from Biomol Research Laboratories (Plymouth Meeting, PA), and RG50864 (AG213) was from Rhone-Poulenc Rorer (Collegeville, PA). Anti-phosphotyrosine monoclonal antibody, PY20, was from Transduction Laboratories (Lexington, KY). Rabbit antibodies to Neu, FGF-R2, Met, and ERK2 and agarose-conjugated glutathione S-transferase (GST)-Grb2-(1217) fusion protein were purchased from Santa Cruz Biotechnology (Santa Cruz, CA). Rabbit anti-phosphoERK antibody was purchased from New England Biolabs (Mississauga, ON). Rabbit anti-EGF-R antibody, RK2, and sheep anti-rat Fx1A were described previously.29,30 [3H]AA (100 Ci/mmol), and [3H]PGE2 (200 Ci/mmol) were from New England Nuclear (Boston, MA). Electrophoresis and immunoblotting reagents were from Bio-Rad Laboratories (Mississauga, ON). Male Sprague-Dawley rats were purchased from Charles River Canada (St. Constant, PQ).
Cell Culture and Transfection
Rat GEC culture and characterization have been published previously.17 GEC were cultured in K1 medium on plastic substratum. Experiments measuring free [3H]AA used GEC that stably overexpress cPLA2. Parental GEC or GEC that express the neomycin-resistance gene (neo) were generally used in other experiments. Production and characterization of these cell lines were described previously.18,22
Incubation of GEC with Complement
The standard protocol involved incubation of GEC in monolayer culture with rabbit anti-GEC antiserum (510% v/v) in modified Krebs-Henseleit buffer containing 145 mmol/L NaCl, 5 mmol/L KCl, 0.5 mmol/L MgSO4, 1 mmol/L Na2HPO4, 0.5 mmol/L CaCl2, 5 mmol/L glucose, and 20 mmol/L Hepes, pH 7.4, for 40 minutes at 22°C.3,4,19-22 GEC were then incubated at 37°C with normal human serum (2.5% v/v in Krebs-Henseleit buffer), or with heat-inactivated (decomplemented) human serum (56°C) in controls. In some experiments, antibody-sensitized GEC were incubated with 2.5% C8-deficient human serum (C8DS) supplemented with purified C8 (80 µg/ml undiluted serum), or with 2.5% C8DS alone in controls. We have generally used heterologous complement to facilitate studies with complement-deficient sera and to minimize possible signaling via complement-regulatory proteins; however, in previous studies, results of several experiments were confirmed with homologous (rat) complement.18 Sublytic concentrations of complement (<5% normal human serum) were established previously.22 In GEC, complement is not activated in the absence of antibody.17
Sublytic complement cytotoxicity was monitored by measuring release of biscarboxyethyl carboxyfluorescein (BCECF) as detailed previously.17,22 Complement lysis was determined by measuring release of lactate dehydrogenase, similarly to the method described previously.17
Induction of PHN
PHN was induced by a single intravenous injection of 0.4 ml of sheep anti-rat Fx1A antiserum.30 Urine was collected overnight at day 1314 postinjection. Glomeruli were isolated by differential sieving on day 1430 and were suspended in modified Krebs-Henseleit buffer for experiments.
Tyrosine Phosphorylation
After incubation with antibody and complement, ~6 x 106 GEC were lysed, and proteins were immunoprecipitated with primary rabbit antisera directed to specific RTKs, as described previously.25 After immunoprecipitation, immune complexes were incubated with agarose-coupled protein A. For analysis of GST-Grb2-associated proteins, ~2 x 107 GEC were lysed and incubated with agarose-conjugated GST-Grb2 fusion protein (4 µg) for 3 hours at 4°C. Complexes were boiled in Laemmli sample buffer and subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) under reducing conditions. Proteins were then electrophoretically transferred onto nitrocellulose paper, blocked with 3% bovine serum albumin/2% ovalbumin, and incubated with antibody to phosphotyrosine. Blots were developed using alkaline phosphatase-conjugated secondary antibody and colorimetric detection.31 To assess ERK2 activation, ~1 x 106 GEC were lysed and 25 µg of lysate were subjected to SDS-PAGE. Activation of ERK2 was monitored by immunoblotting with anti-phosphoERK antibody, ie, antibody that reacts with ERK phosphotyrosine204. RTK tyrosine phosphorylation and ERK2 tyrosine204 phosphorylation were quantitated by densitometry, as described previously.29 Tyrosine phosphorylation of glomerular proteins was monitored in an analogous manner. Immunoblotting for RTK or ERK2 proteins was carried out as described above, except that blots were developed with RTK- or ERK2-specific antibodies.
Measurement of Free [3H]AA
GEC phospholipids were labeled to isotopic equilibrium with [3H]AA for 48 to 72 hours, as detailed previously.3,18-22 Lipids were extracted from ~1 x 106 cells and cell supernatants. Methods for extracting and separating radiolabeled lipids by thin layer chromatography are published.3,18-22
Measurement of PGE2
PGE2 was measured by radioimmunoassay in lipid extracts of GEC plus culture supernatants, or in glomerular supernatants, using anti-PGE2 antiserum and [3H]PGE2 tracer, as described previously,7 and according to the manufacturers protocol (Sigma). For GEC, [3H]PGE2 (1000 cpm) was added just before extraction to correct for extraction efficiency. Briefly, samples were incubated with [3H]PGE2 and anti-PGE2 antibody for 1 hour at 4°C, after which unbound PGE2 was removed by the addition of activated charcoal. The radioactivity of the supernatant was counted in a ß-scintillation counter, and PGE2 concentration was calculated from standard formulas. The range of the standard curve in the assay was 15 to 500 pg of PGE2 per 100-µl sample.
Statistics
Data are presented as mean ± SE. The t statistic was used to determine significant differences between two groups. For more than two groups, one-way analysis of variance (ANOVA) was used to determine significant differences among groups; where significant differences were found, individual comparisons were made between groups using the t statistic and adjusting the critical value according to the Bonferroni method.
| Results |
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Sublytic C5b-9 activates phospholipases and protein kinases in
cultured GEC.18-22
To determine how sublytic C5b-9
induces activation of these enzymes, we examined if assembly of C5b-9
in the plasma membrane may result in the transactivation of RTKs, by
monitoring tyrosine phosphorylation of RTKs. Compared with control
incubations (heat-inactivated serum), activation of complement (normal
serum) produced marked increases in tyrosine phosphorylation of EGF-R,
Neu (erbB-2, an EGF-R family member),32
FGF-R2,33
and Met,34
the receptor for
hepatocyte growth factor (Figure 1)
.
Quantitation of RTK tyrosine phosphorylation by densitometry
(Table 1)
confirmed the visual impression
in Figure 1
. Complement, however, had no effect on the expression of
RTK proteins (Figure 1)
, indicating that RTK phosphorylation was most
likely due to posttranslational modification.
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Activated EGF-R can recruit several substrate proteins, eg, Grb2, that
bind via SH2 domains to receptor phosphotyrosine residues. To determine
whether complement-induced EGF-R tyrosine phosphorylation correlated
with EGF-R activation, we examined if EGF-R interacted with a GST-Grb2
fusion protein. A phosphoprotein of ~170 kd associated with GST-Grb2
after incubation of GEC with complement (normal serum), but not in
control incubations (Figure 2
, middle
panel). This phosphoprotein was recognized by anti-EGF-R antibody
(Figure 2
, left panel), and on SDS-PAGE, it co-migrated with a
phosphoprotein that associated with GST-Grb2 after treatment of GEC
with EGF (Figure 2
, right panel). These data indicate that the 170-kd
protein was most likely EGF-R. Figure 2
(middle panel) also
demonstrates some fainter phosphoprotein bands in complement-treated
cells. These phosphoproteins may represent other RTKs or RTK
substrates; however, it was not possible to identify these proteins
definitively, because Grb2 interactions with RTKs tend to be weak as
compared with, for example, antigen-antibody
interactions,24
and in GEC, they were at the lower limit
of detectability.
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In previous studies, we demonstrated that C5b-9 increases free
[3H]AA via activation of
cPLA2. Using GEC that stably overexpress
cPLA2, we showed that cPLA2
activation is dependent on a rise in cytosolic
Ca2+ concentration and on the activation of PKC,
but is independent of the Ras-ERK pathway.18,20,22
In
keeping with previous results, we demonstrate that incubation of
antibody-sensitized GEC with normal serum stimulated a marked increase
in free [3H]AA as compared with
heat-inactivated serum (Figure 3A)
. By
analogy, incubation with C8DS (C5b-7) had no significant effect on
basal levels of [3H]AA, but when C8DS was
reconstituted with purified C8, free [3H]AA
increased markedly (Figure 3B)
. Complement-induced release of
[3H]AA release occurred within 30 minutes, and
elevated levels of free [3H]AA persisted for at
least 3 hours (Figure 4)
. In these
experiments (and in studies of ERK2 activation, described below),
C8DS+C8 and normal serum were used at the same final concentrations
(2.5% v/v); however, the effects of C8DS+C8 on
[3H]AA release were generally less potent than
those of normal serum. Studies carried out to assess sublytic GEC
injury, ie, BCECF release,17,22
demonstrated that specific
BCECF release was lower with C8DS+C8, as compared with normal serum
(Table 2A)
, indicating that the
C8-reconstituted C8DS had less complement activity than normal serum.
Thus, the more potent [3H]AA release by normal
serum could be accounted for by greater complement activity.
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Incubation of GEC for 18 hours with PMA (2 µg/ml) leads to complete depletion (down-regulation) of PKC.20 In keeping with previous results,20 C5b-9-mediated release of [3H]AA was inhibited by 67 ± 5% in GEC depleted of PKC (P < 0.005, 3 experiments). Treatment of PKC-depleted GEC with AG1478 (300 nmol/L) had no additional inhibitory effect on complement-mediated release of [3H]AA (75 ± 4% inhibition; 3 experiments, P not significant). Together, the results suggest that complement-induced transactivation of EGF-R and activation of PKC occur within the same pathway, but because PKC-induced release of [3H]AA was insensitive to AG1478, PKC activation occurs downstream of EGF-R.
Release of AA due to C5b-9-mediated activation of
cPLA2 is coupled to production of
PGE2.22
These results were confirmed
in the present study (Figure 5)
. In
addition, we demonstrate that AG1478 blocked the complement-mediated
increase in PGE2, in keeping with its effect on
AA release (Figure 5)
.
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In a previous study, we used an immune complex kinase assay to
demonstrate that sublytic C5b-9 stimulates ERK2 activity, as well as
ERK2 tyrosine phosphorylation.20
In keeping with these
results, the present study shows that C5b-9 induced ERK2
tyrosine204 phosphorylation, which correlates
with ERK2 activation (Figure 6
, Table 4
). Incubation of GEC with antibody and
C8DS reconstituted with purified C8 induced ERK2
tyrosine204 phosphorylation, whereas in
incubations with C8DS alone (C5b-7), ERK2 phosphorylation was weak,
comparable to basal levels observed in unstimulated GEC
(Figure 6A)
. The effect of the exogenous PKC activator, PMA, on
ERK2 phosphorylation was greater than the effect of
C8DS+C8 (Figure 6A)
. By analogy, incubation of
antibody-sensitized GEC with normal serum markedly increased
ERK2 phosphorylation, as compared with heat-inactivated serum (Figure 6B
and Table 4
). Complement-induced ERK2
tyrosine204 phosphorylation occurred within 30
minutes, and elevated levels of free [3H]AA
persisted for ~3 hours, thereafter declining to baseline (Figure 4)
.
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The above studies used GEC in culture to characterize biochemical pathways activated by C5b-9. However, it is also important to demonstrate that analogous pathways are activated in vivo, specifically, in the PHN model of membranous nephropathy, where C5b-9 assembles in GEC plasma membranes and induces injury.8,9 Studies were carried out in rats with autologous phase PHN (day 14), which is known to be complement-mediated.37 At the 14-day time point, rats with PHN excreted 434 ± 23 mg of urinary protein per 24 hours (n = 12), as compared with 12 ± 2 mg per 24 hours in normal control rats (n = 8, P < 0.0001 PHN versus control).
In short-term incubations, glomeruli isolated from rats with PHN
synthesized eicosanoids at a rate greater than isolated normal
glomeruli, indicating that the C5b-9 assembled in vivo
remained active after glomerular isolation.10-12
Thus, we
carried out experiments to determine whether the mechanism for the
C5b-9-stimulated PGE2 production in PHN may
involve the EGF-R tyrosine kinase. Glomeruli were isolated from rats
with PHN on day 14 and from control rats, and were incubated briefly
with or without AG1478. PGE2 production was then
measured in glomerular supernatants. PGE2
production was greater in glomeruli from rats with PHN, as compared
with controls, and was reduced significantly when glomeruli from PHN
rats were incubated in the presence of AG1478 (Figure 7)
. AG1478 did not, however, affect
PGE2 production significantly in control
glomeruli (Figure 7)
.
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Glomeruli were isolated from normal rats and from rats with PHN
(day 14), and glomerular proteins were subjected to immunoblotting with
anti-phosphotyrosine antibody. Multiple phosphoproteins were present in
both PHN and control glomeruli. However, a band at ~42 kd was
significantly more prominent in PHN glomeruli as compared with control
(Figure 8A)
. The molecular mass of this
protein suggested that it was ERK2. Glomerular proteins were then
immunoblotted with anti-phosphoERK antibody. There was weak basal ERK2
tyrosine204 phosphorylation in control glomeruli,
but phosphorylation was enhanced in PHN glomeruli (Figure 8B)
. There
were, however, no differences in the expression of ERK2 protein between
PHN and control glomeruli (results not shown). To confirm the visual
impression in Figure 8B
, glomerular ERK2
tyrosine204 phosphorylation and protein content,
were quantitated by densitometry. The phosphoERK-to-ERK ratio was
0.23 ± 0.06 units in control glomeruli (n
= 5) and was increased to 0.36 ± 0.04 units in PHN glomeruli
(n = 6, P < 0.04
versus control). It should be noted that the 42-kd band
identified by anti-phosphotyrosine antibody in PHN glomeruli is
markedly more intense than in control glomeruli (Figure 8A)
, whereas
the difference in the relative intensities of the bands recognized by
anti-phosphoERK antibody was not as dramatic (Figure 8B)
. This result
suggests that the 42-kd phosphoprotein may not be exclusively ERK2.
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| Discussion |
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Further support for the role of RTKs in mediating C5b-9-dependent ERK2
activation and release of AA was provided by experiments demonstrating
that the natural ligands of EGF-R and Met (ie, EGF or hepatocyte growth
factor, respectively) could also activate these two pathways in GEC
(Figures 3 and 6)
. Thus, EGF-R and Met actually couple with ERK2 and
cPLA2 pathways in GEC. It should also be noted
that in GEC, EGF induces tyrosine phosphorylation of both EGF-R and
Neu, a RTK that is related to EGF-R, but does not bind EGF
directly.32
This result (unpublished observation)
indicates that Neu phosphorylation may occur secondarily to that of
EGF-R. bFGF did not appear to stimulate ERK2 activation or AA release.
Possibly, FGF-R2 does not couple to these effectors in GEC. So far, we
have not examined complement transactivation of any other RTKs in GEC.
Transactivation of EGF-R by G-protein-coupled receptors has been
reported recently.26-28
In these studies, agonists that
bind to receptors coupled with G-proteins, including endothelin-1,
lysophosphatidic acid, or thrombin, activated ERK and induced
mitogenesis via phosphorylation of EGF-R and Neu tyrosine kinases.
These effects appeared to be specific to EGF-R (or Neu), and did not,
for example, involve the platelet-derived growth factor receptor. In
another study, ultraviolet light or osmotic stress were reported to
induce activation of the c-Jun amino terminal kinase, in part, via
EGF-R tyrosine phosphorylation.39
Results of the
G-protein-coupled receptor studies differ somewhat from ours in that
RTK transactivation via C5b-9 was not restricted to a single RTK or one
RTK family. It has been proposed that transactivation of RTKs enables
the RTK to serve as a scaffold and permit docking of molecules that
lead to activation of effector pathways.26-28
Our earlier
studies have demonstrated that C5b-9-induced activation of
cPLA2 is dependent on the activation of PKC, but
is independent of Ras-ERK2 and is associated with tyrosine
phosphorylation of phospholipase C-
1, and 1,2-diacylglycerol
production.20
C5b-9-induced activation of ERK2 is mediated
via both the PKC pathway, as well as independently of PKC, probably via
Ras.20
Therefore, transactivation of EGF-R by C5b-9 likely
results in binding of Grb2-Sos by the phosphotyrosine residues of the
cytoplasmic domain (Figure 2)
, leading to activation of Ras, Raf, and
the ERK2 pathway, and it could also result in binding/activation of
phospholipase C-
1, followed by diacylglycerol production and
stimulation of PKC.24,25
Presently, it is unknown whether RTK transactivation is due to a direct molecular interaction between proteins within the C5b-9 complex and RTKs, whether C5b-9 alters the composition of the plasma membrane such that RTK enzymatic activity increases, or if there may be activation of an intermediary tyrosine kinase by C5b-9, which then secondarily phosphorylates RTKs. Similarly, the mechanism by which G-protein-coupled receptors transactivate EGF-R26-28 has not been established. Stimulation of cells with ultraviolet light or osmotic stress appeared to induce clustering of multiple receptors, including EGF-R, in the plasma membrane, and it was proposed that receptor clustering was required for activation of c-Jun amino terminal kinase.39 We attempted to localize EGF-Rs in GEC before and after C5b-9 stimulation, using immunofluorescence microscopy, however, we were not able to detect EGF-R consistently (unpublished observations), probably because GEC express EGF-R at relatively low levels.36 We also considered that C5b-9 may have induced production of reactive oxygen species,40 which led to inhibition of phosphotyrosine phosphatases, with a consequent increase in RTK activity.41 However, inclusion of reactive oxygen species scavengers in incubations did not affect C5b-9-dependent release of [3H]AA (unpublished observations), suggesting that phosphatase inhibition was not involved. The precise mechanism for induction of RTK phosphorylation by C5b-9 will require further study.
The results that demonstrated RTK transactivation by C5b-9 in cultured
GEC were extended to the PHN model of membranous nephropathy, an
in vivo model of GEC injury.8,9
In PHN, C5b-9
assembles in GEC plasma membranes and induces injury and
proteinuria.8,9
We and others have shown that in brief
incubations, glomeruli isolated from rats with PHN synthesize
eicosanoids at a rate greater than in isolated normal glomeruli,
indicating that the effect of C5b-9 assembled in vivo
persists after glomerular isolation. Moreover, treatment of rats with
PHN or PHN kidneys perfused ex vivo with inhibitors of
cyclooxygenase or thromboxane synthase can substantially reduce urinary
protein excretion.10-14
In this study, it was not
practical to undertake chronic blockade of RTKs in rats with PHN;
however, we demonstrated that in brief incubations, the
complement-mediated increase in PGE2 production
in glomeruli isolated from rats with PHN was attenuated by AG1478
(Figure 7)
. Basal PGE2 production, ie, in control
glomeruli, was not affected by AG1478 (Figure 7)
. Thus, C5b-9-induced
PGE2 production in glomeruli in vivo
may be, at least in part, mediated via EGF-R (and EGF-R activation
persists after glomerular isolation). However, basal glomerular
PGE2 production is EGF-R-independent.
By analogy to GEC in culture, ERK2 tyrosine204
phosphorylation was enhanced in PHN glomeruli in vivo
(Figure 8)
. Using an approach analogous to the
PGE2 studies, examination of complement-mediated
ERK2 tyrosine204 phosphorylation after incubation
of glomeruli with AG1478 demonstrated a significant attenuation of
phosphorylation in glomeruli from rats with PHN, but no significant
change in glomeruli from control rats (Table 6)
. To our knowledge, this
is the first report of ERK2 activation in PHN, although ERK2 activation
was previously observed in glomeruli from rats with proliferating
glomerular injury (anti-glomerular basement membrane
nephritis).42
At present, the role of C5b-9-induced ERK2
activation in GEC is not known. GEC proliferation is not a prominent
feature of PHN, although in PHN there is expression of
proliferation-associated genes.43
Studies have
demonstrated the induction of various other genes and/or proteins
during the course of PHN, including platelet-derived growth factor
B-chain,42
cytochrome
b558,44
matrix
metalloproteinase-9,45
and
cyclooxygenase-2.46
Thus, C5b-9-induced activation of
pathways that potentially mediate transcription, such as the ERK2
cascade, may be necessary for the induction of these genes. Additional
studies will be required to further define the role of ERK2 in
C5b-9-mediated glomerular injury.
| Footnotes |
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Supported by research grants from the Medical Research Council of Canada and the Kidney Foundation of Canada. A.V. C. holds a scholarship from the Fonds de la Recherche en Santé du Québec.
Accepted for publication July 23, 1999.
| References |
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