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Recent Developments in Myofibroblast Biology

Paradigms for Connective Tissue Remodeling
Open AccessPublished:March 05, 2012DOI:https://doi.org/10.1016/j.ajpath.2012.02.004
      The discovery of the myofibroblast has opened new perspectives for the comprehension of the biological mechanisms involved in wound healing and fibrotic diseases. In recent years, many advances have been made in understanding important aspects of myofibroblast basic biological characteristics. This review summarizes such advances in several fields, such as the following: i) force production by the myofibroblast and mechanisms of connective tissue remodeling; ii) factors controlling the expression of α-smooth muscle actin, the most used marker of myofibroblastic phenotype and, more important, involved in force generation by the myofibroblast; and iii) factors affecting genesis of the myofibroblast and its differentiation from precursor cells, in particular epigenetic factors, such as DNA methylation, microRNAs, and histone modification. We also review the origin and the specific features of the myofibroblast in diverse fibrotic lesions, such as systemic sclerosis; kidney, liver, and lung fibrosis; and the stromal reaction to certain epithelial tumors. Finally, we summarize the emerging strategies for influencing myofibroblast behavior in vitro and in vivo, with the ultimate goal of an effective therapeutic approach for myofibroblast-dependent diseases.
      Myofibroblasts regulate connective tissue remodeling by combining the extracellular matrix (ECM)–synthesizing features of fibroblasts with cytoskeletal characteristics of contractile smooth muscle cells. Since their first description in granulation tissue 40 years ago, remarkable progress has been made in understanding myofibroblast biological characteristics and their participation in physiological and pathological situations.
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      • Galli A.
      • Bochaton-Piallat M.L.
      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      It is well established that myofibroblasts have multiple origins, contribute importantly to connective tissue remodeling by exerting traction forces and synthesizing ECM components, regress and disappear by apoptosis on wound epithelialization, and may persist in fibrotic situations and cause organ dysfunction.
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      • Galli A.
      • Bochaton-Piallat M.L.
      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      Since our last review on the subject in this journal,
      • Hinz B.
      • Phan S.H.
      • Thannickal V.J.
      • Galli A.
      • Bochaton-Piallat M.L.
      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      many new findings have emerged to advance our understanding of myofibroblast biological features, but many questions remain unanswered. Unresolved questions include the following: i) what is the progenitor or precursor cell for the myofibroblast, ii) is there a specific myofibroblast marker, iii) what regulates myofibroblast contractile activity, and iv) what is the basis for myofibroblast persistence in chronic or progressive fibrosis? Recent rapid progress in microRNA (miRNA) and epigenetics research
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      • Schor I.E.
      • Kornblihtt A.R.
      • Misteli T.
      Epigenetics in alternative pre-mRNA splicing.
      has furnished new tools and concepts for assessing molecular regulation of myofibroblast differentiation and perpetuation of the myofibroblast phenotype, as potentially mediated by epigenetic mechanisms. The ultimate aim is to suggest therapeutic strategies for influencing the widespread pathological situations that depend on this enigmatic cell.

      Myofibroblast Basics

      During normal tissue repair, such as skin wound healing, controlled and transient activation of myofibroblasts contributes to restoration of tissue integrity by forming a mechanically sound scar.
      • Hinz B.
      • Phan S.H.
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      • Galli A.
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      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      For example, scars stabilize the heart muscle after myocardial infarction and tendon, bone, and cartilage after fracture or rupture.
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      The myofibroblast: paradigm for a mechanically active cell.
      However, when myofibroblast activities become excessive and persist, beneficial tissue repair turns into the detrimental tissue deformities characteristic of organ fibrosis. In this review, we will discuss in more detail fibrosis of the skin, lungs, liver, and kidney. In addition to these organs, myofibroblasts play a substantial role promoting heart fibrosis and vascular remodeling, but because of space limitation, these topics are not covered herein, and we refer the reader to recent reviews of this rapidly growing body of literature.
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      Myocardial remodeling after infarction: the role of myofibroblasts.
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      Myofibroblast-mediated adventitial remodeling: an underestimated player in arterial pathology.
      Another fibrotic condition is the desmoplastic or stromal reaction to epithelial tumors, during which myofibroblasts contribute to the mediator and mechanical environment that promotes tumor progression.
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      Cancer invasion and metastasis: interacting ecosystems.
      We will discuss the similarities of the tumor-associated fibroblasts and myofibroblasts with those present in other fibrotic lesions.

      Specific Aspects of Myofibroblast Contraction

      High contractile activity of myofibroblasts is necessary for generating tissue contractures. In addition to the expression of α-smooth muscle actin (α-SMA; gene ACTA) in stress fibers, which promotes stronger force generation compared with other actin isoforms in fibroblastic cells, myofibroblasts appear to use specific modes of contraction.
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      The myofibroblast: paradigm for a mechanically active cell.
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      Regulation of myofibroblast activities: calcium pulls some strings behind the scene.
      In contrast to the reversible and comparably short-lived contraction of striated and smooth muscles, myofibroblast contractile activity, together with ECM synthesis and degradation, leads to connective tissue remodeling, followed by irreversible and long contractures in a process that can span weeks, months, or even years.
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      Regulation of myofibroblast activities: calcium pulls some strings behind the scene.
      It is still unknown how myofibroblasts stabilize contractions that occur at the cellular or subcellular level to counteract the stress present in a tissue undergoing remodeling. Recent in vitro studies
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      A new lock-step mechanism of matrix remodelling based on subcellular contractile events.
      indicate that myofibroblasts use a lockstep or ratchet mechanism of cyclic and incremental contractile events. This mechanism consists of strong (micronewtons) and far-ranging (tens of micrometers) contractions mediated by RhoA/Rho-associated kinase and weak (approximately 100 pN) and short-ranging (approximately 0.4 μm) cyclic contractions promoted by changes in intracellular calcium concentrations.
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      A new lock-step mechanism of matrix remodelling based on subcellular contractile events.
      The model proposes that strong isometric contraction generates slack in the myofibroblast-associated fibrous and stressed collagen. Such tension-released fibrils are then straightened by the weak, but repeated, subcellular contractile events. By local ECM remodeling and/or deposition of new ECM, the shortened and repeatedly stressed collagen fibrils stabilize the status quo of the ECM, and a new myofibroblast contraction cycle can begin. It is intriguing that the level of stress (ie, the resistance of collagen fibers to pulling) may determine which mechanism of contraction will be engaged.

      Characteristic Features of the Myofibroblast

      Although there is considerable evidence to indicate the fibroblastic origin of myofibroblasts, other cell types, mostly from mesenchymal lineages, have been suggested as alternative or additional precursors.
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      The myofibroblast: one function, multiple origins.
      Because different subsets of myofibroblast precursors are recruited in different organs, we will further address the question of the myofibroblast origin later. To target the fibrotic activity of myofibroblasts, irrespective of their provenance, it is important to define common denominators, a need that has stimulated the search for specific molecular markers. The most widely used molecular marker of the differentiated myofibroblast in research and clinical diagnostics is the de novo expression of α- SMA.
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      The myofibroblast: one function, multiple origins.
      The convenience of a unique molecular marker has fostered the misconception that a myofibroblast must express α-SMA to be a myofibroblast. However, the most important defining feature of myofibroblasts is the de novo development of in vivo stress fibers and contractile force.
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      The myofibroblast: paradigm for a mechanically active cell.
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      Regulation of myofibroblast activities: calcium pulls some strings behind the scene.
      Several novel markers and modulators of the myofibroblast phenotype have been suggested. These include endosialin in tumor-associated fibroblasts,
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      LOXL2-mediated matrix remodeling in metastasis and mammary gland involution.
      • van der Slot A.J.
      • Zuurmond A.M.
      • Bardoel A.F.
      • Wijmenga C.
      • Pruijs H.E.
      • Sillence D.O.
      • Brinckmann J.
      • Abraham D.J.
      • Black C.M.
      • Verzijl N.
      • DeGroot J.
      • Hanemaaijer R.
      • TeKoppele J.M.
      • Huizinga T.W.
      • Bank R.A.
      Identification of PLOD2 as telopeptide lysyl hydroxylase, an important enzyme in fibrosis.
      • Elkabets M.
      • Gifford A.M.
      • Scheel C.
      • Nilsson B.
      • Reinhardt F.
      • Bray M.A.
      • Carpenter A.E.
      • Jirstrom K.
      • Magnusson K.
      • Ebert B.L.
      • Ponten F.
      • Weinberg R.A.
      • McAllister S.S.
      Human tumors instigate granulin-expressing hematopoietic cells that promote malignancy by activating stromal fibroblasts in mice.
      • Yang L.
      • Besschetnova T.Y.
      • Brooks C.R.
      • Shah J.V.
      • Bonventre J.V.
      Epithelial cell cycle arrest in G2/M mediates kidney fibrosis after injury.
      • Leask A.
      Potential therapeutic targets for cardiac fibrosis: TGFbeta, angiotensin, endothelin, CCN2, and PDGF, partners in fibroblast activation.
      • Kohan M.
      • Muro A.F.
      • White E.S.
      • Berkman N.
      EDA-containing cellular fibronectin induces fibroblast differentiation through binding to alpha4beta7 integrin receptor and MAPK/Erk 1/2-dependent signaling.
      • Muro A.F.
      • Moretti F.A.
      • Moore B.B.
      • Yan M.
      • Atrasz R.G.
      • Wilke C.A.
      • Flaherty K.R.
      • Martinez F.J.
      • Tsui J.L.
      • Sheppard D.
      • Baralle F.E.
      • Toews G.B.
      • White E.S.
      An essential role for fibronectin extra type III domain A in pulmonary fibrosis.
      • Bielesz B.
      • Sirin Y.
      • Si H.
      • Niranjan T.
      • Gruenwald A.
      • Ahn S.
      • Kato H.
      • Pullman J.
      • Gessler M.
      • Haase V.H.
      • Susztak K.
      Epithelial Notch signaling regulates interstitial fibrosis development in the kidneys of mice and humans.
      ). It remains to be confirmed whether these markers are tissue and/or condition specific or whether they are useful in identifying myofibroblasts in more general terms. To our knowledge, none of the other markers described over the years is unique to the myofibroblast.
      Table 1Myofibroblast-Modulating Factors
      Myofibroblast-inducing factorsMyofibroblast-suppressing factors
      Transcription-Regulating Factors
      Smad3 and Smad2
      • Hu B.
      • Wu Z.
      • Phan S.H.
      Smad3 mediates transforming growth factor-beta-induced alpha-smooth muscle actin expression.
      Smad7
      MeCP2
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Essential role of MeCP2 in the regulation of myofibroblast differentiation during pulmonary fibrosis.
      NF-κB
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      KLF5
      • Phan S.H.
      Biology of fibroblasts and myofibroblasts.
      KLF4
      • Hu B.
      • Wu Z.
      • Phan S.H.
      Smad3 mediates transforming growth factor-beta-induced alpha-smooth muscle actin expression.
      • Cogan J.G.
      • Subramanian S.V.
      • Polikandriotis J.A.
      • Kelm Jr, R.J.
      • Strauch A.R.
      Vascular smooth muscle alpha-actin gene transcription during myofibroblast differentiation requires Sp1/3 protein binding proximal to the MCAT enhancer.
      • Hu B.
      • Wu Z.
      • Liu T.
      • Ullenbruch M.R.
      • Jin H.
      • Phan S.H.
      Gut-enriched Kruppel-like factor interaction with Smad3 inhibits myofibroblast differentiation.
      HMGA2
      • Pandit K.V.
      • Corcoran D.
      • Yousef H.
      • Yarlagadda M.
      • Tzouvelekis A.
      • Gibson K.F.
      • Konishi K.
      • Yousem S.A.
      • Singh M.
      • Handley D.
      • Richards T.
      • Selman M.
      • Watkins S.C.
      • Pardo A.
      • Ben-Yehudah A.
      • Bouros D.
      • Eickelberg O.
      • Ray P.
      • Benos P.V.
      • Kaminski N.
      Inhibition and role of let-7d in idiopathic pulmonary fibrosis.
      PPARγ
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      • Burgess H.A.
      • Daugherty L.E.
      • Thatcher T.H.
      • Lakatos H.F.
      • Ray D.M.
      • Redonnet M.
      • Phipps R.P.
      • Sime P.J.
      PPARgamma agonists inhibit TGF-beta induced pulmonary myofibroblast differentiation and collagen production: implications for therapy of lung fibrosis.
      SRF
      • Sandbo N.
      • Kregel S.
      • Taurin S.
      • Bhorade S.
      • Dulin N.O.
      Critical role of serum response factor in pulmonary myofibroblast differentiation induced by TGF-beta.
      • Chan M.W.
      • Hinz B.
      • McCulloch C.A.
      Mechanical induction of gene expression in connective tissue cells.
      Nkx2.5
      • Hu B.
      • Wu Y.M.
      • Wu Z.
      • Phan S.H.
      Nkx2.5/Csx represses myofibroblast differentiation.
      RTEF-1
      • Gan Q.
      • Yoshida T.
      • Li J.
      • Owens G.K.
      Smooth muscle cells and myofibroblasts use distinct transcriptional mechanisms for smooth muscle alpha-actin expression.
      YB-1
      • Zhang A.
      • Liu X.
      • Cogan J.G.
      • Fuerst M.D.
      • Polikandriotis J.A.
      • Kelm Jr, R.J.
      • Strauch A.R.
      YB-1 coordinates vascular smooth muscle alpha-actin gene activation by transforming growth factor beta1 and thrombin during differentiation of human pulmonary myofibroblasts.
      Sp1 and Sp3
      • Phan S.H.
      Biology of fibroblasts and myofibroblasts.
      • Cogan J.G.
      • Subramanian S.V.
      • Polikandriotis J.A.
      • Kelm Jr, R.J.
      • Strauch A.R.
      Vascular smooth muscle alpha-actin gene transcription during myofibroblast differentiation requires Sp1/3 protein binding proximal to the MCAT enhancer.
      C/EBPβ
      • Hu B.
      • Ullenbruch M.R.
      • Jin H.
      • Gharaee-Kermani M.
      • Phan S.H.
      An essential role for CCAAT/enhancer binding protein beta in bleomycin-induced pulmonary fibrosis.
      CSL
      • Noseda M.
      • Fu Y.
      • Niessen K.
      • Wong F.
      • Chang L.
      • McLean G.
      • Karsan A.
      Smooth muscle alpha-actin is a direct target of Notch/CSL.
      c-Myb
      • Buck M.
      • Kim D.J.
      • Houglum K.
      • Hassanein T.
      • Chojkier M.
      c-Myb modulates transcription of the alpha-smooth muscle actin gene in activated hepatic stellate cells.
      MRTF-A/MRTF-B
      • Chan M.W.
      • Hinz B.
      • McCulloch C.A.
      Mechanical induction of gene expression in connective tissue cells.
      • Small E.M.
      • Thatcher J.E.
      • Sutherland L.B.
      • Kinoshita H.
      • Gerard R.D.
      • Richardson J.A.
      • Dimaio J.M.
      • Sadek H.
      • Kuwahara K.
      • Olson E.N.
      Myocardin-related transcription factor-a controls myofibroblast activation and fibrosis in response to myocardial infarction.
      • Masszi A.
      • Speight P.
      • Charbonney E.
      • Lodyga M.
      • Nakano H.
      • Szaszi K.
      • Kapus A.
      Fate-determining mechanisms in epithelial-myofibroblast transition: major inhibitory role for Smad3.
      • Crider B.J.
      • Risinger Jr, G.M.
      • Haaksma C.J.
      • Howard E.W.
      • Tomasek J.J.
      Myocardin-related transcription factors A and B are key regulators of TGF-β1-induced fibroblast to myofibroblast differentiation.
      Fli-1
      • Wang Y.
      • Fan P.S.
      • Kahaleh B.
      Association between enhanced type I collagen expression and epigenetic repression of the FLI1 gene in scleroderma fibroblasts.
      Epigenetic Regulators and miRNAs
      DNMT1
      • Bechtel W.
      • McGoohan S.
      • Zeisberg E.M.
      • Muller G.A.
      • Kalbacher H.
      • Salant D.J.
      • Muller C.A.
      • Kalluri R.
      • Zeisberg M.
      Methylation determines fibroblast activation and fibrogenesis in the kidney.
      Other DNMTs
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Essential role of MeCP2 in the regulation of myofibroblast differentiation during pulmonary fibrosis.
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Epigenetic regulation of myofibroblast differentiation by DNA methylation.
      HDAC4
      • Glenisson W.
      • Castronovo V.
      • Waltregny D.
      Histone deacetylase 4 is required for TGFbeta1-induced myofibroblastic differentiation.
      • Guo W.
      • Shan B.
      • Klingsberg R.C.
      • Qin X.
      • Lasky J.A.
      Abrogation of TGF-beta1-induced fibroblast-myofibroblast differentiation by histone deacetylase inhibition.
      miR-29
      • Chau B.N.
      • Brenner D.A.
      What goes up must come down: the emerging role of microRNA in fibrosis.
      • Maurer B.
      • Stanczyk J.
      • Jungel A.
      • Akhmetshina A.
      • Trenkmann M.
      • Brock M.
      • Kowal-Bielecka O.
      • Gay R.E.
      • Michel B.A.
      • Distler J.H.
      • Gay S.
      • Distler O.
      MicroRNA-29, a key regulator of collagen expression in systemic sclerosis.
      • Cushing L.
      • Kuang P.P.
      • Qian J.
      • Shao F.
      • Wu J.
      • Little F.
      • Thannickal V.J.
      • Cardoso W.V.
      • Lü J.
      miR-29 is a major regulator of genes associated with pulmonary fibrosis.
      • van Rooij E.
      • Sutherland L.B.
      • Thatcher J.E.
      • DiMaio J.M.
      • Naseem R.H.
      • Marshall W.S.
      • Hill J.A.
      • Olson E.N.
      Dysregulation of microRNAs after myocardial infarction reveals a role of miR-29 in cardiac fibrosis.
      • Roderburg C.
      • Urban G.W.
      • Bettermann K.
      • Vucur M.
      • Zimmermann H.
      • Schmidt S.
      • Janssen J.
      • Koppe C.
      • Knolle P.
      • Castoldi M.
      • Tacke F.
      • Trautwein C.
      • Luedde T.
      Micro-RNA profiling reveals a role for miR-29 in human and murine liver fibrosis.
      • Wang B.
      • Komers R.
      • Carew R.
      • Winbanks C.E.
      • Xu B.
      • Herman-Edelstein M.
      • Koh P.
      • Thomas M.
      • Jandeleit-Dahm K.
      • Gregorevic P.
      • Cooper M.E.
      • Kantharidis P.
      Suppression of microRNA-29 expression by TGF-beta1 promotes collagen expression and renal fibrosis.
      (HDAC6 and HDAC8)
      • Glenisson W.
      • Castronovo V.
      • Waltregny D.
      Histone deacetylase 4 is required for TGFbeta1-induced myofibroblastic differentiation.
      miR-192
      • Kato M.
      • Arce L.
      • Wang M.
      • Putta S.
      • Lanting L.
      • Natarajan R.
      A microRNA circuit mediates transforming growth factor-beta1 autoregulation in renal glomerular mesangial cells.
      Let7
      • Pandit K.V.
      • Corcoran D.
      • Yousef H.
      • Yarlagadda M.
      • Tzouvelekis A.
      • Gibson K.F.
      • Konishi K.
      • Yousem S.A.
      • Singh M.
      • Handley D.
      • Richards T.
      • Selman M.
      • Watkins S.C.
      • Pardo A.
      • Ben-Yehudah A.
      • Bouros D.
      • Eickelberg O.
      • Ray P.
      • Benos P.V.
      • Kaminski N.
      Inhibition and role of let-7d in idiopathic pulmonary fibrosis.
      miR-132
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      miR-200a
      • Wang B.
      • Koh P.
      • Winbanks C.
      • Coughlan M.T.
      • McClelland A.
      • Watson A.
      • Jandeleit-Dahm K.
      • Burns W.C.
      • Thomas M.C.
      • Cooper M.E.
      • Kantharidis P.
      miR-200a prevents renal fibrogenesis through repression of TGF-beta2 expression.
      miR-21
      • Liu G.
      • Friggeri A.
      • Yang Y.
      • Milosevic J.
      • Ding Q.
      • Thannickal V.J.
      • Kaminski N.
      • Abraham E.
      miR-21 mediates fibrogenic activation of pulmonary fibroblasts and lung fibrosis.
      miR-129
      • Kato M.
      • Putta S.
      • Wang M.
      • Yuan H.
      • Lanting L.
      • Nair I.
      • Gunn A.
      • Nakagawa Y.
      • Shimano H.
      • Todorov I.
      • Rossi J.J.
      • Natarajan R.
      TGF-beta activates Akt kinase through a microRNA-dependent amplifying circuit targeting PTEN.
      miR-200b/c
      • Kato M.
      • Arce L.
      • Wang M.
      • Putta S.
      • Lanting L.
      • Natarajan R.
      A microRNA circuit mediates transforming growth factor-beta1 autoregulation in renal glomerular mesangial cells.
      miR-216a
      • Kato M.
      • Wang L.
      • Putta S.
      • Wang M.
      • Yuan H.
      • Sun G.
      • Lanting L.
      • Todorov I.
      • Rossi J.J.
      • Natarajan R.
      Post-transcriptional up-regulation of Tsc-22 by Ybx1, a target of miR-216a, mediates TGF-{beta}-induced collagen expression in kidney cells.
      Growth Factors, Cytokines, and Others
      TGFβ1
      • Wipff P.J.
      • Hinz B.
      Integrins and the activation of latent transforming growth factor beta1: an intimate relationship.
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      • Varga J.
      • Pasche B.
      Transforming growth factor beta as a therapeutic target in systemic sclerosis.
      Interferon-γ
      • Pittet B.
      • Rubbia-Brandt L.
      • Desmoulière A.
      • Sappino A.P.
      • Roggero P.
      • Guerret S.
      • Grimaud J.A.
      • Lacher R.
      • Montandon D.
      • Gabbiani G.
      Effect of gamma-interferon on the clinical and biologic evolution of hypertrophic scars and Dupuytren's disease: an open pilot study.
      P311
      • Tan J.
      • Peng X.
      • Luo G.
      • Ma B.
      • Cao C.
      • He W.
      • Yuan S.
      • Li S.
      • Wilkins J.A.
      • Wu J.
      Investigating the role of P311 in the hypertrophic scar.
      CXCL10
      • Jiang D.
      • Liang J.
      • Campanella G.S.
      • Guo R.
      • Yu S.
      • Xie T.
      • Liu N.
      • Jung Y.
      • Homer R.
      • Meltzer E.B.
      • Li Y.
      • Tager A.M.
      • Goetinck P.F.
      • Luster A.D.
      • Noble P.W.
      Inhibition of pulmonary fibrosis in mice by CXCL10 requires glycosaminoglycan binding and syndecan-4.
      Wnt
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      • Kim K.K.
      • Wei Y.
      • Szekeres C.
      • Kugler M.C.
      • Wolters P.J.
      • Hill M.L.
      • Frank J.A.
      • Brumwell A.N.
      • Wheeler S.E.
      • Kreidberg J.A.
      • Chapman H.A.
      Epithelial cell alpha3beta1 integrin links beta-catenin and Smad signaling to promote myofibroblast formation and pulmonary fibrosis.
      Jagged1
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      • Liu T.
      • Hu B.
      • Choi Y.Y.
      • Chung M.
      • Ullenbruch M.
      • Yu H.
      • Lowe J.B.
      • Phan S.H.
      Notch1 signaling in FIZZ1 induction of myofibroblast differentiation.
      FAK
      • Varga J.
      • Pasche B.
      Transforming growth factor beta as a therapeutic target in systemic sclerosis.
      • Mimura Y.
      • Ihn H.
      • Jinnin M.
      • Asano Y.
      • Yamane K.
      • Tamaki K.
      Constitutive phosphorylation of focal adhesion kinase is involved in the myofibroblast differentiation of scleroderma fibroblasts.
      NOX4
      • Hecker L.
      • Vittal R.
      • Jones T.
      • Jagirdar R.
      • Luckhardt T.R.
      • Horowitz J.C.
      • Pennathur S.
      • Martinez F.J.
      • Thannickal V.J.
      NADPH oxidase-4 mediates myofibroblast activation and fibrogenic responses to lung injury.
      • Amara N.
      • Goven D.
      • Prost F.
      • Muloway R.
      • Crestani B.
      • Boczkowski J.
      NOX4/NADPH oxidase expression is increased in pulmonary fibroblasts from patients with idiopathic pulmonary fibrosis and mediates TGFbeta1-induced fibroblast differentiation into myofibroblasts.
      • Carnesecchi S.
      • Deffert C.
      • Donati Y.
      • Basset O.
      • Hinz B.
      • Preynat-Seauve O.
      • Guichard C.
      • Arbiser J.L.
      • Banfi B.
      • Pache J.C.
      • Barazzone-Argiroffo C.
      • Krause K.H.
      A key role for NOX4 in epithelial cell death during development of lung fibrosis.
      • Waghray M.
      • Cui Z.
      • Horowitz J.C.
      • Subramanian I.M.
      • Martinez F.J.
      • Toews G.B.
      • Thannickal V.J.
      Hydrogen peroxide is a diffusible paracrine signal for the induction of epithelial cell death by activated myofibroblasts.
      ECM, ECM-Modulating Proteins, and Physical Factors
      Stiff ECM
      • Hinz B.
      The myofibroblast: paradigm for a mechanically active cell.
      • Wells R.G.
      The role of matrix stiffness in regulating cell behavior.
      • Grinnell F.
      • Petroll W.M.
      Cell motility and mechanics in three-dimensional collagen matrices.
      • Wipff P.J.
      • Rifkin D.B.
      • Meister J.J.
      • Hinz B.
      Myofibroblast contraction activates latent TGF-beta1 from the extracellular matrix.
      • Zhou Y.
      • Hagood J.S.
      • Lu B.
      • Merryman W.D.
      • Murphy-Ullrich J.E.
      Thy-1-integrin alphav beta5 interactions inhibit lung fibroblast contraction-induced latent transforming growth factor-beta1 activation and myofibroblast differentiation.
      Soft ECM
      • Hinz B.
      The myofibroblast: paradigm for a mechanically active cell.
      • Wells R.G.
      The role of matrix stiffness in regulating cell behavior.
      • Grinnell F.
      • Petroll W.M.
      Cell motility and mechanics in three-dimensional collagen matrices.
      ROS
      • Sambo P.
      • Baroni S.S.
      • Luchetti M.
      • Paroncini P.
      • Dusi S.
      • Orlandini G.
      • Gabrielli A.
      Oxidative stress in scleroderma: maintenance of scleroderma fibroblast phenotype by the constitutive up-regulation of reactive oxygen species generation through the NADPH oxidase complex pathway.
      • Toullec A.
      • Gerald D.
      • Despouy G.
      • Bourachot B.
      • Cardon M.
      • Lefort S.
      • Richardson M.
      • Rigaill G.
      • Parrini M.C.
      • Lucchesi C.
      • Bellanger D.
      • Stern M.H.
      • Dubois T.
      • Sastre-Garau X.
      • Delattre O.
      • Vincent-Salomon A.
      • Mechta-Grigoriou F.
      Oxidative stress promotes myofibroblast differentiation and tumour spreading.
      LOX
      • Georges P.C.
      • Hui J.J.
      • Gombos Z.
      • McCormick M.E.
      • Wang A.Y.
      • Uemura M.
      • Mick R.
      • Janmey P.A.
      • Furth E.E.
      • Wells R.G.
      Increased stiffness of the rat liver precedes matrix deposition: implications for fibrosis.
      LOXL2
      • Barry-Hamilton V.
      • Spangler R.
      • Marshall D.
      • McCauley S.
      • Rodriguez H.M.
      • Oyasu M.
      • Mikels A.
      • Vaysberg M.
      • Ghermazien H.
      • Wai C.
      • Garcia C.A.
      • Velayo A.C.
      • Jorgensen B.
      • Biermann D.
      • Tsai D.
      • Green J.
      • Zaffryar-Eilot S.
      • Holzer A.
      • Ogg S.
      • Thai D.
      • Neufeld G.
      • Van Vlasselaer P.
      • Smith V.
      Allosteric inhibition of lysyl oxidase-like-2 impedes the development of a pathologic microenvironment.
      • Barker H.E.
      • Chang J.
      • Cox T.R.
      • Lang G.
      • Bird D.
      • Nicolau M.
      • Evans H.R.
      • Gartland A.
      • Erler J.T.
      LOXL2-mediated matrix remodeling in metastasis and mammary gland involution.
      Lysyl hydroxylase and PLOD2
      • van der Slot A.J.
      • Zuurmond A.M.
      • Bardoel A.F.
      • Wijmenga C.
      • Pruijs H.E.
      • Sillence D.O.
      • Brinckmann J.
      • Abraham D.J.
      • Black C.M.
      • Verzijl N.
      • DeGroot J.
      • Hanemaaijer R.
      • TeKoppele J.M.
      • Huizinga T.W.
      • Bank R.A.
      Identification of PLOD2 as telopeptide lysyl hydroxylase, an important enzyme in fibrosis.
      Osteopontin
      • Elkabets M.
      • Gifford A.M.
      • Scheel C.
      • Nilsson B.
      • Reinhardt F.
      • Bray M.A.
      • Carpenter A.E.
      • Jirstrom K.
      • Magnusson K.
      • Ebert B.L.
      • Ponten F.
      • Weinberg R.A.
      • McAllister S.S.
      Human tumors instigate granulin-expressing hematopoietic cells that promote malignancy by activating stromal fibroblasts in mice.
      Periostin
      • Vi L.
      • Feng L.
      • Zhu R.D.
      • Wu Y.
      • Satish L.
      • Gan B.S.
      • O'Gorman D.B.
      Periostin differentially induces proliferation, contraction and apoptosis of primary Dupuytren's disease and adjacent palmar fascia cells.
      • Darby I.A.
      • Vuillier-Devillers K.
      • Pinault E.
      • Sarrazy V.
      • Lepreux S.
      • Balabaud C.
      • Bioulac-Sage P.
      • Desmouliere A.
      Proteomic analysis of differentially expressed proteins in peripheral cholangiocarcinoma.
      CCN2 (CTGF)
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      • Yang L.
      • Besschetnova T.Y.
      • Brooks C.R.
      • Shah J.V.
      • Bonventre J.V.
      Epithelial cell cycle arrest in G2/M mediates kidney fibrosis after injury.
      • Leask A.
      Potential therapeutic targets for cardiac fibrosis: TGFbeta, angiotensin, endothelin, CCN2, and PDGF, partners in fibroblast activation.
      ED-A fibronectin
      • Hinz B.
      • Phan S.H.
      • Thannickal V.J.
      • Galli A.
      • Bochaton-Piallat M.L.
      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      • Kohan M.
      • Muro A.F.
      • White E.S.
      • Berkman N.
      EDA-containing cellular fibronectin induces fibroblast differentiation through binding to alpha4beta7 integrin receptor and MAPK/Erk 1/2-dependent signaling.
      • Muro A.F.
      • Moretti F.A.
      • Moore B.B.
      • Yan M.
      • Atrasz R.G.
      • Wilke C.A.
      • Flaherty K.R.
      • Martinez F.J.
      • Tsui J.L.
      • Sheppard D.
      • Baralle F.E.
      • Toews G.B.
      • White E.S.
      An essential role for fibronectin extra type III domain A in pulmonary fibrosis.
      Membrane-Bound and Surface-Expressed Proteins
      Endosialin (Tem1)
      • Christian S.
      • Winkler R.
      • Helfrich I.
      • Boos A.M.
      • Besemfelder E.
      • Schadendorf D.
      • Augustin H.G.
      Endosialin (Tem1) is a marker of tumor-associated myofibroblasts and tumor vessel-associated mural cells.
      Integrin
       α11β1
      • Carracedo S.
      • Lu N.
      • Popova S.N.
      • Jonsson R.
      • Eckes B.
      • Gullberg D.
      The fibroblast integrin alpha11beta1 is induced in a mechanosensitive manner involving activin A and regulates myofibroblast differentiation.
       α3β1
      • Carracedo S.
      • Lu N.
      • Popova S.N.
      • Jonsson R.
      • Eckes B.
      • Gullberg D.
      The fibroblast integrin alpha11beta1 is induced in a mechanosensitive manner involving activin A and regulates myofibroblast differentiation.
      • Kim K.K.
      • Wei Y.
      • Szekeres C.
      • Kugler M.C.
      • Wolters P.J.
      • Hill M.L.
      • Frank J.A.
      • Brumwell A.N.
      • Wheeler S.E.
      • Kreidberg J.A.
      • Chapman H.A.
      Epithelial cell alpha3beta1 integrin links beta-catenin and Smad signaling to promote myofibroblast formation and pulmonary fibrosis.
       αvβ3
      • Carracedo S.
      • Lu N.
      • Popova S.N.
      • Jonsson R.
      • Eckes B.
      • Gullberg D.
      The fibroblast integrin alpha11beta1 is induced in a mechanosensitive manner involving activin A and regulates myofibroblast differentiation.
      • Wipff P.J.
      • Hinz B.
      Integrins and the activation of latent transforming growth factor beta1: an intimate relationship.
       αvβ5
      • Wipff P.J.
      • Hinz B.
      Integrins and the activation of latent transforming growth factor beta1: an intimate relationship.
      Notch1
      • Noseda M.
      • Fu Y.
      • Niessen K.
      • Wong F.
      • Chang L.
      • McLean G.
      • Karsan A.
      Smooth muscle alpha-actin is a direct target of Notch/CSL.
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      • Liu T.
      • Hu B.
      • Choi Y.Y.
      • Chung M.
      • Ullenbruch M.
      • Yu H.
      • Lowe J.B.
      • Phan S.H.
      Notch1 signaling in FIZZ1 induction of myofibroblast differentiation.
      • Bielesz B.
      • Sirin Y.
      • Si H.
      • Niranjan T.
      • Gruenwald A.
      • Ahn S.
      • Kato H.
      • Pullman J.
      • Gessler M.
      • Haase V.H.
      • Susztak K.
      Epithelial Notch signaling regulates interstitial fibrosis development in the kidneys of mice and humans.
      The table summarizes recently identified proteins and factors that have regulated myofibroblast differentiation either directly or indirectly. For well-established myofibroblast modulators, such as TGFβ1, review articles are referenced.
      C/EBP, CCAAT enhancer binding protein; CTGF, connective tissue growth factor; ED-A, extradomain A; FAK, focal adhesion kinase; Fli-1, friend leukemia integration; KLF, Kruppellike factor; PLOD, procollagen-lysine, 2-oxoglutarate 5-dioxygenase; ROS, reactive oxygen species; RTEF, R-transcription enhancer factor; Sp, specificity protein; SRF, serum response factor; YB-1, Y-box binding protein-1.

      Myofibroblast-Inducing Factors and Conditions

      Mechanical resistance of the ECM, in conjunction with the action of profibrotic transforming growth factor β1 (TGFβ1), is an amply documented primary stimulus for myofibroblast differentiation and persistence.
      • Hinz B.
      • Phan S.H.
      • Thannickal V.J.
      • Galli A.
      • Bochaton-Piallat M.L.
      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      Myofibroblasts develop in vitro and in vivo their highly contractile cytoskeletal apparatus only above a certain ECM stiffness threshold.
      • Hinz B.
      The myofibroblast: paradigm for a mechanically active cell.
      • Wells R.G.
      The role of matrix stiffness in regulating cell behavior.
      Various fibrotic organs and tissues have recently exceeded this threshold at the micromechanical level.
      • Liu F.
      • Mih J.D.
      • Shea B.S.
      • Kho A.T.
      • Sharif A.S.
      • Tager A.M.
      • Tschumperlin D.J.
      Feedback amplification of fibrosis through matrix stiffening and COX-2 suppression.
      • Olsen A.L.
      • Bloomer S.A.
      • Chan E.P.
      • Gaca M.D.
      • Georges P.C.
      • Sackey B.
      • Uemura M.
      • Janmey P.A.
      • Wells R.G.
      Hepatic stellate cells require a stiff environment for myofibroblastic differentiation.
      • Bissell M.J.
      • Hines W.C.
      Why don't we get more cancer? a proposed role of the microenvironment in restraining cancer progression.
      Tissue stiffness increases as a consequence of ECM-remodeling activities of fibroblasts and myofibroblasts.
      • Grinnell F.
      • Petroll W.M.
      Cell motility and mechanics in three-dimensional collagen matrices.
      Contracting cells then generate the conditions that make them even more contractile in a detrimental feed-forward loop. The chicken-and-egg question of how fibroblastic cells are initiated to become contractile in the soft ECM present after the injury may be answered by recent biomechanical studies. In an animal model of liver fibrosis, increased tissue stiffness precedes the activation of fibroblastic cells and the accumulation of collagen, thus suggesting that such early mechanical changes may be sufficient to trigger the contraction cascade.
      • Georges P.C.
      • Hui J.J.
      • Gombos Z.
      • McCormick M.E.
      • Wang A.Y.
      • Uemura M.
      • Mick R.
      • Janmey P.A.
      • Furth E.E.
      • Wells R.G.
      Increased stiffness of the rat liver precedes matrix deposition: implications for fibrosis.
      Collagen cross-linking catalyzed by lysyl oxidase (LOX) enzymes is one possible factor responsible for early structural changes and tissue stiffening in these conditions.
      • Georges P.C.
      • Hui J.J.
      • Gombos Z.
      • McCormick M.E.
      • Wang A.Y.
      • Uemura M.
      • Mick R.
      • Janmey P.A.
      • Furth E.E.
      • Wells R.G.
      Increased stiffness of the rat liver precedes matrix deposition: implications for fibrosis.
      Fibrosis-specific and stable collagen cross-links are further formed by lysyl hydroxylase and pro-collagen-lysine, 2-oxoglutarate 5-dioxygenase, which are responsible for pyridinoline and aldehyde-derived collagen cross-links in the fibrotic skin.
      • van der Slot A.J.
      • Zuurmond A.M.
      • Bardoel A.F.
      • Wijmenga C.
      • Pruijs H.E.
      • Sillence D.O.
      • Brinckmann J.
      • Abraham D.J.
      • Black C.M.
      • Verzijl N.
      • DeGroot J.
      • Hanemaaijer R.
      • TeKoppele J.M.
      • Huizinga T.W.
      • Bank R.A.
      Identification of PLOD2 as telopeptide lysyl hydroxylase, an important enzyme in fibrosis.
      Furthermore, antibody-mediated inhibition of the enzyme LOX-like 2 (LOXL2) suppresses fibrosis and its progression in a variety of organ systems, including tumor desmoplasia.
      • Barry-Hamilton V.
      • Spangler R.
      • Marshall D.
      • McCauley S.
      • Rodriguez H.M.
      • Oyasu M.
      • Mikels A.
      • Vaysberg M.
      • Ghermazien H.
      • Wai C.
      • Garcia C.A.
      • Velayo A.C.
      • Jorgensen B.
      • Biermann D.
      • Tsai D.
      • Green J.
      • Zaffryar-Eilot S.
      • Holzer A.
      • Ogg S.
      • Thai D.
      • Neufeld G.
      • Van Vlasselaer P.
      • Smith V.
      Allosteric inhibition of lysyl oxidase-like-2 impedes the development of a pathologic microenvironment.
      However, it remains unclear whether this effect is due to reduced ECM stiffness. The potential role of initial tissue stiffening in the onset of fibrosis is particularly interesting given that cultured myofibroblasts can activate latent TGFβ1 from a sufficiently stiffened ECM by integrin-mediated contraction.
      • Wipff P.J.
      • Rifkin D.B.
      • Meister J.J.
      • Hinz B.
      Myofibroblast contraction activates latent TGF-beta1 from the extracellular matrix.
      • Zhou Y.
      • Hagood J.S.
      • Lu B.
      • Merryman W.D.
      • Murphy-Ullrich J.E.
      Thy-1-integrin alphav beta5 interactions inhibit lung fibroblast contraction-induced latent transforming growth factor-beta1 activation and myofibroblast differentiation.
      A purely mechanically driven mechanism of profibrotic growth factor activation has been experimentally proved in a cell-free system
      • Buscemi L.
      • Ramonet D.
      • Klingberg F.
      • Formey A.
      • Smith-Clerc J.
      • Meister J.J.
      • Hinz B.
      The single-molecule mechanics of the latent TGF-beta1 complex.
      and is supported by the recently revealed structure of latent TGFβ1.
      • Shi M.
      • Zhu J.
      • Wang R.
      • Chen X.
      • Mi L.
      • Walz T.
      • Springer T.A.
      Latent TGF-beta structure and activation.
      These findings establish a direct link between the mechanical and chemical factors regulating myofibroblast differentiation and ultimately causing fibrosis.
      • Wipff P.J.
      • Hinz B.
      Integrins and the activation of latent transforming growth factor beta1: an intimate relationship.
      • Ramirez F.
      • Rifkin D.B.
      Extracellular microfibrils: contextual platforms for TGFbeta and BMP signaling.
      Table 1 summarizes myofibroblast-inducing and myofibroblast-inhibiting factors.

      Myofibroblast Differentiation and Regulation of ACTA Gene Expression

      Because α-SMA expression is a common key element for detection of myofibroblast differentiation and a major player in contractile force production, most of the available data focus on the regulatory mechanisms underlying expression of this gene. Abundant information is available on transcriptional regulation of the ACTA gene, which indicates complex combinatorial mechanisms involving both stimulatory and inhibitory factors (Figure 1A and Table 1).
      Figure thumbnail gr1
      Figure 1Myofibroblast epigenetics. A: Transcriptional regulation of the ACTA gene in myofibroblast differentiation. Activating or repressing transcription factors are shown directed at the relative locations of their cognate binding elements in the ACTA gene promoter. The interaction of Kruppellike factor (KLF) 4 with Smad3 results in decreased Smad3 binding to the Smad-binding element (SBE). In contrast, MRTF enhances serum response factor binding to its cognate element to activate differentiation. PPARγ and NF-κB are also shown, but the location/nature of their direct interaction with the promoter is uncertain (indicated with a question mark). The activation of Notch signaling activates its downstream factor CSL. CArG, CC(A/T)6GG; C/EBP, CCAAT enhancer binding protein; CSL, from CBF1/RBP-J in mammals, suppressor of hairless [Su(H)] in drosophila and xenopus, and Lag-1 in Caenorhabditis elegans; IM-CAT, binding element with sequence CATCCT; LAP, liver activator protein; LIP, liver inhibitory protein; NKE, Nkx2.5 binding element; SRF, serum response factor; TEF, transcription enhancer factor; THR, TGF-β1 hypersensitivity region; TSS, transcription start site. B: DNA methylation and miRNAs in myofibroblast differentiation. Methylated CpG islands are shown in the ACTA gene promoter in the fibroblast, which are maintained by DNMT. The differentiated myofibroblast shows reduced methylation with activation of ACTA gene expression. The methylated DNA-binding protein MeCP2 promotes myofibroblast differentiation; however, multiple target genes are regulated by this protein. The indicated miRNA species regulate their target mRNAs with downstream consequences on myofibroblast differentiation, as indicated. Although ACTA is used as a hallmark gene of the myofibroblast, other fibrosis-relevant genes have been regulated by hypermethylation as well (see Myofibroblast DNA Methylation). C: Histone deacetylation and myofibroblast differentiation. The indicated HDAC isoforms modulate differentiation via multiple mechanisms. In addition, inhibition/depletion of HDAC4 suppresses TGFβ activation of Akt via 5′-TG-3′-interacting factor 1,2 (TGIF1,2) and protein phosphatase 2A/1 (PP2A/PP1).

      Activators of the α-SMA Promoter

      Among the activators are serum response factor and the transcription enhancer factor-1 family member R-transcription enhancer factor, which bind to CC(A/T)6GG (CArG) and CATTCCT (MCAT) elements, respectively, in the upstream regulatory sequence of the α-SMA promoter.
      • Sandbo N.
      • Kregel S.
      • Taurin S.
      • Bhorade S.
      • Dulin N.O.
      Critical role of serum response factor in pulmonary myofibroblast differentiation induced by TGF-beta.
      • Gan Q.
      • Yoshida T.
      • Li J.
      • Owens G.K.
      Smooth muscle cells and myofibroblasts use distinct transcriptional mechanisms for smooth muscle alpha-actin expression.
      In addition to the importance of Smad3 and its binding element,
      • Hu B.
      • Wu Z.
      • Phan S.H.
      Smad3 mediates transforming growth factor-beta-induced alpha-smooth muscle actin expression.
      another element found to be important in TGFβ1-induced differentiation is a proximal TGFβ control element, to which several factors [eg, Krüppel-like factor 5, specificity protein (Sp) 1, and Sp3] can bind to activate transcription.
      • Phan S.H.
      Biology of fibroblasts and myofibroblasts.
      • Gan Q.
      • Yoshida T.
      • Li J.
      • Owens G.K.
      Smooth muscle cells and myofibroblasts use distinct transcriptional mechanisms for smooth muscle alpha-actin expression.
      • Cogan J.G.
      • Subramanian S.V.
      • Polikandriotis J.A.
      • Kelm Jr, R.J.
      • Strauch A.R.
      Vascular smooth muscle alpha-actin gene transcription during myofibroblast differentiation requires Sp1/3 protein binding proximal to the MCAT enhancer.
      Other upstream elements include the TGFβ hypersensitivity region and an Smad-binding element, which are activated by binding to Sp1/Sp3 and Smad3, respectively.
      • Hu B.
      • Wu Z.
      • Phan S.H.
      Smad3 mediates transforming growth factor-beta-induced alpha-smooth muscle actin expression.
      • Cogan J.G.
      • Subramanian S.V.
      • Polikandriotis J.A.
      • Kelm Jr, R.J.
      • Strauch A.R.
      Vascular smooth muscle alpha-actin gene transcription during myofibroblast differentiation requires Sp1/3 protein binding proximal to the MCAT enhancer.
      Studies in several different cell types have implicated additional transcription factors, such as CCAAT enhancer–binding protein β, CSL (from CBF1/RBP-J in mammals, Suppressor of Hairless [Su(H)] in Drosophila and Xenopus, and Lag-1 in Caenorhabditis elegans) (a down3stream target of Notch signaling), and c-Myb, in regulation of ACTA gene expression (Table 1).
      • Hu B.
      • Ullenbruch M.R.
      • Jin H.
      • Gharaee-Kermani M.
      • Phan S.H.
      An essential role for CCAAT/enhancer binding protein beta in bleomycin-induced pulmonary fibrosis.
      • Noseda M.
      • Fu Y.
      • Niessen K.
      • Wong F.
      • Chang L.
      • McLean G.
      • Karsan A.
      Smooth muscle alpha-actin is a direct target of Notch/CSL.
      • Buck M.
      • Kim D.J.
      • Houglum K.
      • Hassanein T.
      • Chojkier M.
      c-Myb modulates transcription of the alpha-smooth muscle actin gene in activated hepatic stellate cells.
      An important factor linking ACTA gene transcription to the level of mechanical stress and the state of the contractile cytoskeleton is myocardin-related transcription factor A (MRTF-A).
      • Chan M.W.
      • Hinz B.
      • McCulloch C.A.
      Mechanical induction of gene expression in connective tissue cells.
      • Small E.M.
      • Thatcher J.E.
      • Sutherland L.B.
      • Kinoshita H.
      • Gerard R.D.
      • Richardson J.A.
      • Dimaio J.M.
      • Sadek H.
      • Kuwahara K.
      • Olson E.N.
      Myocardin-related transcription factor-a controls myofibroblast activation and fibrosis in response to myocardial infarction.
      • Masszi A.
      • Speight P.
      • Charbonney E.
      • Lodyga M.
      • Nakano H.
      • Szaszi K.
      • Kapus A.
      Fate-determining mechanisms in epithelial-myofibroblast transition: major inhibitory role for Smad3.
      In a mechanism that involves the F-actin–organizing factor mDia1, MRTF-A docks to CArG elements and enhances the transcriptional activity of serum response factor.
      • Chan M.W.
      • Hinz B.
      • McCulloch C.A.
      Mechanical induction of gene expression in connective tissue cells.
      MRTF-A and MRTF-B also mediate TGFβ1-induced myofibroblast differentiation and transcription of smooth muscle genes in fibroblasts.
      • Crider B.J.
      • Risinger Jr, G.M.
      • Haaksma C.J.
      • Howard E.W.
      • Tomasek J.J.
      Myocardin-related transcription factors A and B are key regulators of TGF-β1-induced fibroblast to myofibroblast differentiation.
      Other mechanically regulated transcription of fibrosis-related genes have been recently reviewed.
      • Chan M.W.
      • Hinz B.
      • McCulloch C.A.
      Mechanical induction of gene expression in connective tissue cells.

      Repressors of the α-SMA Promoter

      Several factors have down-regulated α-SMA expression and, thus, may be responsible for active suppression of myofibroblast differentiation (Table 1). Among these factors is Kruppellike factor 4, which can compete for binding to the TGFβ control element by its activators and interact with the Mad homology 2 (MH2) domain of Smad3 to suppress its binding to the ACTA promoter.
      • Hu B.
      • Wu Z.
      • Liu T.
      • Ullenbruch M.R.
      • Jin H.
      • Phan S.H.
      Gut-enriched Kruppel-like factor interaction with Smad3 inhibits myofibroblast differentiation.
      Additional repressors are Nkx2.5, peroxisome proliferator–activated receptor (PPAR)-γ, and Y-box binding protein-1.
      • Burgess H.A.
      • Daugherty L.E.
      • Thatcher T.H.
      • Lakatos H.F.
      • Ray D.M.
      • Redonnet M.
      • Phipps R.P.
      • Sime P.J.
      PPARgamma agonists inhibit TGF-beta induced pulmonary myofibroblast differentiation and collagen production: implications for therapy of lung fibrosis.
      • Hu B.
      • Wu Y.M.
      • Wu Z.
      • Phan S.H.
      Nkx2.5/Csx represses myofibroblast differentiation.
      • Zhang A.
      • Liu X.
      • Cogan J.G.
      • Fuerst M.D.
      • Polikandriotis J.A.
      • Kelm Jr, R.J.
      • Strauch A.R.
      YB-1 coordinates vascular smooth muscle alpha-actin gene activation by transforming growth factor beta1 and thrombin during differentiation of human pulmonary myofibroblasts.
      In the case of Nkx2.5, reduction in its expression correlates with myofibroblast differentiation in lung fibroblasts. Thus, differentiation may be mediated by a derepression mechanism dependent on decreased expression of one or more of these repressors.

      Smad-Independent Regulation of the α-SMA Promoter

      In addition to Smad signaling, the multiple, complex signaling mechanisms implicated in regulation of myofibroblast differentiation may also involve mitogen-activated protein (MAP) kinases.
      • Hu B.
      • Wu Z.
      • Phan S.H.
      Smad3 mediates transforming growth factor-beta-induced alpha-smooth muscle actin expression.
      Depending, in part, on the precursor cell type, Wnt signaling pathways may also be involved.
      • Kim K.K.
      • Wei Y.
      • Szekeres C.
      • Kugler M.C.
      • Wolters P.J.
      • Hill M.L.
      • Frank J.A.
      • Brumwell A.N.
      • Wheeler S.E.
      • Kreidberg J.A.
      • Chapman H.A.
      Epithelial cell alpha3beta1 integrin links beta-catenin and Smad signaling to promote myofibroblast formation and pulmonary fibrosis.
      Notch signaling is important in endothelial-to-mesenchymal transition and myofibroblast differentiation from lung fibroblasts.
      • Noseda M.
      • Fu Y.
      • Niessen K.
      • Wong F.
      • Chang L.
      • McLean G.
      • Karsan A.
      Smooth muscle alpha-actin is a direct target of Notch/CSL.
      • Liu T.
      • Hu B.
      • Choi Y.Y.
      • Chung M.
      • Ullenbruch M.
      • Yu H.
      • Lowe J.B.
      • Phan S.H.
      Notch1 signaling in FIZZ1 induction of myofibroblast differentiation.
      This is likely mediated by CSL interacting with its binding element identified in the ACTA promoter. Induction of Jagged1, a ligand for Notch1, results in activation of this signaling pathway, with subsequent activation of ACTA gene transcription. Impaired Notch signaling in vivo results in reduced myofibroblast differentiation in an animal model.
      • Liu T.
      • Hu B.
      • Choi Y.Y.
      • Chung M.
      • Ullenbruch M.
      • Yu H.
      • Lowe J.B.
      • Phan S.H.
      Notch1 signaling in FIZZ1 induction of myofibroblast differentiation.
      Another important pathway in myofibroblast differentiation associated with the desmoplastic response in tumors is Hedgehog signaling, although the downstream target gene(s) have not been identified.
      • Bailey J.M.
      • Swanson B.J.
      • Hamada T.
      • Eggers J.P.
      • Singh P.K.
      • Caffery T.
      • Ouellette M.M.
      • Hollingsworth M.A.
      Sonic hedgehog promotes desmoplasia in pancreatic cancer.
      All these differing signaling pathways are likely to work in concert at one level or another in more complex scenarios to ultimately affect ACTA gene expression, both directly and indirectly, via other regulatory genes.

      Myofibroblast Epigenetics: A Fibrotic Memory?

      Various approaches have demonstrated differences in the protein, gene, and transcriptional profiles between myofibroblast precursors from different origins and their fibrotic counterparts.
      • Larsson O.
      • Diebold D.
      • Fan D.
      • Peterson M.
      • Nho R.S.
      • Bitterman P.B.
      • Henke C.A.
      Fibrotic myofibroblasts manifest genome-wide derangements of translational control.
      • Sargent J.L.
      • Whitfield M.L.
      Capturing the heterogeneity in systemic sclerosis with genome-wide expression profiling.
      Microarray studies have shown up-regulation of many genes, consistent with activation by TGFβ1, Wnt, and connective tissue growth factor (CCN2) signaling pathways, which are abnormally expressed in patients with fibrotic disorders.
      • Larsson O.
      • Diebold D.
      • Fan D.
      • Peterson M.
      • Nho R.S.
      • Bitterman P.B.
      • Henke C.A.
      Fibrotic myofibroblasts manifest genome-wide derangements of translational control.
      • Wei J.
      • Bhattacharyya S.
      • Tourtellotte W.G.
      • Varga J.
      Fibrosis in systemic sclerosis: emerging concepts and implications for targeted therapy.
      These fibrotic signatures tend to disappear in explanted fibroblasts compared with whole tissue from the same patients.
      • Gardner H.
      • Shearstone J.R.
      • Bandaru R.
      • Crowell T.
      • Lynes M.
      • Trojanowska M.
      • Pannu J.
      • Smith E.
      • Jablonska S.
      • Blaszczyk M.
      • Tan F.K.
      • Mayes M.D.
      Gene profiling of scleroderma skin reveals robust signatures of disease that are imperfectly reflected in the transcript profiles of explanted fibroblasts.
      A common observation in profiling studies is that specific signatures of myofibroblasts are retained over several passages in vitro, suggesting a myofibroblast memory that may be mediated by epigenetic modifications, with consequent preservation of the myofibroblast phenotype and its persistence. Epigenetic regulation of gene expression in a variety of fibrotic conditions has involved DNA methylation, modification of histones, and regulation of miRNAs targeting select genes (Figure 1, B and C).

      Myofibroblast DNA Methylation

      In the case of DNA methylation, modification at CpG islands represents an important mechanism for gene silencing, and this appears to be the case for the ACTA gene
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Essential role of MeCP2 in the regulation of myofibroblast differentiation during pulmonary fibrosis.
      • Sanders Y.Y.
      • Tollefsbol T.O.
      • Varisco B.M.
      • Hagood J.S.
      Epigenetic regulation of thy-1 by histone deacetylase inhibitor in rat lung fibroblasts.
      (Figure 1B). Lung alveolar epithelial type II cells, which do not express α-SMA, exhibit high levels of methylation in the three CpG islands identified in the regulatory regions of this gene and in intronic regions. In contrast, lung fibroblasts exhibit significantly lower levels of DNA methylation in this gene, and its inhibition using 5-aza-2′-deoxycytidine activates gene transcription. DNA methylation is not limited to the ACTA gene in fibrotic conditions. In lung fibroblasts, hypermethylation of the promoter region of the TYHY1 gene has been implicated in its silencing, correlating with fibrosis in the lung.
      • Sanders Y.Y.
      • Tollefsbol T.O.
      • Varisco B.M.
      • Hagood J.S.
      Epigenetic regulation of thy-1 by histone deacetylase inhibitor in rat lung fibroblasts.
      • Kis K.
      • Liu X.
      • Hagood J.S.
      Myofibroblast differentiation and survival in fibrotic disease.
      In scleroderma fibroblasts, ECM-inhibitory genes, such as Smad7 or Fli-1 are also hypermethylated and consequently down-regulated, suggesting that DNA methylation could cause derepression of ECM genes involved in fibrosis.
      • Wang Y.
      • Fan P.S.
      • Kahaleh B.
      Association between enhanced type I collagen expression and epigenetic repression of the FLI1 gene in scleroderma fibroblasts.
      Similarly induced specific deficiency of DNA methyl transferases (DNMTs), using small-interfering RNAs, causes activation of ACTA gene transcription in these fibroblasts
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Epigenetic regulation of myofibroblast differentiation by DNA methylation.
      (Figure 1B). In the fibrotic kidney, DNMT1 is associated with persistent fibroblast activation and fibrogenesis via promotion of hypermethylation of RASAL1, a gene that encodes an inhibitor of the Ras oncogene.
      • Bechtel W.
      • McGoohan S.
      • Zeisberg E.M.
      • Muller G.A.
      • Kalbacher H.
      • Salant D.J.
      • Muller C.A.
      • Kalluri R.
      • Zeisberg M.
      Methylation determines fibroblast activation and fibrogenesis in the kidney.
      DNMT1+/− heterozygous mice exhibit reduced renal fibrogenesis and kidney fibrosis. Conversely, induced DNMT overexpression in lung fibroblasts, using expression plasmids, results in repression of ACTA gene expression and, thus, of myofibroblast differentiation.
      • Bechtel W.
      • McGoohan S.
      • Zeisberg E.M.
      • Muller G.A.
      • Kalbacher H.
      • Salant D.J.
      • Muller C.A.
      • Kalluri R.
      • Zeisberg M.
      Methylation determines fibroblast activation and fibrogenesis in the kidney.
      The use of these approaches to alter DNMT expression and/or inhibition of DNA methylation is likely to affect other genes as well, which may indirectly affect ACTA gene expression. This is the case in a study
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      of hepatic stellate cells (HSCs), in which inhibition of DNA methylation results in activation of PPARγ and NF-κB, which then repress ACTA gene expression. Direct and indirect effects of the methylated DNA-binding protein MeCP2 have also been observed. MeCP2 binds directly to the ACTA gene promoter and is essential for ACTA gene expression.
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Essential role of MeCP2 in the regulation of myofibroblast differentiation during pulmonary fibrosis.
      Moreover, MeCP2 deficiency significantly reduces pulmonary fibrosis and myofibroblast differentiation in an animal model. The relative contribution of these direct versus indirect mechanisms may be decisive in determining the ultimate effect on myofibroblast differentiation.

      Myofibroblasts, Fibrosis, and miRNAs

      In addition to epigenetic modulation through DNA methylation, different miRNAs appear to contribute to the myofibroblast memory
      • Chau B.N.
      • Brenner D.A.
      What goes up must come down: the emerging role of microRNA in fibrosis.
      (Figure 1B and Table 1). miR-29 expression is markedly reduced in skin biopsy specimens and explanted skin fibroblasts from patients with scleroderma, suggesting a post-translational epigenetic mechanism for increased ECM gene expression.
      • Maurer B.
      • Stanczyk J.
      • Jungel A.
      • Akhmetshina A.
      • Trenkmann M.
      • Brock M.
      • Kowal-Bielecka O.
      • Gay R.E.
      • Michel B.A.
      • Distler J.H.
      • Gay S.
      • Distler O.
      MicroRNA-29, a key regulator of collagen expression in systemic sclerosis.
      In fibrotic lung, low levels of miR-29 correlate with high expression levels of profibrotic genes, including previously unrecognized ECM and ECM remodeling genes. Knockdown or TGFβ1-mediated down-regulation of miR-29 in cultured lung fibroblast derepressed fibrosis-associated genes.
      • Cushing L.
      • Kuang P.P.
      • Qian J.
      • Shao F.
      • Wu J.
      • Little F.
      • Thannickal V.J.
      • Cardoso W.V.
      • Lü J.
      miR-29 is a major regulator of genes associated with pulmonary fibrosis.
      Down-regulation of miR-29 in cardiac fibroblasts in vitro and in vivo induces fibrosis-associated genes, whereas its overexpression has a fibrosis-suppressing effect.
      • van Rooij E.
      • Sutherland L.B.
      • Thatcher J.E.
      • DiMaio J.M.
      • Naseem R.H.
      • Marshall W.S.
      • Hill J.A.
      • Olson E.N.
      Dysregulation of microRNAs after myocardial infarction reveals a role of miR-29 in cardiac fibrosis.
      A comparable fibrosis-suppressing role has been demonstrated for miR-200a in the kidney
      • Wang B.
      • Koh P.
      • Winbanks C.
      • Coughlan M.T.
      • McClelland A.
      • Watson A.
      • Jandeleit-Dahm K.
      • Burns W.C.
      • Thomas M.C.
      • Cooper M.E.
      • Kantharidis P.
      miR-200a prevents renal fibrogenesis through repression of TGF-beta2 expression.
      and liver.
      • Roderburg C.
      • Urban G.W.
      • Bettermann K.
      • Vucur M.
      • Zimmermann H.
      • Schmidt S.
      • Janssen J.
      • Koppe C.
      • Knolle P.
      • Castoldi M.
      • Tacke F.
      • Trautwein C.
      • Luedde T.
      Micro-RNA profiling reveals a role for miR-29 in human and murine liver fibrosis.
      Conversely, in an animal model of kidney fibrosis, up-regulation of miR-192 is reported on TGFβ1 signaling, and overexpression of an miR-192 analogue induces ECM production.
      • Kato M.
      • Arce L.
      • Wang M.
      • Putta S.
      • Lanting L.
      • Natarajan R.
      A microRNA circuit mediates transforming growth factor-beta1 autoregulation in renal glomerular mesangial cells.
      Similarly, miR-129,
      • Kato M.
      • Putta S.
      • Wang M.
      • Yuan H.
      • Lanting L.
      • Nair I.
      • Gunn A.
      • Nakagawa Y.
      • Shimano H.
      • Todorov I.
      • Rossi J.J.
      • Natarajan R.
      TGF-beta activates Akt kinase through a microRNA-dependent amplifying circuit targeting PTEN.
      miR-192, miR-200b/c,
      • Kato M.
      • Arce L.
      • Wang M.
      • Putta S.
      • Lanting L.
      • Natarajan R.
      A microRNA circuit mediates transforming growth factor-beta1 autoregulation in renal glomerular mesangial cells.
      and miR-216a
      • Kato M.
      • Wang L.
      • Putta S.
      • Wang M.
      • Yuan H.
      • Sun G.
      • Lanting L.
      • Todorov I.
      • Rossi J.J.
      • Natarajan R.
      Post-transcriptional up-regulation of Tsc-22 by Ybx1, a target of miR-216a, mediates TGF-{beta}-induced collagen expression in kidney cells.
      promote expression of fibrotic genes in mouse mesangial cells. Another miRNA involved in fibrosis is miR-132, which mediates inhibition of MeCP2 expression, reduces PPARγ expression, and consequently enhances ACTA gene expression in lung fibroblast.
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      Such an indirect mechanism has also been reported for additional miRNA species. Among these, Let7 and miR-21 affect lung myofibroblast differentiation via effects on HMGA2 and Smad7, respectively, although additional effects on other target genes have not been excluded.
      • Pandit K.V.
      • Corcoran D.
      • Yousef H.
      • Yarlagadda M.
      • Tzouvelekis A.
      • Gibson K.F.
      • Konishi K.
      • Yousem S.A.
      • Singh M.
      • Handley D.
      • Richards T.
      • Selman M.
      • Watkins S.C.
      • Pardo A.
      • Ben-Yehudah A.
      • Bouros D.
      • Eickelberg O.
      • Ray P.
      • Benos P.V.
      • Kaminski N.
      Inhibition and role of let-7d in idiopathic pulmonary fibrosis.
      • Liu G.
      • Friggeri A.
      • Yang Y.
      • Milosevic J.
      • Ding Q.
      • Thannickal V.J.
      • Kaminski N.
      • Abraham E.
      miR-21 mediates fibrogenic activation of pulmonary fibroblasts and lung fibrosis.
      Future miRNA profiling studies, such as the one recently started for bleomycin-induced lung fibrosis,
      • Xie T.
      • Liang J.
      • Guo R.
      • Liu N.
      • Noble P.W.
      • Jiang D.
      Comprehensive microRNA analysis in bleomycin-induced pulmonary fibrosis identifies multiple sites of molecular regulation.
      will hopefully provide a more complete picture of the miRNA species involved in the different aspects of fibrosis.

      Myofibroblast Histone Modifications

      Histone modification is involved in the perpetuation of fibrosis. The importance of histone modification in regulation of ACTA gene expression is generally indirect.
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      The histone deacetylases (HDACs) 4, 6, and 8 have been identified as the key HDACs involved in this mechanism
      • Glenisson W.
      • Castronovo V.
      • Waltregny D.
      Histone deacetylase 4 is required for TGFbeta1-induced myofibroblastic differentiation.
      (Figure 1C and Table 1). Although HDAC4 possibly affects the activation of Akt in TGFβ1-induced differentiation,
      • Guo W.
      • Shan B.
      • Klingsberg R.C.
      • Qin X.
      • Lasky J.A.
      Abrogation of TGF-beta1-induced fibroblast-myofibroblast differentiation by histone deacetylase inhibition.
      the direct target genes of these modified histones have not been identified. Histone acetylation is usually associated with activation of target gene expression; thus, the mechanism of this inhibition on ACTA gene expression is likely due to activation of other genes that repress its expression. In addition to histone acetylation, methylation of histones is involved in myofibroblast development and fibrosis.
      • Mann J.
      • Chu D.C.
      • Maxwell A.
      • Oakley F.
      • Zhu N.L.
      • Tsukamoto H.
      • Mann D.A.
      MeCP2 controls an epigenetic pathway that promotes myofibroblast transdifferentiation and fibrosis.
      Considering the rapid progress made in understanding epigenetic processes, it will be years until the first potential targets are identified and tested for their anti-fibrotic potential.

      Organ Fibrosis

      Systemic Sclerosis

      The Role of Fibrosis in Systemic Sclerosis

      Systemic sclerosis or scleroderma is a chronic autoimmune and fibrotic disease of unknown etiology with no effective disease-modifying therapies and significant mortality. The disease is highly heterogeneous in its clinical manifestations. Widespread fibrosis affecting virtually every organ distinguishes scleroderma from organ-based fibrotic processes, such as pulmonary fibrosis, keloids, glomerulosclerosis, and hepatic fibrosis. The dermis, lung parenchyma, heart, gastrointestinal tract, tendons, and ligaments are prominently affected, with endocrine organs, such as the thyroid gland, occasionally affected.
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      Interestingly, neither the liver nor the central nervous system show significant fibrosis in scleroderma. Activated fibroblasts and myofibroblasts are the primary effector cells of fibrosis in scleroderma.
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      The skin in scleroderma is characterized by replacement of the normal dermal architecture with collagen-rich connective tissue. Progressive dermal thickening and sclerosis obliterate eccrine and sebaceous glands, hair follicles, and small blood vessels. Analysis demonstrates excessive deposition of the main fibrillar collagens (types I and III) and types V and VII collagens, normally restricted to the dermal-epidermal junction.
      • Rudnicka L.
      • Varga J.
      • Christiano A.M.
      • Iozzo R.V.
      • Jimenez S.A.
      • Uitto J.
      Elevated expression of type VII collagen in the skin of patients with systemic sclerosis: regulation by transforming growth factor-beta.
      The extradomain A fibronectin splice variant, which is critical for myofibroblast differentiation, shows increased deposition.
      • Rajkumar V.S.
      • Howell K.
      • Csiszar K.
      • Denton C.P.
      • Black C.M.
      • Abraham D.J.
      Shared expression of phenotypic markers in systemic sclerosis indicates a convergence of pericytes and fibroblasts to a myofibroblast lineage in fibrosis.
      Other structural ECM molecules that are aberrantly expressed in scleroderma include fibronectin, proteoglycans, fibrillin, and elastin fibrils.
      • Bayle J.
      • Fitch J.
      • Jacobsen K.
      • Kumar R.
      • Lafyatis R.
      • Lemaire R.
      Increased expression of Wnt2 and SFRP4 in Tsk mouse skin: role of Wnt signaling in altered dermal fibrillin deposition and systemic sclerosis.
      Fibrillin accumulation is of particular interest, because fibrillin-1 regulates the activation of ECM-bound latent TGFβ1, and mice with a fibrillin-1 mutation (tight skin mice) develop a sclerodermalike phenotype.
      • Siracusa L.D.
      • McGrath R.
      • Ma Q.
      • Moskow J.J.
      • Manne J.
      • Christner P.J.
      • Buchberg A.M.
      • Jimenez S.A.
      A tandem duplication within the fibrillin 1 gene is associated with the mouse tight skin mutation.
      Microarray analysis of scleroderma skin reveals up-regulation of genes normally associated with bone and cartilage, including type XI collagen and cartilage oligomeric matrix protein (COMP). Integrins involved in cell-cell and cell-ECM adhesion and latent growth factor activation are also overexpressed in the lesional tissue.
      • Sargent J.L.
      • Whitfield M.L.
      Capturing the heterogeneity in systemic sclerosis with genome-wide expression profiling.
      • Wei J.
      • Bhattacharyya S.
      • Tourtellotte W.G.
      • Varga J.
      Fibrosis in systemic sclerosis: emerging concepts and implications for targeted therapy.

      The Origin of Myofibroblasts in Scleroderma

      Fibroblasts and myofibroblasts are the principal stromal cells responsible for the excessive ECM deposition and remodeling in scleroderma. Although in situ hybridization studies have identified an increased proportion of biosynthetically active fibroblasts in scleroderma dermis, in vitro clonal analysis of explanted skin fibroblasts shows substantial heterogeneity with respect to collagen synthesis, suggesting the existence of distinct subpopulations of dermal mesenchymal cells with different origins. Cells positive for α-SMA are present in the skin with lesional scleroderma but are not detected in healthy skin.
      • Rajkumar V.S.
      • Howell K.
      • Csiszar K.
      • Denton C.P.
      • Black C.M.
      • Abraham D.J.
      Shared expression of phenotypic markers in systemic sclerosis indicates a convergence of pericytes and fibroblasts to a myofibroblast lineage in fibrosis.
      • Jelaska A.
      • Korn J.H.
      Role of apoptosis and transforming growth factor beta1 in fibroblast selection and activation in systemic sclerosis.
      Accumulation is prominent in areas with significant collagen deposition. Myofibroblastic cells are also observed in the esophagus and lung, even in the liver, despite the absence of fibrosis. Culture of bronchoalveolar lavage fluids from patients with scleroderma shows spontaneous outgrowth of α-SMA–positive cells with high production of collagen and fibronectin.
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      In contrast, myofibroblasts are not detected in bronchoalveolar lavage fluids from healthy individuals. The number of myofibroblasts in the lesional skin in scleroderma correlates with both the extent of local collagen deposition and the clinical assessment of skin stiffness.
      • Kissin E.Y.
      • Merkel P.A.
      • Lafyatis R.
      Myofibroblasts and hyalinized collagen as markers of skin disease in systemic sclerosis.
      Moreover, the myofibroblast score in the skin shows a decrease over 6 to 12 months in patients treated with cyclophosphamide, suggesting that myofibroblast levels in the skin may be used as biomarkers of changing skin involvement.
      The origin of myofibroblasts in the fibrotic lesions has not been conclusively established. They may arise from the in situ activation of normally quiescent resident fibroblasts in response to extracellular triggers, such as TGFβ1, Wnt, Jagged/Notch, CCN2, endothelin-1, lysophophatidic acid, and other signaling molecules, as well as hypoxia and mechanical stress due to increased ECM stiffness.
      • Varga J.
      • Abraham D.
      Systemic sclerosis: a prototypic multisystem fibrotic disorder.
      Each of these stimuli, which induce α-SMA expression and stress fiber formation in explanted healthy skin fibroblasts, has been aberrantly expressed or regulated in scleroderma. Alternatively, myofibroblasts in scleroderma lesional tissue may arise from other cell types, including vascular smooth muscle cells, pericytes,
      • Rajkumar V.S.
      • Howell K.
      • Csiszar K.
      • Denton C.P.
      • Black C.M.
      • Abraham D.J.
      Shared expression of phenotypic markers in systemic sclerosis indicates a convergence of pericytes and fibroblasts to a myofibroblast lineage in fibrosis.
      and endothelial cells under the influence of TGFβ1
      • Li Z.
      • Jimenez S.A.
      Protein kinase Cδ and the c-Abl kinase are required for transforming growth factor β induction of endothelial-mesenchymal transition in vitro.
      or epithelial cells in the skin or lungs.
      • Aden N.
      • Nuttall A.
      • Shiwen X.
      • de Winter P.
      • Leask A.
      • Black C.M.
      • Denton C.P.
      • Abraham D.J.
      • Stratton R.J.
      Epithelial cells promote fibroblast activation via IL-1alpha in systemic sclerosis.
      • Zhou G.
      • Dada L.A.
      • Wu M.
      • Kelly A.
      • Trejo H.
      • Zhou Q.
      • Varga J.
      • Sznajder J.I.
      Hypoxia-induced alveolar epithelial-mesenchymal transition requires mitochondrial ROS and hypoxia-inducible factor 1.
      Because both myofibroblasts and pericytes are associated with vascular remodeling and injury, which are prominent in patients with scleroderma, vascular smooth muscle cells and pericytes might provide the pathogenetic link between vascular injury and fibrosis characteristic of scleroderma. Although the significance of mesenchymal differentiation pathways in the context of scleroderma has not been conclusively demonstrated, and the mechanisms underlying such cellular plasticity in vivo remain mostly unknown, it is tempting to consider scleroderma therapies that are based on targeting these events.

      Persistence of Scleroderma Fibroblasts

      Historically, the study of scleroderma fibroblasts focuses primarily on the skin, because it is readily accessible for biopsy. Pioneering studies by Leroy
      • Leroy E.C.
      Connective tissue synthesis by scleroderma skin fibroblasts in cell culture.
      30 years ago are the first to demonstrate the feasibility of studying explanted skin fibroblasts in scleroderma. These observations indicate that scleroderma-derived skin fibroblasts display a biosynthetically activated phenotype in vitro that is independent of extracellular signals. A cell-autonomous activated phenotype is maintained for multiple in vitro passages.
      • Leroy E.C.
      Connective tissue synthesis by scleroderma skin fibroblasts in cell culture.
      These studies have been subsequently reproduced and extended by other investigators.
      • Trojanowska M.
      What did we learn by studying scleroderma fibroblasts?.
      In some studies, most explanted scleroderma fibroblasts are positive for α-SMA in vitro, with increased production of collagen and tissue inhibitor of metalloproteinase.
      • Kirk T.Z.
      • Mark M.E.
      • Chua C.C.
      • Chua B.H.
      • Mayes M.D.
      Myofibroblasts from scleroderma skin synthesize elevated levels of collagen and tissue inhibitor of metalloproteinase (TIMP-1) with two forms of TIMP-1.
      Moreover, myofibroblasts explanted from scleroderma skin are resistant to Fas-induced apoptosis.
      • Jelaska A.
      • Korn J.H.
      Role of apoptosis and transforming growth factor beta1 in fibroblast selection and activation in systemic sclerosis.
      Apoptosis resistance may be due to activation of the Akt prosurvival pathway and may account for the persistence of myofibroblasts in scleroderma skin.
      • Jun J.B.
      • Kuechle M.
      • Min J.
      • Shim S.C.
      • Kim G.
      • Montenegro V.
      • Korn J.H.
      • Elkon K.B.
      Scleroderma fibroblasts demonstrate enhanced activation of Akt (protein kinase B) in situ.
      Another potential mechanistic explanation accounting for the persistent α-SMA expression in scleroderma is provided by the demonstration that pharmacological inhibition of focal adhesion kinase phosphorylation significantly attenuates the myofibroblast phenotype of these cells.
      • Mimura Y.
      • Ihn H.
      • Jinnin M.
      • Asano Y.
      • Yamane K.
      • Tamaki K.
      Constitutive phosphorylation of focal adhesion kinase is involved in the myofibroblast differentiation of scleroderma fibroblasts.
      Scleroderma fibroblasts show an elevated level of focal adhesion kinase phosphorylation, presumably reflecting their stimulation by autocrine TGFβ1. Consistent with the autocrine TGFβ1 hypothesis, explanted scleroderma fibroblasts show constitutive nuclear localization of phosphorylated Smad2/3, even in the absence of added TGFβ1.
      • Mori Y.
      • Chen S.J.
      • Varga J.
      Expression and regulation of intracellular SMAD signaling in scleroderma skin fibroblasts.
      These studies suggest that an autocrine TGFβ1-stimulatory loop induces focal adhesion kinase phosphorylation and apoptosis resistance, with consequent persistence of α-SMA–expressing myofibroblasts.
      • Varga J.
      • Pasche B.
      Transforming growth factor beta as a therapeutic target in systemic sclerosis.
      In addition to enhanced ECM production, scleroderma fibroblasts in culture produce chemokines and growth factors and spontaneously generate reactive oxygen radicals, such as H2O2, through the NADPH oxidase (NOX) complex pathway, which is up-regulated in scleroderma skin.
      • Sambo P.
      • Baroni S.S.
      • Luchetti M.
      • Paroncini P.
      • Dusi S.
      • Orlandini G.
      • Gabrielli A.
      Oxidative stress in scleroderma: maintenance of scleroderma fibroblast phenotype by the constitutive up-regulation of reactive oxygen species generation through the NADPH oxidase complex pathway.
      In turn, intracellular production of reactive oxygen species is at least partially responsible for the constitutive up-regulation of collagen synthesis in these cells. The expression of surface receptors for relevant growth factors and chemokines, including TGFβ1, platelet-derived growth factor, and CCR2, are also elevated on scleroderma fibroblasts, suggesting an additional feed-forward amplification mechanism that might underlie the persistently activated phenotype.
      • Pannu J.
      • Gardner H.
      • Shearstone J.R.
      • Smith E.
      • Trojanowska M.
      Increased levels of transforming growth factor beta receptor type I and up-regulation of matrix gene program: a model of scleroderma.

      Renal Fibrosis

      Renal interstitial fibrosis is a common pathological feature of chronic kidney disease (CKD), irrespective of etiology. The myofibroblast is a major player in the onset and evolution of renal fibrosis and has been implicated in pathogenesis.
      • Liu Y.
      Cellular and molecular mechanisms of renal fibrosis.

      The Origin of Renal Myofibroblasts

      Despite their pivotal role in disease progression, the source of renal myofibroblasts is still a matter of debate. Several progenitors have been proposed in addition to local fibroblasts, including circulating fibrocytes, local pericytes,
      • Humphreys B.D.
      • Lin S.L.
      • Kobayashi A.
      • Hudson T.E.
      • Nowlin B.T.
      • Bonventre J.V.
      • Valerius M.T.
      • McMahon A.P.
      • Duffield J.S.
      Fate tracing reveals the pericyte and not epithelial origin of myofibroblasts in kidney fibrosis.
      • Lin S.L.
      • Kisseleva T.
      • Brenner D.A.
      • Duffield J.S.
      Pericytes and perivascular fibroblasts are the primary source of collagen-producing cells in obstructive fibrosis of the kidney.
      and resident epithelial cells, through epithelial-to-mesenchymal transition (EMT).
      • Zeisberg M.
      • Kalluri R.
      The role of epithelial-to-mesenchymal transition in renal fibrosis.
      The possible contribution of EMT to fibrosis in vivo was recently challenged by a study
      • Humphreys B.D.
      • Lin S.L.
      • Kobayashi A.
      • Hudson T.E.
      • Nowlin B.T.
      • Bonventre J.V.
      • Valerius M.T.
      • McMahon A.P.
      • Duffield J.S.
      Fate tracing reveals the pericyte and not epithelial origin of myofibroblasts in kidney fibrosis.
      using a mouse model of renal interstitial fibrosis and genetic cell lineage tracing. However, under the same conditions of kidney obstruction, but using a different approach, EMT was observed by another group.
      • Inoue T.
      • Okada H.
      • Takenaka T.
      • Watanabe Y.
      • Suzuki H.
      A case report suggesting the occurrence of epithelial-mesenchymal transition in obstructive nephropathy.
      These conflicting data have been addressed elsewhere in several excellent critical articles.
      • Zeisberg M.
      • Duffield J.S.
      Resolved: EMT produces fibroblasts in the kidney.
      • Popov Y.
      • Schuppan D.
      Epithelial-to-mesenchymal transition in liver fibrosis: dead or alive?.

      Tubuloepithelial-to-Mesenchymal Cross Talk Contributes to Kidney Myofibroblast Generation

      It appears increasingly likely that loss of the normal, homeostatic microenvironment, due to alterations in the tubulointerstitium per se, triggers myofibroblast activation and causes progression of fibrosis.
      • Koesters R.
      • Kaissling B.
      • Lehir M.
      • Picard N.
      • Theilig F.
      • Gebhardt R.
      • Glick A.B.
      • Hahnel B.
      • Hosser H.
      • Grone H.J.
      • Kriz W.
      Tubular overexpression of transforming growth factor-beta1 induces autophagy and fibrosis but not mesenchymal transition of renal epithelial cells.
      This established concept is based on the histological evidence that proximal tubule cell (PTC) injury precedes interstitial fibrosis and that regions of active interstitial fibrosis predominantly exhibit a peritubular, rather than a perivascular, distribution. This notion is supported by in vitro studies
      • Johnson D.W.
      • Saunders H.J.
      • Baxter R.C.
      • Field M.J.
      • Pollock C.A.
      Paracrine stimulation of human renal fibroblasts by proximal tubule cells.
      showing that cortical fibroblast proliferation is stimulated by paracrine signals generated by PTC in co-culture.
      Moreover, in proteinuric nephropathies with progressive injury of the glomerular filtering barrier, abnormal uptake of ultrafiltered proteins by PTCs induces release of TGFβ1, which, in turn, promotes interstitial fibrogenesis.
      • Abbate M.
      • Zoja C.
      • Rottoli D.
      • Corna D.
      • Tomasoni S.
      • Remuzzi G.
      Proximal tubular cells promote fibrogenesis by TGF-beta1-mediated induction of peritubular myofibroblasts.
      Re-establishment in vitro of epithelial cell polarization and differentiation inhibits proliferation of mesenchymal stem cells (MSCs) from co-cultured adipose tissue fragments,
      • Udo K.
      • Aoki S.
      • Uchihashi K.
      • Kawasaki M.
      • Matsunobu A.
      • Tokuda Y.
      • Ootani A.
      • Toda S.
      • Uozumi J.
      Adipose tissue explants and MDCK cells reciprocally regulate their morphogenesis in coculture.
      confirming that uninjured differentiated renal tubular cells in their normal configuration contribute to the maintenance of the homeostatic state of MSCs. A seminal work
      • Yang L.
      • Besschetnova T.Y.
      • Brooks C.R.
      • Shah J.V.
      • Bonventre J.V.
      Epithelial cell cycle arrest in G2/M mediates kidney fibrosis after injury.
      evaluating the effects in vitro of aristolochic acid on several PTC lines reveals that damaged epithelial cells markedly up-regulate expression of profibrotic TGFβ1 and CCN2. This up-regulation is associated with a marked increase in the percentage of cells in the G2/M phase of the cell cycle, which is confirmed in vivo using different acute kidney disease mouse models.
      • Yang L.
      • Besschetnova T.Y.
      • Brooks C.R.
      • Shah J.V.
      • Bonventre J.V.
      Epithelial cell cycle arrest in G2/M mediates kidney fibrosis after injury.
      The contribution of PTCs is further supported in a tetracycline-inducible transgenic mouse model, in which conditional overexpression of TGFβ1, limited to renal tubules, induces widespread peritubular fibrosis and focal nephron degeneration.
      • Koesters R.
      • Kaissling B.
      • Lehir M.
      • Picard N.
      • Theilig F.
      • Gebhardt R.
      • Glick A.B.
      • Hahnel B.
      • Hosser H.
      • Grone H.J.
      • Kriz W.
      Tubular overexpression of transforming growth factor-beta1 induces autophagy and fibrosis but not mesenchymal transition of renal epithelial cells.
      During the course of this process, the remnants of one cell were removed by phagocytosis by neighboring cells with a mechanism akin to that seen in tubular atrophy.
      • Schelling J.R.
      • Cleveland R.P.
      Involvement of Fas-dependent apoptosis in renal tubular epithelial cell deletion in chronic renal failure.
      Outside these degenerating tubules, a marked proliferation of resident fibroblasts, without contribution of EMT and only sparse macrophages, is associated with progressive deposition of ECM.
      Notch signaling is involved in orchestrating kidney development in tubular epithelial cells and plays a role in tubulointerstitial development.
      • Bielesz B.
      • Sirin Y.
      • Si H.
      • Niranjan T.
      • Gruenwald A.
      • Ahn S.
      • Kato H.
      • Pullman J.
      • Gessler M.
      • Haase V.H.
      • Susztak K.
      Epithelial Notch signaling regulates interstitial fibrosis development in the kidneys of mice and humans.
      Interestingly, specific expression of cleaved Notch1 in tubular epithelial cells causes fibrosis in the surrounding interstitium, with a histological appearance that resembles the lesions seen in human CKD. Conversely, tubular-specific deletion of Notch signaling protects against kidney fibrosis.
      • Bielesz B.
      • Sirin Y.
      • Si H.
      • Niranjan T.
      • Gruenwald A.
      • Ahn S.
      • Kato H.
      • Pullman J.
      • Gessler M.
      • Haase V.H.
      • Susztak K.
      Epithelial Notch signaling regulates interstitial fibrosis development in the kidneys of mice and humans.
      The importance of an altered tubule-interstitial microenvironment to fibrosis is also supported by the clinical observation that the severity of acute kidney injury (AKI) with massive tubular epithelial cell death is a robust predictor of progression to CKD.
      • Chawla L.S.
      • Amdur R.L.
      • Amodeo S.
      • Kimmel P.L.
      • Palant C.E.
      The severity of acute kidney injury predicts progression to chronic kidney disease.
      Even if mechanisms for AKI to CKD progression are unknown, it can be hypothesized that AKI progression toward CKD arises from incomplete repair of regenerating tubules. Another explanation is that persistently high profibrotic signaling activity in regenerating tubule epithelium produces paracrine activity that drives fibroblast proliferation and inflammation. Thus, in severe AKI and CKD, epithelial-mesenchymal cross talk alterations possibly lead to tubulointerstitial fibrosis and kidney failure.
      It appears that an altered renal microenvironment is the main cause of myofibroblast differentiation in renal fibrosis, and cross talk between epithelial cells and fibroblasts is pivotal for maintenance of the local homeostatic microenvironment, a concept previously suggested for idiopathic pulmonary fibrosis
      • Selman M.
      • Pardo A.
      Role of epithelial cells in idiopathic pulmonary fibrosis: from innocent targets to serial killers.
      • Thannickal V.J.
      • Toews G.B.
      • White E.S.
      • Lynch 3rd, J.P.
      • Martinez F.J.
      Mechanisms of pulmonary fibrosis.
      and for stromal reaction to carcinoma.
      • De Wever O.
      • Demetter P.
      • Mareel M.
      • Bracke M.
      Stromal myofibroblasts are drivers of invasive cancer growth.
      Therefore, interfering with tubular-mesenchymal cross talk emerges as a promising strategy for the development of new anti-fibrotic drugs, which are not solely directed to block myofibroblast activation.

      Pulmonary Fibrosis

      Structural Aspects of the Lung Relevant for Fibrosis

      The adult human lung is a structurally complex organ system composed of >40 cell types. The upper conducting airway, composed of the trachea and a series of branching bronchi and bronchioles, terminates in the gas-exchanging alveoli of the lower respiratory tract. At each level, the epithelium-lined airways and endothelium-lined vasculature are integrated, both structurally and functionally, by an interconnected reticulum of mesenchymal cells and ECM extending from the upper airway down to the alveoli.
      • Evans M.J.
      • Van Winkle L.S.
      • Fanucchi M.V.
      • Plopper C.G.
      The attenuated fibroblast sheath of the respiratory tract epithelial-mesenchymal trophic unit.
      The lung is susceptible to various forms of short-/long-term injuries, both airborne and blood borne, that may culminate in fibrosis. In addition, fibrosis may involve the small conducting airways (eg, asthma and chronic obstructive pulmonary disease), vasculature (eg, pulmonary hypertension), or pleura (eg, pleural fibrosis). Some forms of fibrosis, such as acute lung injury or cryptogenic organizing pneumonia, are at least partially reversible, whereas others, in particular idiopathic pulmonary fibrosis, are progressive and usually fatal.
      • Selman M.
      • Pardo A.
      Role of epithelial cells in idiopathic pulmonary fibrosis: from innocent targets to serial killers.
      • Thannickal V.J.
      • Toews G.B.
      • White E.S.
      • Lynch 3rd, J.P.
      • Martinez F.J.
      Mechanisms of pulmonary fibrosis.
      A central role for the myofibroblast in tissue remodeling and fibrosis involving these different tissue compartments and varied disease processes has been demonstrated.
      • Araya J.
      • Nishimura S.L.
      Fibrogenic reactions in lung disease.

      Origin of Lung Myofibroblasts

      The concept that lung myofibroblasts may derive from multiple cellular sources, including bone marrow progenitors and the lung epithelium, has been previously reviewed.
      • Hinz B.
      • Phan S.H.
      • Thannickal V.J.
      • Galli A.
      • Bochaton-Piallat M.L.
      • Gabbiani G.
      The myofibroblast: one function, multiple origins.
      Depending on the experimental model and tools used, conclusions on participation of myofibroblast progenitors to lung fibrosis sometimes appear contradictory. For example, recent studies using a surfactant protein C-CreER(T2) knock-in allele to follow the fate of type II alveolar cells in vivo indicated no contribution to myofibroblasts in the fibrotic reaction to an acute lung injury involving intratracheal instillation of bleomycin.
      • Rock J.R.
      • Barkauskas C.E.
      • Cronce M.J.
      • Xue Y.
      • Harris J.R.
      • Liang J.
      • Noble P.W.
      • Hogan B.L.
      Multiple stromal populations contribute to pulmonary fibrosis without evidence for epithelial to mesenchymal transition.
      The resolving nature of bleomycin-induced lung fibrosis in mice contrasts with the progressive nature of the most recalcitrant forms of lung fibrosis in humans, in particular idiopathic pulmonary fibrosis. Whether chronicity of the injury may account for processes, such as EMT, remains to be determined. Chronicity and irreversibility of the fibrotic process may also be linked to the epigenetic (dys) regulation
      • Luco R.F.
      • Allo M.
      • Schor I.E.
      • Kornblihtt A.R.
      • Misteli T.
      Epigenetics in alternative pre-mRNA splicing.
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Essential role of MeCP2 in the regulation of myofibroblast differentiation during pulmonary fibrosis.
      • Hu B.
      • Gharaee-Kermani M.
      • Wu Z.
      • Phan S.H.
      Epigenetic regulation of myofibroblast differentiation by DNA methylation.
      • Sanders Y.Y.
      • Tollefsbol T.O.
      • Varisco B.M.
      • Hagood J.S.
      Epigenetic regulation of thy-1 by histone deacetylase inhibitor in rat lung fibroblasts.
      that controls the differentiation and fate of endogenous reparative cells.

      Specific Features of Myofibroblasts in the Lung

      The fate of myofibroblasts, regardless of their origin(s), in injured tissues may ultimately determine whether normal healing occurs or whether progression to end-stage fibrosis ensues.
      • Thannickal V.J.
      • Toews G.B.
      • White E.S.
      • Lynch 3rd, J.P.
      • Martinez F.J.
      Mechanisms of pulmonary fibrosis.
      • Thannickal V.J.
      • Horowitz J.C.
      Evolving concepts of apoptosis in idiopathic pulmonary fibrosis.
      There is likely to be significant heterogeneity in lung fibroblasts, including anti-fibrotic subpopulations, such as Thy-1–expressing fibroblasts and lipofibroblasts.
      • Zhou Y.
      • Hagood J.S.
      • Lu B.
      • Merryman W.D.
      • Murphy-Ullrich J.E.
      Thy-1-integrin alphav beta5 interactions inhibit lung fibroblast contraction-induced latent transforming growth factor-beta1 activation and myofibroblast differentiation.
      • Sanders Y.Y.
      • Tollefsbol T.O.
      • Varisco B.M.
      • Hagood J.S.
      Epigenetic regulation of thy-1 by histone deacetylase inhibitor in rat lung fibroblasts.
      • Kis K.
      • Liu X.
      • Hagood J.S.
      Myofibroblast differentiation and survival in fibrotic disease.
      The mechanisms that produce an apoptosis-resistant myofibroblast phenotype have not been fully elucidated, although some of the same factors that mediate myofibroblast differentiation appear to promote myofibroblast survival.
      • Kis K.
      • Liu X.
      • Hagood J.S.
      Myofibroblast differentiation and survival in fibrotic disease.
      • Horowitz J.C.
      • Lee D.Y.
      • Waghray M.
      • Keshamouni V.G.
      • Thomas P.E.
      • Zhang H.
      • Cui Z.
      • Thannickal V.J.
      Activation of the pro-survival phosphatidylinositol 3-kinase/AKT pathway by transforming growth factor-beta1 in mesenchymal cells is mediated by p38 MAPK-dependent induction of an autocrine growth factor.
      • Horowitz J.C.
      • Rogers D.S.
      • Sharma V.
      • Vittal R.
      • White E.S.
      • Cui Z.
      • Thannickal V.J.
      Combinatorial activation of FAK and AKT by transforming growth factor-beta1 confers an anoikis-resistant phenotype to myofibroblasts.
      A member of the NOX family of enzymes, NOX4 has been required for TGFβ1-induced myofibroblast differentiation, ECM production, and contractility of lung myofibroblasts.
      • Hecker L.
      • Vittal R.
      • Jones T.
      • Jagirdar R.
      • Luckhardt T.R.
      • Horowitz J.C.
      • Pennathur S.
      • Martinez F.J.
      • Thannickal V.J.
      NADPH oxidase-4 mediates myofibroblast activation and fibrogenic responses to lung injury.
      • Amara N.
      • Goven D.
      • Prost F.
      • Muloway R.
      • Crestani B.
      • Boczkowski J.
      NOX4/NADPH oxidase expression is increased in pulmonary fibroblasts from patients with idiopathic pulmonary fibrosis and mediates TGFbeta1-induced fibroblast differentiation into myofibroblasts.
      NOX4 is up-regulated in lungs of human subjects with idiopathic pulmonary fibrosis, and genetic or pharmacological targeting of NOX4 attenuated lung fibrogenesis in two different murine models of lung injury.
      • Hecker L.
      • Vittal R.
      • Jones T.
      • Jagirdar R.
      • Luckhardt T.R.
      • Horowitz J.C.
      • Pennathur S.
      • Martinez F.J.
      • Thannickal V.J.
      NADPH oxidase-4 mediates myofibroblast activation and fibrogenic responses to lung injury.
      It is unknown if the profibrotic effects of NOX4 are related solely to activation of myofibroblasts or if its expression in alveolar epithelial cells may also contribute to fibrogenesis.
      • Carnesecchi S.
      • Deffert C.
      • Donati Y.
      • Basset O.
      • Hinz B.
      • Preynat-Seauve O.
      • Guichard C.
      • Arbiser J.L.
      • Banfi B.
      • Pache J.C.
      • Barazzone-Argiroffo C.
      • Krause K.H.
      A key role for NOX4 in epithelial cell death during development of lung fibrosis.
      • Waghray M.
      • Cui Z.
      • Horowitz J.C.
      • Subramanian I.M.
      • Martinez F.J.
      • Toews G.B.
      • Thannickal V.J.
      Hydrogen peroxide is a diffusible paracrine signal for the induction of epithelial cell death by activated myofibroblasts.
      It is also yet to be determined if targeting NOX4 modulates the apoptosis-resistant phenotype of myofibroblasts and whether this strategy may be effective in established fibros