osteogenesis imperfecta
DESCRIPTION
osteogenesis imperfectaTRANSCRIPT
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Osteogenesis Imperfecta
Osteogenesis imperfecta is a condition inherited in mendelian fashion that illustrates
many principles of human genetics. It is a heterogeneous and pleiotropic group of
disorders characterized by a tendency toward fragility of bone. Advances in the last two
decades demonstrate that nearly every case is caused by a mutation of the COL1A1 or
COL1A2 genes, which encode the subunits of type I collagen, pro1(I) and pro 2(I),
respectively. More than 100 different mutant alleles have been described for
osteogenesis imperfecta; the relationships between different DNA sequence alterations
and the type of disease (genotype-phenotype correlations) illustrate several
pathophysiologic principles in human genetics.
Clinical Manifestations
The clinical and genetic characteristics of osteogenesis imperfecta are summarized in
Table 23, in which the timing and severity of fractures, radiologic findings, presence of
additional clinical features, and family history are used to discriminate among four
different subtypes. All forms of osteogenesis imperfecta are characterized by increased
susceptibility to fractures ("brittle bones"), but there is considerable phenotypic
heterogeneity, even within individual subtypes. Individuals with type I or type IV
osteogenesis imperfecta present in early childhood with one or a few fractures of long
bones in response to minimal or no trauma; x-ray films reveal mild osteopenia, little or
no bony deformity, and often evidence of earlier subclinical fractures. However, most
individuals with type I or type IV osteogenesis imperfecta do not have fractures in utero.
Type I and type IV osteogenesis imperfecta are distinguished by the severity (less in
type I than in type IV) and by scleral hue, which indicates the thickness of this tissue
and the deposition of type I collagen. Individuals with type I osteogenesis imperfecta
have blue scleras, whereas the scleras of those with type IV are normal or slightly gray.
In type I, the typical number of fractures during childhood is 1020; fracture incidence
decreases after puberty, and the main features in adult life are mild short stature, a
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tendency toward conductive hearing loss, and occasionally dentinogenesis imperfecta.
Individuals with type IV osteogenesis imperfecta generally experience more fractures
than those with type I and have significant short stature caused by a combination of
long bone and spinal deformities, but they often are able to walk independently.
Approximately one fourth of the cases of type I or type IV osteogenesis imperfecta
represent new mutations; in the remainder, the history and examination of other family
members reveal findings consistent with autosomal dominant inheritance.
Table 23 Clinical and Molecular Subtypes of Osteogenesis Imperfecta.
Type Phenotype Genetics Molecular Pathophysiology
Type
I
Mild: Short stature, postnatal
fractures, little or no
deformity, blue scleras,
premature hearing loss
Autosomal
dominant
Loss-of-function mutation in
pro 1(I) chain resulting in
decreased amount of mRNA;
quality of collagen is normal;
quantity is reduced twofold
Type
II
Perinatal lethal: Severe
prenatal fractures, abnormal
bone formation, severe
deformities, blue scleras,
connective tissue fragility
Sporadic
(autosomal
dominant)
Structural mutation in pro 1(I) or
pro 2(I) chain that has mild
effect on heterotrimer assembly;
quality of collagen is severely
abnormal; quantity often
reduced also
Type
III
Progressive deforming:
Prenatal fractures,
deformities usually present at
birth, very short stature,
Autosomal
dominant1
Structural mutation in pro 1(I) or
pro 2(I) chain that has mild
effect on heterotrimer assembly;
quality of collagen is severely
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usually nonambulatory, blue
scleras, hearing loss
abnormal; quantity can be
normal
Type
IV
Deforming with normal
scleras: Postnatal fractures,
mild to moderate deformities,
premature hearing loss,
normal or gray scleras,
dental abnormalities
Autosomal
dominant
Structural mutation in the pro
2(I), or, less frequently, pro 1(I)
chain that has little or no effect
on heterotrimer assembly;
quality of collagen is usually
abnormal; quantity can be
normal
1Autosomal recessive in rare cases.
Type II osteogenesis imperfecta presents at or before birth (diagnosed by prenatal
ultrasonography) with multiple fractures, bony deformities, increased fragility of nonbony
connective tissue, and blue scleras and usually results in death in infancy. Two typical
radiologic findings are the presence of isolated "islands" of mineralization in the skull
(wormian bones) and a beaded appearance to the ribs. Nearly all cases of type II
osteogenesis imperfecta represent a new dominant mutation, and there is no family
history. Death usually results from respiratory difficulties.
Type III osteogenesis imperfecta presents at birth or in infancy with progressive bony
deformities, multiple fractures, and blue scleras. It is intermediate in severity between
types II and IV; most affected individuals will require multiple corrective surgeries and
lose the ability to ambulate by early adulthood. Unlike other forms of osteogenesis
imperfecta, which are nearly always due to mutations that act dominantly, type III can
be inherited in either a dominant or (rarely) recessive fashion. From a biochemical and
molecular perspective, type III osteogenesis imperfecta is the least well understood
form.
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Although different subtypes of osteogenesis imperfecta can often be distinguished
biochemically, the classification presented in Table 23 is clinical rather than molecular,
and the disease phenotypes for each subtype show a spectrum of severities that
overlap one another. For example, a few individuals diagnosed with type II
osteogenesis imperfecta based on the presence of severe bony deformities in utero will
survive for many years and thus overlap the type III subtype. Similarly, some individuals
with type IV osteogenesis imperfecta have fractures in utero and develop deformities
that lead to loss of ambulation. Distinguishing this presentation from type III
osteogenesis imperfecta may be possible only if other affected family members exhibit a
milder course.
Additional subtypes of osteogenesis imperfecta have been suggested for individuals
that do not match types IIV, and there are additional disorders associated with
congenital fractures that are usually not considered to be "classic" osteogenesis
imperfecta. In some cases, mutations of type I collagen genes have been excluded as
potential causes of these additional disorders. However, the approach to clinical
classification depicted in Table 23 is helpful for most affected individuals in predicting
the course and inheritance pattern of the illness. The classification also serves as an
important framework within which to correlate molecular abnormalities with disease
phenotypes.
Pathophysiology
Osteogenesis imperfecta is a disease of type I collagen, which constitutes the major
extracellular protein in the body. It is the major collagen in the dermis, the connective
tissue capsules of most organs, and the vascular and GI adventitia and is the only
collagen in bone. A mature type I collagen fibril is a rigid structure that contains multiple
type I collagen molecules packed in a staggered array and stabilized by intermolecular
covalent cross-links. Each mature type I collagen molecule contains two 1 chains and
one 2 chain, encoded by the COL1A1 and COL1A2 genes, respectively (Figure 22).
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The COL1A1 and COL1A2 genes have 51 and 52 exons, respectively, of which exons
649 encode the entire triple-helical domain. The 1 and 2 chains are synthesized as
larger precursors with amino and carboxyl terminal "propeptide" extensions, assemble
with each other inside the cell, and are ultimately secreted as a heterotrimeric type I
procollagen molecule. During intracellular assembly, the three chains wind around each
other in a triple helix that is stabilized by interchain interactions between hydroxy proline
and adjacent carbonyl residues. There is a dynamic relationship between the
posttranslational action of prolyl hydroxylase and assembly of the triple helix, which
begins at the carboxyl terminal end of the molecule. Increased levels of hydroxylation
result in a more stable helix, but helix formation prevents further prolyl hydroxylation.
The nature of the triple helix causes the side chain of every third amino acid to point
inward, and steric constraints allow only a proton in this position. Thus, the amino acid
sequence of virtually all collagen chains in the triple-helical portion is (Gly-X-Y)n, where
Y is proline about one third of the time.
The fundamental defect in most individuals with type I osteogenesis imperfecta is
reduced synthesis of type I collagen resulting from loss-of-function mutations in
COL1A1. In most cases, the mutant COL1A1 allele gives rise to greatly reduced (partial
loss-of-function) or no (complete loss-of-function) mRNA. Because the nonmutant
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COL1A1 allele continues to produce mRNA at a normal rate (ie, there is no dosage
compensation), heterozygosity for a complete loss-of-function mutation results in a 50%
reduction in the total rate of pro 1(I) mRNA synthesis, whereas heterozygosity for a
partial loss-of-function mutation results in a less severe reduction. A reduced
concentration of pro 1(I) chains limits the production of type I procollagen, leading to (1)
a reduced amount of structurally normal type I collagen and (2) an excess of
unassembled pro 2(I) chains, which are degraded inside the cell (Figure 23).
There are several potential molecular defects responsible for COL1A1 mutations in type
I osteogenesis imperfecta, including alterations in a regulatory region leading to reduced
transcription, splicing abnormalities leading to reduced steady state levels of RNA, and
deletion of the entire COL1A1 gene. However, in many cases, the underlying defect is a
single base pair change that creates a premature stop codon (also known as a
"nonsense mutation") in exons 649. In a process referred to as "nonsense-mediated
decay," partially synthesized mRNA precursors that carry the nonsense codon are
recognized and degraded by the cell. With collagen and many other genes, production
of a truncated protein (as might be predicted from a nonsense mutation) would be more
damaging to the cell than production of no protein at all. Thus, nonsense-mediated
decay, which has been observed to occur for mutations in many different multiexon
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genes, serves as a protective phenomenon and is an important component of genetic
pathophysiology.
An example of these principles is apparent from considering type II osteogenesis
imperfecta, which is caused by structurally abnormal forms of type I collagen and is
more severe than type I osteogenesis imperfecta. Mutations in type II osteogenesis
imperfecta can be caused by defects in either COL1A1 or COL1A2 and usually are
missense alterations of a glycine residue that allow the mutant peptide chain to bind to
normal chains in the initial steps of trimer assembly (Figure 23). However, triple-helix
formation is ineffective, often because amino acids with large side chains are
substituted for glycine. Ineffective triple-helix formation leads to increased
posttranslational modification by prolyl hydroxylase and a reduced rate of secretion.
These appear to be critical events in the cellular pathogenesis of type II osteogenesis
imperfecta, because glycine substitutions toward the carboxyl terminal end of the
molecule are generally more severe than those at the amino terminal end.
These considerations help to explain why type II osteogenesis imperfecta is more
severe than type I and exemplify the principle of dominant negative gene action. The
effects of an amino acid substitution in a pro 1(I) peptide chain are amplified at the
levels of both triple-helix assembly and fibril formation. Because every type I
procollagen molecule has two pro 1(I) chains, only 25% of type I procollagen molecules
will contain two normal pro 1(I) chains even though only one of the two COL1A1 alleles
is mutated. Furthermore, because each molecule in a fibril interacts with several others,
incorporation of an abnormal molecule can have disproportionately large effects on fibril
structure and integrity.
Collagen mutations that cause type III and type IV osteogenesis imperfecta are diverse
and include glycine substitutions in the amino terminal portion of the collagen triple
helix, a few internal deletions of COL1A1 and COL1A2 that do not significantly disturb
triple helix formation, and some unusual alterations in the nontriple-helical extensions
at the amino and carboxyl terminals of pro chains.
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Genetic Principles
As already described, most cases of type I osteogenesis imperfecta are caused by
partial or complete loss-of-function mutations in COL1A1. However, in approximately
one third of affected individuals, the disease is caused by a new mutation; in addition,
there are many ways in which DNA sequence alterations can reduce gene expression.
Consequently, there is a wide range of mutant alleles (ie, allelic heterogeneity), which
represents a challenge for the development of molecular diagnostic tests. In a family in
which type I osteogenesis imperfecta is known to occur clinically and a proband seeks a
diagnostic test for the purposes of reproductive planning, it is possible in most cases to
use linkage analysis at the COL1A1 locus. In this approach, one distinguishes between
chromosomes that carry the mutant and nonmutant COL1A1 alleles using closely linked
DNA-based polymorphisms, even though the causative molecular defect is not known.
Once this information is established for a particular family, inheritance of the mutant
allele can be predicted in future pregnancies.
For types III and IV osteogenesis imperfecta, mutations can occur in COL1A1 or
COL1A2 (ie, locus heterogeneity), and in this situation linkage analysis is more difficult
because one cannot be sure which locus is abnormal.
For both type I and type IV osteogenesis imperfecta, the most important question in the
clinical setting often relates to the natural history of the illness. For example,
reproductive decision making in families at risk for osteogenesis imperfecta is
influenced greatly by the relative likelihood of producing a child who will never walk and
will require multiple orthopedic operations versus a child whose major problems will be
a few long bone fractures and an increased risk of mixed sensorineural and conductive
hearing loss in childhood and adulthood. As evident from the prior discussion, both
different mutant genes and different mutant alleles, as well as other genes that modify
the osteogenesis imperfecta phenotype, can contribute to this phenotypic heterogeneity.
When allelic rather than locus heterogeneity is operative, as in type I osteogenesis
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imperfecta, comparison of interfamilial with intrafamilial variability allows one to assess
the relative contribution of different mutant alleles to phenotypic heterogeneity. For most
genetic diseases, including type I osteogenesis imperfecta, intrafamilial variability is less
than interfamilial variability.
In type II osteogenesis imperfecta, a single copy of the mutant allele causes the
abnormal phenotype and, therefore, has a dominant mechanism of action. Although the
type II phenotype itself is never inherited, there are rare situations in which a
phenotypically normal individual harbors a COL1A1 mutant allele among his or her
germ cells. These individuals with so-called gonadal mosaicism can produce multiple
offspring with type II osteogenesis imperfecta (Figure 24), a pattern of segregation that
can be confused with recessive inheritance. In fact, many other mutations, including
Duchenne's muscular dystrophy, which is X linked, and type 1 neurofibromatosis, which
is autosomal dominant, also occasionally show unusual inheritance patterns explained
by gonadal mosaicism.
DISEASES ASSOCIATED WITH DEFECTS IN EXTRACELLULAR STRUCTURAL PROTEINS
The interaction of the organic components of bone matrix is complex and a focus of intense
scientific investigation. The importance of the structural bone proteins is exemplified by the
diseases associated with deranged metabolism of the collagens important in bone and cartilage
formation (types 1, 2, 9, 10, and 11). Their clinical manifestations are highly variable, ranging
from lethal disease to premature osteoarthritis.
Type 1 Collagen Diseases (Osteogenesis Imperfecta)
Osteogenesis imperfecta, or brittle bone disease, is a phenotypically diverse disorder caused by
deficiencies in the synthesis of type 1 collagen. It is the most common inherited disorder of
connective tissue. It principally affects bone, but also impacts other tissues rich in type 1
collagen (joints, eyes, ears, skin, and teeth). Osteogenesis imperfecta usually results from
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autosomal dominant mutations (over 800 have been identified) in the genes that enco de the1 and 2 chains of collagen.[19] Many of these mutations involve the substitution of glycine residues in the triple-helical domain. The genotypephenotype relationship underlying
osteogenesis imperfecta is based on the location of the mutation within the protein. Mutations
resulting in decreased synthesis of qualitatively normal collagen are associated with mild skeletal
abnormalities. More severe or lethal phenotypes have abnormal polypeptide chains that cannot
be arranged in the triple helix. Recently, mutations in the genes for cartilage-associated protein
(CRTAP) and leucine proline-enriched proteoglycan 1 (LEPRE1) have been shown to be
responsible for three rare variants of the disease.[20]
Clinically, osteogenesis imperfecta is separated into four major subtypes that vary widely in
severity ( Table 26-3 ). The type II variant is at one end of the spectrum and is uniformly fatal in
utero or during the perinatal period. It is characterized by extraordinary bone fragility with
multiple intrauterine fractures ( Fig. 26-6 ). In contrast, individuals with the type I form have a
normal life span but experience childhood fractures that decrease in frequency following
puberty. Other findings include blue sclerae caused by decreased collagen content, making the
sclera translucent and allowing partial visualization of the underlying choroid; hearing loss
related to both a sensorineural deficit and impeded conduction due to abnormalities in the bones
of the middle and inner ear; and dental imperfections (small, misshapen, and blue-yellow teeth)
secondary to a deficiency in dentin. The basic abnormality in all forms of osteogenesis
imperfecta is too little bone, thus constituting a type of osteoporosis with marked cortical
thinning and attenuation of trabeculae.
TABLE 26-3 -- Subtypes of Osteogenesis Imperfecta
Subtype Inheritance Collagen Defect Major Clinical Features
OI type I Compatible
with survival
Autosomal
dominant
Decreased synthesis
of pro-1(1) chain Postnatal fractures, blue
sclera
Abnormal pro-1(1) or pro-2(1) chains
Normal stature
Skeletal fragility
Dentinogenesis imperfecta
Hearing impairment
Joint laxity
Blue sclerae
OI type
II
Perinatal lethal Most autosomal
recessive
Abnormally short
pro-1(1) chain Death in utero or within
days of birth
Some
autosomal
dominant
Unstable triple helix Skeletal deformity with
excessive fragility and
multiple fractures
?New mutations Abnormal or
insufficient pro-
Blue sclera
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Subtype Inheritance Collagen Defect Major Clinical Features
2(1)
OI type
III
Progressive,
deforming
Autosomal
dominant (75%)
Altered structure of
pro-peptides of pro-
2(1)
Compatible with survival
Autosomal
recessive (25%)
Impaired formation
of triple helix
Growth retardation
Multiple fractures
Progressive kyphoscoliosis
Blue sclera at birth that
become white
Hearing impairment
Dentinogenesis imperfecta
OI type
IV
Compatible
with survival
Autosomal
dominant
Short pro-2(1) chain
Postnatal fractures, normal
sclerae
Unstable triple helix Moderate skeletal fragility
Short stature
Sometimes dentinogenesis
imperfecta
Extracellular Matrix and Cell-Matrix Interactions
Tissue repair and regeneration depend not only on the activity of soluble factors, but also on
interactions between cells and the components of the extracellular matrix (ECM). The ECM
regulates the growth, proliferation, movement, and differentiation of the cells living within it. It
is constantly remodeling, and its synthesis and degradation accompanies morphogenesis,
regeneration, wound healing, chronic fibrotic processes, tumor invasion, and metastasis. The
ECM sequesters water, providing turgor to soft tissues, and minerals that give rigidity to bone,
but it does much more than just fill the spaces around cells to maintain tissue structure. Its
various functions include:
Mechanical support for cell anchorage and cell migration, and maintenance of cell
polarity
Control of cell growth. ECM components can regulate cell proliferation by signaling
through cellular receptors of the integrin family.
Maintenance of cell differentiation. The type of ECM proteins can affect the degree of
differentiation of the cells in the tissue, also acting largely via cell surface integrins.
Scaffolding for tissue renewal. The maintenance of normal tissue structure requires a basement membrane or stromal scaffold. The integrity of the basement membrane or the
stroma of the parenchymal cells is critical for the organized regeneration of tissues. It is
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particularly noteworthy that although labile and stable cells are capable of regeneration,
injury to these tissues results in restitution of the normal structure only if the ECM is not
damaged. Disruption of these structures leads to collagen deposition and scar formation
(see Fig. 3-2 ).
Establishment of tissue microenvironments. Basement membrane acts as a boundary between epithelium and underlying connective tissue and also forms part of the filtration
apparatus in the kidney.
Storage and presentation of regulatory molecules. For example, growth factors like FGF and HGF are secreted and stored in the ECM in some tissues. This allows the rapid
deployment of growth factors after local injury, or during regeneration.
The ECM is composed of three groups of macromolecules: fibrous structural proteins, such as
collagens and elastins that provide tensile strength and recoil; adhesive glycoproteins that
connect the matrix elements to one another and to cells; and proteoglycans and hyaluronan that
provide resilience and lubrication. These molecules assemble to form two basic forms of ECM:
interstitial matrix and basement membranes. The interstitial matrix is found in spaces between
epithelial, endothelial, and smooth muscle cells, as well as in connective tissue. It consists mostly
of fibrillar and nonfibrillar collagen, elastin, fibronectin, proteoglycans, and hyaluronan.
Basement membranes are closely associated with cell surfaces, and consist of nonfibrillar
collagen (mostly type IV), laminin, heparin sulfate, and proteoglycans.[71]
We will now consider the main components of the ECM.
COLLAGEN
Collagen is the most common protein in the animal world, providing the extracellular framework
for all multicellular organisms. Without collagen, a human being would be reduced to a clump
of cells, like the Blob (the gelatinous horror from outer space of 1950s movie fame), interconnected by a few neurons. Currently, 27 different types of collagens encoded by 41 genes
dispersed on at least 14 chromosomes are known[72]
( Table 3-2 ). Each collagen is composed of
three chains that form a trimer in the shape of a triple helix. The polypeptide is characterized by
a repeating sequence in which glycine is in every third position (Gly-X-Y, in which X and Y can
be any amino acid other than cysteine or tryptophan), and it contains
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FIGURE 3-12 Main components of the extracellular matrix (ECM), including collagens, proteoglycans, and adhesive glycoproteins.
Both epithelial and mesenchymal cells (e.g., fibroblasts) interact with ECM via integrins. Basement membranes and interstitial ECM
have different architecture and general composition, although there is some overlap in their constituents. For the sake of
simplification, many ECM components (e.g., elastin, fibrillin, hyaluronan, and syndecan) are not included.
the specialized amino acids 4-hydroxyproline and hydroxylysine. Prolyl residues in the Y-
position are characteristically hydroxylated to produce hydroxyproline, which serves to stabilize
the triple helix. Types I, II, III and V, and XI are the fibrillar collagens, in which the triple-
helical domain is uninterrupted for more than 1000 residues; these proteins are found in
extracellular fibrillar structures. Type IV collagens have long but interrupted triple-helical
domains and form sheets instead of fibrils; they are the main components of the basement
membrane, together with laminin. Another collagen with a long interrupted triple-helical domain
(type VII) forms the anchoring fibrils between some epithelial and mesenchymal structures, such
as epidermis and dermis. Still other collagens are transmembrane and may also help to anchor
epidermal and dermal structures.
TABLE 3-2 -- Main Types of Collagens, Tissue Distribution, and Genetic Disorders
Collagen
Type Tissue Distribution Genetic Disorders
FIBRILLAR COLLAGENS
I Ubiquitous in hard and soft
tissues
Osteogenesis imperfecta; Ehlers-Danlos
syndromearthrochalasias type I
II Cartilage, intervertebral disk,
vitreous
Achondrogenesis type II, spondyloepiphysea
dysplasia syndrome
III Hollow organs, soft tissues Vascular Ehlers-Danlos syndrome
V Soft tissues, blood vessels Classical Ehlers-Danlos syndrome
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Collagen
Type Tissue Distribution Genetic Disorders
IX Cartilage, vitreous Stickler syndrome
BASEMENT MEMBRANE COLLAGENS
IV Basement membranes Alport syndrome
OTHER COLLAGENS
VI Ubiquitous in microfibrils Bethlem myopathy
VII Anchoring fibrils at dermal-
epidermal junctions
Dystrophic epidermolysis bullosa
IX Cartilage, intervertebral disks Multiple epiphyseal dysplasias
XVII Transmembrane collagen in
epidermal cells
Benign atrophic generalized epidermolysis
bullosa
XV and
XVIII
Endostatin-forming collagens,
endothelial cells
Knobloch syndrome (type XVIII collagen)
Courtesy of Dr. Peter H. Byers, Department of Pathology, University of Washington, Seattle,
WA.
The messenger RNAs transcribed from fibrillar collagen genes are translated into pre-pro- chains that assemble in a type-specific manner into trimers. Hydroxylation of proline and lysine
residues and lysine glycosylation occur during translation. Three chains of a particular collagen
type assemble to form the triple helix ( Fig. 3-15 ). Procollagen is secreted from the cell and
cleaved by proteases to form the basic unit of the fibrils. Collagen fibril formation is associated
with the oxidation of lysine and hydroxylysine residues by the extracellular enzyme lysyl
oxidase. This results in cross-linking between the chains of adjacent molecules, which stabilizes
the array, and is a major contributor to the tensile strength of collagen. Vitamin C is required for
the hydroxylation of procollagen, a requirement that explains the inadequate wound healing in
scurvy ( Chapter 9 ). Genetic defects in collagen production (see Table 3-2 ) cause many
inherited syndromes, including various forms of the Ehlers-Danlos syndrome and osteogenesis
imperfecta[73]
( Chapters 5 and 26 .
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FIGURE 3-15 Angiogenesis by mobilization of endothelial precursor cells (EPCs) from the bone marrow and from preexisting
vessels (capillary growth). A, In angiogenesis from preexisting vessels, endothelial cells from these vessels become motile and
proliferate to form capillary sprouts. Regardless of the initiating mechanism, vessel maturation (stabilization) involves the
recruitment of pericytes and smooth muscle cells to form the periendothelial layer. B, EPCs are mobilized from the bone marrow and
may migrate to a site of injury or tumor growth. At these sites, EPCs differentiate and form a mature network by linking to existing
vessels. (Modified from Conway EM et al: Molecular mechanisms of blood vessel growth. Cardiovasc Res 49:507, 2001.)
ELASTIN, FIBRILLIN, AND ELASTIC FIBERS
Tissues such as blood vessels, skin, uterus, and lung require elasticity for their function. Proteins
of the collagen family provide tensile strength, but the ability of these tissues to expand and
recoil (compliance) depends on the elastic fibers. These fibers can stretch and then return to their
original size after release of the tension. Morphologically, elastic fibers consist of a central core
made of elastin, surrounded by a peripheral network of microfibrils. Substantial amounts of
elastin are found in the walls of large blood vessels, such as the aorta, and in the uterus, skin, and
ligaments. The peripheral microfibrillar network that surrounds the core consists largely of
fibrillin, a 350-kD secreted glycoprotein, which associates either with itself or with other
components of the ECM. The microfibrils serve, in part, as scaffolding for deposition of elastin
and the assembly of elastic fibers. They also influence the availability of active TGF in the ECM. As already mentioned, inherited defects in fibrillin result in formation of abnormal elastic
fibers in Marfan syndrome, manifested by changes in the cardiovascular system (aortic
dissection) and the skeleton[74]
( Chapter 5 ).
CELL ADHESION PROTEINS
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Most adhesion proteins, also called CAMs (cell adhesion molecules), can be classified into four
main families: immunoglobulin family CAMs, cadherins, integrins, and selectins. These proteins
function as transmembrane receptors but are sometimes stored in the cytoplasm.[75]
As receptors,
CAMs can bind to similar or different molecules in other cells, providing for interaction between
the same cells (homotypic interaction) or different cell types (heterotypic interaction). Selectins
have been discussed in Chapter 2 in the context of leukocyte/endothelial interactions. Selected
aspects of other cell adhesion proteins are described here. Integrins bind to ECM proteins such as
fibronectin, laminin, and osteopontin providing a connection between cells and ECM, and also to
adhesive proteins in other cells, establishing cell-to-cell contact. Fibronectin is a large protein
that binds to many molecules, such as collagen, fibrin, proteoglycans, and cell surface receptors.
It consists of two glycoprotein chains, held together by disulfide bonds. Fibronectin messenger
RNA has two splice forms, giving rise to tissue fibronectin and plasma fibronectin. The plasma
form binds to fibrin, helping to stabilize the blood clot that fills the gaps created by wounds, and
serves as a substratum for ECM deposition and formation of the provisional matrix during
wound healing (discussed later). Laminin is the most abundant glycoprotein in the basement
membrane and has binding domains for both ECM and cell surface receptors. In the basement
membrane, polymers of laminin and collagen type IV form tightly bound networks. Laminin can
also mediate the attachment of cells to connective tissue substrates.
Cadherins and integrins link the cell surface with the cytoskeleton through binding to actin and
intermediate filaments. These linkages, particularly for the integrins, provide a mechanism for
the transmission of mechanical force and the activation of intracellular signal transduction
pathways that respond to these forces. Ligand binding to integrins causes clustering of the
receptors in the cell membrane and formation of focal adhesion complexes. The cytoskeletal
proteins that co-localize with integrins at the cell focal adhesion complex include talin, vinculin,
and paxillin. The integrin-cytoskeleton complexes function as activated receptors and trigger a
number of signal transduction pathways, including the MAP kinase, PKC, and PI3K pathways,
which are also activated by growth factors. Not only is there a functional overlap between
integrin and growth factor receptors, but integrins and growth factor receptors interact (cross-talk) to transmit environmental signals to the cell that regulate proliferation, apoptosis, and differentiation ( Fig. 3-13 ).
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FIGURE 3-13 Mechanisms by which ECM components and growth factors interact and activate signaling pathways. Integrins bind
ECM components and interact with the cytoskeleton at focal adhesion complexes (protein aggregates that include vinculin, -actin, and talin). This can initiate the production of intracellular messengers or can directly mediate nuclear signals. Cell surface receptors
for growth factors may activate signal transduction pathways that overlap with those activated by integrins. Signaling from ECM
components and growth factors is integrated by the cell to produce various responses, including changes in cell proliferation,
locomotion, and differentiation.
The name cadherin is derived from the term calcium-dependent adherence protein. This family contains almost 90 members, which participate in interactions between cells of the same type.
These interactions connect the plasma membrane of adjacent cells, forming two types of cell
junctions called (1) zonula adherens, small, spotlike junctions located near the apical surface of
epithelial cells, and (2) desmosomes, stronger and more extensive junctions, present in epithelial
and muscle cells. Migration of keratinocytes in the re-epithelialization of skin wounds is
dependent on the formation of dermosomal junctions. Linkage of cadherins with the cytoskeleton
occurs through two classes of catenins. -catenin links cadherins with -catenin, which, in turn, connects to actin, thus completing the connection with the cytoskeleton. Cell-to-cell interactions
mediated by cadherins and catenins play a major role in regulating cell motility, proliferation,
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and differentiation and account for the inhibition of cell proliferation that occurs when cultured
normal cells contact each other (contact inhibition). Diminished function of E-cadherin contributes to certain forms of breast and gastric cancer. As already mentioned, free -catenin acts independently of cadherins in the Wnt signaling pathway, which participates in stem cell
homeostasis and regeneration. Mutation and altered expression of the Wnt/-catenin pathway is implicated in cancer development, particularly in gastrointestinal and liver cancers ( Chapter 7 ).
In addition to the main families of adhesive proteins described earlier, some other secreted
adhesion molecules are mentioned because of their potential role in disease processes: (1)
SPARC (secreted protein acidic and rich in cysteine), also known as osteonectin, contributes to
tissue remodeling in response to injury and functions as an angiogenesis inhibitor; (2) the
thrombospondins, a family of large multifunctional proteins, some of which, similar to SPARC,
also inhibit angiogenesis; (3) osteopontin (OPN) is a glycoprotein that regulates calcification, is a
mediator of leukocyte migration involved in inflammation, vascular remodeling, and fibrosis in
various organs[76,][77]
(discussed later in this chapter); and (4) the tenascin family, which consist
of large multimeric proteins involved in morphogenesis and cell adhesion.
GLYCOSAMINOGLYCANS (GAGS) AND PROTEOGLYCANS
GAGs make up the third type of component in the ECM, besides the fibrous structural proteins
and cell adhesion proteins. GAGs consist of long repeating polymers of specific disaccharides.
With the exception of hyaluronan (discussed later), GAGs are linked to a core protein, forming
molecules called proteoglycans.[78]
Proteoglycans are remarkable in their diversity. At most sites,
ECM may contain several different core proteins, each containing different GAGs.
Proteoglycans were originally described as ground substances or mucopolysaccharides, whose
main function was to organize the ECM, but it is now recognized that these molecules have
diverse roles in regulating connective tissue structure and permeability ( Fig. 3-14 ).
Proteoglycans can be integral membrane proteins and, through their binding to other proteins and
the activation of growth factors and chemokines, act as modulators of inflammation, immune
responses, and cell growth and differentiation.
-
FIGURE 3-14 Proteoglycans, glycosaminoglycans (GAGs), and hyaluronan. A, Regulation of FGF-2 activity by ECM and cellular
proteoglycans. Heparan sulfate binds FGF-2 (basic FGF) secreted into the ECM. Syndecan is a cell surface proteoglycan with a
transmembrane core protein, extracellular GAG side chains that can bind FGF-2, and a cytoplasmic tail that binds to the actin
cytoskeleton. Syndecan side chains bind FGF-2 released by damage to the ECM and facilitate the interaction with cell surface
receptors. B, Synthesis of hyaluronan at the inner surface of the plasma membrane. The molecule extends to the extracellular space,
while still attached to hyaluronan synthase. C, Hyaluronan chains in the extracellular space are bound to the plasma membrane
through the CD44 receptor. Multiple proteoglycans may attach to hyaluronan chains in the ECM. (B and C, modified from Toole
KR: Hyaluronan: from extracellular glue to pericellular cue. Nat Rev Cancer 4:528, 2004.)
There are four structurally distinct families of GAGs: heparan sulfate, chondroitin/dermatan
sulfate, keratan sulfate, and hyaluronan (HA). The first three of these families are synthesized
and assembled in the Golgi apparatus and rough endoplasmic reticulum as proteoglycans. By
contrast, HA is produced at the plasma membrane by enzymes called hyaluronan synthases and
is not linked to a protein backbone.
HA is a polysaccharide of the GAG family found in the ECM of many tissues and is abundant in
heart valves, skin and skeletal tissues, synovial fluid, the vitreous of the eye, and the umbilical
cord.[79]
It is a huge molecule that consists of many repeats of a simple disaccharide stretched
end-to-end. It binds a large amount of water (about 1000-fold its own weight), forming a viscous
hydrated gel that gives connective tissue the ability to resist compression forces. HA helps
provide resilience and lubrication to many types of connective tissue, notably for the cartilage in
joints. Its concentration increases in inflammatory diseases such as rheumatoid arthritis,
scleroderma, psoriasis, and osteoarthritis. Enzymes called hyaluronidases fragment HA into
lower molecular weight molecules (LMW HA) that have different functions than the parent
-
molecule. LMW HA produced by endothelial cells binds to the CD44 receptor on leukocytes,
promoting the recruitment of leukocytes to the sites of inflammation. In addition, LMW HA
molecules stimulate the production of inflammatory cytokines and chemokines by white cells
recruited to the sites of injury. The leukocyte recruitment process and the production of pro-
inflammatory molecules by LMW HA are strictly regulated processes; these activities are
beneficial if short-lived, but their persistence may lead to prolonged inflammation.