experimentAl cArdiology: review

Functions of cyclophilin A in atherosclerosis

Zhang Tian-tian MM1, Zhang Jun-feng MM1, Ge Heng MD2

Zhang t, Zhang J, Ge H. functions of cyclophilin a in
atherosclerosis. exp clin cardiol 2013;18(2):e118-e124.
Cyclophilin A (CypA) is a ubiquitously distributed protein present both in
intracellular and extracellular spaces. In atherosclerosis, various cells, includ-
ing endothelial cells, monocytes, vascular smooth muscle cells and platelets,
secrete CypA in response to excessive levels of reactive oxygen species.
Atherosclerosis, a complicated disease, is the result of the interplay of differ-
ent risk factors. Researchers have found that CypA links many risk factors,
including hyperlipidemia, hypertension and diabetes, to atherosclerosis that
develop into a vicious cycle. Furthermore, most studies have shown that
secreted CypA participates in the developmental process of atherosclerosis
via many important intracellular mechanisms. CypA can cause injury to
and apoptosis of endothelial cells, leading to dysfunction of the endothe-
lium. CypA may also induce the activation and migration of leukocytes,
producing proinflammatory cytokines that promote inflammation in blood
vessels. In addition, CypA can promote the proliferation of monocytes/
macrophages and vascular smooth muscle cells, leading to the formation of
foam cells and the remodelling of the vascular wall. Studies investigating
the roles of CypA in atherosclerosis may provide new direction for preven-
tive and interventional treatment strategies in atherosclerosis.
Key Words: Atherosclerosis; Cyclophilin A; CD147

A therosclerosis is a complicated, progressive inflammatory disease

resulting from various risk factors including hyperlipidemia,
hypertension and diabetes (1-2). Many proinflammatory cytokines
and immune factors are involved in atherogenesis and exert their roles
in an interplay with atherosclerosis-related cells such as endothelial
cells (ECs), T lymphocytes, monocytes/macrophages and vascular
smooth muscle cells (VSMCs).
Recently, mounting evidence has highlighted the potential effects
of cyclophilin A (CypA) in atherosclerosis. The CypA protein belongs
to the immunophilin superfamily, which is widely distributed both in
intracellular and extracellular spaces. In response to a variety of
inflammatory stimuli (3-4), CypA can be secreted by ECs, monocytes,
VSMCs and platelets in atherosclerotic lesions (5-8). Large quantities
of CypA have been found in plaques from mouse models of athero-
sclerosis (Figure 1) (9-11). Extracellular CypA is strongly associated
with various risk factors for atherosclerosis including hyperlipidemia,
hypertension and diabetes (12-14). In addition, CypA is capable of figure 1) Immunostaining of cyclophilin A (CypA) in atherosclerotic
triggering the activation and apoptosis of ECs (10). CypA also exhib- plaques from ApoE−/− mice. Sections of aortic sinus lesions of ApoE−/− mice
its potent chemotactic effects on inflammatory cells, such as mono- after 12 weeks of Western diet were stained with hematoxylin-eosin or poly-
cytes and T lymphocytes, by promoting their inflammatory activities clonal anti-CypA antibodies. a and c Hematoxylin-eosin stain (original
(10,15). For example, the production of macrophage colony stimulat- magnification ×10 and ×40, respectively). b and D CypA staining with
ing factor (M-CSF) and matrix metalloproteinases (MMPs) – two key anti-CypA antibody (original magnification ×10 and ×40, respectively).
proatherosclerotic cytokines secreted by inflammatory cells that facili- Solid arrowhead indicates vascular smooth muscle cells in media, solid arrow
tate plaque formation and instability – are markedly increased by the indicates cholesterol clefts, open arrowhead indicates extracellularly near the
stimulation of CypA (10,11). However, the absence of CypA decreases elastic lamina, and open arrow indicates endothelial cells. Results are repre-
lesion area (10). All of this evidence suggests that CypA plays an sentative of four vessels (9). Reproduced with permission from reference 9
important role in the development of atherosclerosis. CypA, therefore,
represents a potential new target for the treatment of atherosclerosis.
The purpose of the present article is to summarize the multiple func-
tions of CypA in atherosclerosis. with a relative molecular mass of approximately 18×103 Daltons (16-
18). While other cyclophilins exist in the endoplasmic reticulum
Distribution, structure anD (ER), mitochondria and nucleus, previous studies found that arche-
functions of cypa typal CypA existed only in the cytoplasm of tissue cells. Later studies
Cyclophilins are proteins belonging to the superfamily of immuno- revealed that CypA could also be released into the extracellular space.
philins. They have been found in many types of cells in different CypA is expressed by various cell types, although its expression levels
organisms and all have peptidyl-prolyl cis-trans isomerase (PPIase) differ depending on cell type and environmental conditions. For
activity. CypA was first purified from bovine thymocytes in 1984 and example, CypA levels are higher in the serum and synovial fluids of
was identified as an intracellular protein with a high affinity for the rheumatoid arthritis patients (3); CypA levels are also elevated in
immunosuppressive drug cyclosporin A (CsA). Human genes of tumours including non-small cell lung cancer, pancreatic cancer and
CypA, also known as Cyp18, are located on chromosome 7p11.2-p13 breast cancer (19). In atherosclerosis, activated ECs, monocytes,
and encode the protein, which consists of 165 amino acid residues VSMCs and platelets are all able to secrete CypA (5-8).
1Department of Cardiology, No.3 People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine; 2Department of Cardiology,
Ren Ji Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
Correspondence: Zhang Jun-feng, Department of Cardiology, No.3 People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine,
No.280, Mohe Road, Baoshan District, Shanghai, China. Telephone 86-21-566-911-01-6260, fax 86-21-566-916-62,
e-mail zhangjf1222@aliyun.com

e118 ©2013 Pulsus Group Inc. All rights reserved Exp Clin Cardiol Vol 18 No 2 2013

figure 2) Ribbon representation of Cyclophilin A (CypA). Cyclosporine A
(CsA) – Calcineurin (Cn). Colour codes are CnA, gold; CnB, cyan;
CsA, green; CypA, red; Zn2+ and Fe3+, pink; and calcium, blue. The
residues from Cn involved in binding of CypA-CsA are shown as blue
spheres (17). Reproduced with permission from reference 17
The structure of human CypA is highly conserved: an eight-
stranded antiparallel beta-barrel structure with two alpha helices
enclosing the barrel from either side and a compact hydrophobic core
formed by seven aromatic and other hydrophobic residues within the
barrel where CsA usually binds constitute one CypA molecule. A loop
from amino acid residue Lys 118 to His 126 and four beta strands (β3-
β6) compose the binding site for CsA (Figure 2) (16,17).
Although structurally conserved, CypA is a protein with various
biological functions (3,4,15-29). Similar to other cyclophilins, CypA
possesses PPIase activity that can catalyze cis-trans isomerization reac-
tions of proline peptide bonds. It is very important to the folding,
assembly and trafficking of proteins, especially proteins containing
many proline residues. The PPIase activity of CypA also enables it to
act as a chaperone, regulating the activities of a variety of proteins
(15-16,20,21). As the target of CsA in cells, CypA may function as an
immunomodulator. The compound CsA-CypA is reported to inhibit
the activity of calcineurins and block the dephosphorylation of
nuclear factor of activated T cells; consequently, it inhibits the synthe-
sis and release of some cytokines, including interleukin (IL)-2 and
promotes the immunosuppressive role of CsA (16-18). In addition,
CypA plays important roles in various pathological process such as
rheumatoid arthritis, cancers, viral infection and atherosclerosis
(3,5,15,19,22,24,25,27-30) (Box 1).
receptors of cypa in atHerosclerosis
Several molecules have been reported to be extracellular receptors of
CypA, including CD147, CD14 and CD91 (31). Among these, it has
been suggested that CD147 is the most involved in atherosclerosis.
CD147 is a single transmembrane glycoprotein belonging to the super-
family of immunoglobulins (Figure 3) (32). It plays a critical role in fetal,
neuronal and lymphocyte development, and is associated with patho-
logical conditions such as heart disease, Alzheimer’s disease, stroke,
tumour, inflammation and autoimmune disease. The proline 180 and
glycine 181 residues in the extracellular domain of CD147 are important
to CypA-induced signalling events involving mitogen-activated protein
kinases (MAPK) and nuclear factor kappa B (NF-κB), which may par-
ticipate in many biological functions in atherosclerosis, including the
activation, migration and proliferation of atherosclerosis-related cells and
the regulation of various proinflammatory cytokines. Active site residues
of CypA are also crucial to the structural stability of CD147 (33).
Exp Clin Cardiol Vol 18 No 2 2013
Function of cyclophilin A in atherosclerosis
boX 1
functions of cyclophilin a (cypa) in various pathological process
rheumatic arthritis: CypA contributes to the inflammatory pro-
cess through enhacing neutrophils, eosinophils and monocytes
chemotaxis, matrix metalloproteinases (MMPs) production and
invasiveness of synoviocytes (3,22-24).
cancer: CypA plays important roles in tumour development,
malignant transformation, increased proliferation, blockage of
apoptosis and metastasis (19).
Viral infection: For example, CypA is involved in the assembly/
deassembly of HIV-1 virion and is required for the full infectious
activity of HIV (25).
atherosclerosis: CypA initiates the apoptosis of endothelial cells,
which may lead to the dysfunction of endothelium. CypA may also
function as a chemotactic factor that attracts inflammatory cells,
such as T lymphocytes and monocytes, to migrate to inflammatory
areas. CypA participates in the formation of the compound caveolin-1/
CyPA cyclophilin40/HSP56 in NIH3T3 cells, which is the main
carrier of cholesterols, maintaining the balance between intracellu-
lar and extracellular cholesterols. It promotes the proliferation of
monocytes/macrophages, which causes the remodelling of the vas-
cular wall (5,15,27-30).
relationsHip betWeen cypa anD risK
factors in atHeroGenesis
Atherosclerosis is a complicated disease with many different risk fac-
tors implicated in, for example, hyperlipidemia, hypertension and
diabetes. CypA is tightly associated with the atherogenic process
mediated by these risk factors (2,12-14,34,35).
cypa and hyperlipidemia
Hyperlipidemia causes injury to the vascular endothelium and is an
important risk factor for atherosclerosis. Oxidized low-density lipopro-
tein (ox-LDL) is known to damage endothelium by disrupting the
activation of the compound caveolin-1/CyPA/cyclophilin40/HSP56,
preventing the translocation and stimulation of endothelial nitric
oxide (NO) synthase (eNOS), leading to reduced NO expression,
abnormal endothelium-dependent vascular relaxation, decreased
blood flow, platelet aggregation, leukocyte adhesion and migration,
and VSMC proliferation. All of these changes increase the risk for
atherosclerosis (36,37).
Caveolae are flask-shaped invaginations of the plasma membrane
involved in transcytosis. Early studies showed that caveolin-1 plays an
important role in intracellular cholesterol trafficking from the ER to
the plasma membrane by forming a complex with CypA, Cyp40 and
heat-shock protein 56, maintaining the balance between intracellular
and extracellular cholesterols. CypA has been associated with the
cytoplasmic side of plasma membrane caveolae. The inhibitor CsA
was tested to determine whether it could prevent the rapid transloca-
tion of cholesterol from the ER to caveolae (12).
Cholesterol is critical to the structure and function of caveolae.
Studies have reported that ox-LDL disrupts the organization of the
complex by removing caveolae cholesterol, while high-density lipo-
protein prevented the depletion of caveolae cholesterol by ox-LDL.
Therefore, a damaging effect has been attributed to ox-LDL, whereas
high-density lipoprotein appears to play a general protective role in
vascular disease including atherosclerosis. It is believed that both chol-
esterol carriers and lipoprotein dysfunction are involved in hyperlipi-
demia in blood vessels (12).
cypa and hypertension
Hypertension is another important risk factor for atherosclerosis. As a
reactive oxygen species (ROS) mediator that secretes oxidative stress-
induced factor, CypA mediates the production of ROS through the
ERK1/2, AKT and JAK signalling pathways from various cells, such as
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Zhang et al
figure 3) Scheme of the CD147 molecule. CD147 is a transmembrance
glycoprotein composed of an extracellular domain of 185 residues, a 24-resi-
due transmembrance domain and a 39-amino acid cytoplasmic region.
Three N-linked glycosylation sites critical to the function of CD147 have
been identified with CD47 immunoglobulin domains. Three N-linked oligo-
saccharides are shown by helixes (31). CD Cytoplasmic domain; ECI First
extracellular immunoglobulin domain; ECII Second extracellular immuno-
globulin domain; TD Transmembrane domain. Reproduced with permission
from reference 31
ECs and VSMCs, causing the decrease of eNOS levels, whose function
is to promote the generation of NO and blood pressure regulation
(26). In addition, CypA affects the activity of atrial natriuretic factor
and its receptor membrane-bond guanylate cyclase-A (GC-A), which
are involved in the regulation of blood pressure. Previous studies have
shown that CypA can inhibit the activation of GC-A by atrial natri-
uretic factor. A hypothesized mechanism is that CypA binds to GC-A
and catalyzes the cis-trans isomerization of Pro 822, 902 or 958, which
maintains GC-A in the inactive state (13). Evidence suggests that
CypA is associated with blood pressure regulation. CypA-mediated
hypertension may be an promotor of atherogenesis.
cypa and diabetes
Diabetes characterized by metabolic abnormalities, such as hypergly-
cemia, increased free fatty acid levels, insulin resistance and the con-
stant rate of low-grade inflammation of endothelium, is also an
important risk factor for atherosclerosis. In diabetes, high glucose lev-
els and ROS activate monocytes to secrete CypA via vesicles. CypA is
a potential screening marker for vascular disease in diabetes (14). It
was observed that CypA levels in plasma samples of patients with
diabetes and coronary artery disease were higher compared with
plasma obtained from healthy volunteers, suggesting that CypA secre-
ted from monocytes in patients with diabetes is an important pro-
inflammatory stimulus for vascular inflammation (14). Secreted CypA
acts as a proinflammtory cytokine that activates endothelial cells and
leukocytes, increasing inflammation in vessels and promoting athero-
genesis. Subsequently, inflammation influences blood glucose levels,
generating a vicious cycle that exacerbates diabetes mellitus. It is clear
that diabetes and atherosclerosis can affect one another, with CypA
being one of the factors connecting diabetes and atherosclerosis.
interaction of risk factors
Atherosclerosis is the result of the complex interplay among differ-
ent risk factors. Endothelial damage, ROS and other free radicals
have predominantly emerged as factors in virtually all pathways
leading to the development of atherosclerosis due to hyperlipi-
demia, hypertension or diabetes (34,35). For example, excessive
ox-LDL levels cause decreased NO expression from the endothel-
ium, leading to abnormal endothelium-dependent vascular relaxa-
tion and decreased blood flow. This is one of the primary causes
of hypertension. Consequently, endothelial dysfunction induced
by hypertension intervenes in the metabolism of lipids, promoting
hyperlipidemia. Hyperlipidemia and hypertension are part of the
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metabolic syndrome, which is characteristic of diabetes. Once dia-
betes develops, chronic inflammation in vessels, together with the
metabolic syndrome, disturbs the regulation of blood lipid levels
and blood pressure. These risk factors interact with one another,
generating a vicious cycle to accelerate atherogenesis, and CypA
appears to be an important cytokine in this process.
Direct effects of cypa on cells in
atHerosclerosis
effects of cypa on ecs
Dysfunction of ecs: Atherosclerosis is a chronic inflammatory dis-
ease in which many proinflammatory factors are implicated. As a
mediator of proinflammatory factors, normal ECs play an important
role in preventing atherosclerosis. The dysfunction of ECs may be the
first step in the development of atherosclerosis (33,38). The endothel-
ial monolayer, which is in contact with flowing blood, maintains the
integrity of the vascular wall and resists pathological adhesion of
leukocytes (39,40). Once injured, the endothelium becomes dysfunc-
tional by releasing less NO and losing the function of endothelium-
dependent vasodilation, thereby facilitating the aggregation of platelets
and promoting the expression of adhesion molecules (37). In response
to risk factors such as hypertension, hyperlipidemia, hyperglycemia
and smoking, several ROS, including superoxide anion (O2−.),
hydroxyl radical (HO˙), nitric oxide (NO˙), lipid radicals, hydrogen
peroxide (H2O2), peroxynitrite (ONOO−) and hypochlorous acid
(HOCL), are released from various cells, leading to the injury of ECs
and the secretion of CypA (5,7,15,41,42). Secreted CypA mediates
the production of ROS through the ERK1/2, AKT and JAK signalling
pathways via a positive feedback loop, causing a decrease in eNOS
activity, whose function is to promote the generation of NO, thus
leading to further damage to the intima (10,20).
activation of ecs: Extracellular CypA also triggers the activation of
ECs to produce various adhesion molecules that attract leukocytes.
Studies show that a high concentration of CypA induces the expres-
sion of adhesion molecules such as vascular cell adhesion molecule
(VCAM)-1 and E-selectin via signalling pathways involving MAPK
and NF-κB, with increases in the expression of toll-like receptors
(TLRs) such as TLR-4 (5,10,42). TLR-4 is found to be able to initiate
a signalling cascade including the binding of adaptor protein myeloid
differentiation factor 88 and the activation of IL-1 receptor-associated
kinase and tumour-necrosis factor (TNF) receptor-associated factor-6,
resulting in the final translocation of NF-κB (43). It also initiates the
activation of MAPK (43). Therefore, the mechanism of the activation
of ECs is possibly associated with the expression of TLRs. These
adhesion molecules, together with many other proinflammatory cyto-
kines, such as very late antigen (VLA)-4 and lymphocyte function-
associated antigen-1, which are released by leukocytes, induce the
adhesion of leukocytes to the vascular endothelium where atheroma
initiates.
apoptosis of ecs: CypA acts as a proapoptotic cytokine that triggers
the apoptosis of ECs. In vitro studies have found that low concentra-
tions of CypA increases EC proliferation, while high concentrations
of CypA has the opposite effect, decreasing EC viability (5). Similar
to TNF-α, CypA has been found to induce cell death in the presence
of cycloheximide (9). The mechanism is associated with increased
JNK and p38 activities (10,44). Recently, CypA has also been found
to bind to apoptosis-inducing factor and participate in the unclear
translocation of apoptosis-inducing factor to induce apoptosis (45).
CypA deficiency was associated with a marked decrease in ECs apop-
tosis in early stages of atherosclerosis (10). This information may
provide new insight for the study of EC apoptosis and atherosclerosis
development.
Regenerative ECs will settle at sites where an atheroma grows to
repair the vascular wall, but they do not possess all of the properties of
normal ECs. For example, they lack the signalling pathway that is
dependent on Gi (38). Many leukocytes and lipids deposit under the
dysfunctional endothelium to initiate atherogenesis.
Exp Clin Cardiol Vol 18 No 2 2013

effects of cypa on leukocytes
recruitment of leukocytes: The initial process of active leukocyte
recruitment is the tethering and rolling of leukocytes. Together with
other chemokines and adhesion molecules, E-selectin expressed on the
activated endothelium induced by CypA plays an important role in
the rolling of leukocytes through binding with its ligands such as
glycoprotein P-selectin glycoprotein ligand-1, which is expressed as a
homodimer on leukocytes (46).
As a direct chemoattractant for leukocytes, CypA also induces the
accumulation of leukocytes, such as neutrophils, eosinophils, T lymph-
ocytes and monocytes within atheroma lesions, which facilitate their
adhesion to the injured endothelium (23,27,47). In vivo studies have
shown that most leukocytes tend to migrate toward extracellular
CypA when it is injected into the body. Activated T lymphocytes and
monocytes, which are critical for the development of atherosclerosis,
show high chemotaxis to extracellular CypA and its receptor CD147
(27). The process by which CypA mediates chemotaxis is largely
unclear, but studies have shown that CypA is involved in chemokine
receptor C-X-C chemokine receptor (CXCR) 4-mediated chemotaxis.
It has also been proposed that CypA mediates CXCL12-induced
chemotaxis by regulating MAPK (48). These two mechanisms may
provide new insights for research on the migration of leukocytes
induced by CypA.
adhesion of leukocytes: Once recruited to the injured endothelium,
leukocytes will adhere to ECs on stimulation of adhesion molecules
such as VCAM-1, whose expression is induced by CypA (10).
Endothelial VCAM-1 is a ligand for the integrin α4β1 (VLA-4) pre-
dominantly found on lymphocytes and monocytes. The interaction
between VCAM-1 and VLA-4 mediates rolling and firm adhesion of
leukocytes (49).
Leukocytes then pass through the junctions between the ECs and
differentiate, producing various bioactive factors such as TNF-α, IL-1,
IL-6, IL-8, fibroblast growth factor, transforming growth factor-β,
interferon (IFN)-γ, CD25, IFN-induced transmember 1 (IFITM1),
macrophage chemoattractant protein-1, M-CSF and MMPs which
interplay to promote inflammation in atherosclerosis. This activation
process of leukocytes is also associated with CypA (3,4,41,50). Among
these cytokines, some, such as TNF and IFN, promote atherosclerosis,
while others, such as transforming growth factor, play an anti-inflam-
matory role. Although it is a complicated pathological process, a
remarkable reduction in atherosclerosis in CypA-deficient mice than
normal mice strongly supports that CypA contributes to
atherosclerosis.
formation and activation of foam cells: Hypercholesterolemia is an
important causative risk factor for atherosclerosis. It is well established
that the transport of LDL cholesterol into the artery wall promotes
atherosclerosis (10). Studies (10) have reported that apolipoprotein
E-deficient mice fed a high-cholesterol diet developed more severe
atherosclerosis compared with apolipoprotein E- and CypA-deficient
mice, demonstrating that CypA was atherogenic by enhancing LDL
uptake. This mechanism was associated with the regulation of the
expression of scavenger receptor on the vessel wall.
Many lipid-laden monocytes/macrophages, also known as foam
cells, characterize the early atherosclerotic lesion. After settling
under the endothelium, quantities of monocytes will differentiate
into macrophages that endocytose lipids. They accumulate under the
vascular endothelium to form fatty streaks. CypA contributes to the
formation of foam cells and the upregulation of NF-κB-related pro-
teins, such as the cytokine M-CSF and MMPs, which are released
from foam cells. Experiments show that the expression of M-CSF,
cell-derived MMP-9 and member type 1 MMP (MT1-MMP, MMP-
14) are effectively hindered after either CypA or CD147 inhibition
(11,51). M-CSF plays an important role in the transition of mono-
cytes to lipid-laden macrophages by increasing the expression of
scavenger receptor A, which functions to internalize modified lipo-
proteins to form fatty streaks (10). This augments the production of
cytokines and growth factors from foam cells and promotes the
Exp Clin Cardiol Vol 18 No 2 2013
Function of cyclophilin A in atherosclerosis
proliferation of monocytes/macrophages (1). MMPs, such as MMP-9
and MT1-MMP, which are released from macrophages induced by
CypA and its receptor, CD147, are the main causes for acute cardio-
vascular events. MMPs mainly degrade extracellular matrix, resulting
in the weakening of plaque stability and even the fracture of the
fibrous cap. We found that the expression of MMP-9 from macro-
phages required the activation of MAPK (ERK1/2), which initiated
Iκ-B/NF-κB(4). Therefore, the cascade EMMPRIN (CD147)-ERK-
NF-κB may be the main signalling pathway for CypA-induced
MMP-9 upregulation (4). MT1-MMP is likely to be expressed
through the same pathway because NF-κB is an important transcrip-
tional factor of MT1-MMP expression (50,51). Besides MMP-9 and
MT1, MMP are produced by macrophages within vulnerable athero-
sclerotic plaques, MMP-2 derived from activated VSMCs is also
speculated to be associated with plaque instability (52) because CypA
has been reported to be essential to the production of MMP-2 in the
pathological progression of diseases such as acute myocardial infarc-
tion, rheumatosis and cancers.
Similarly, macrophages may proliferate to try to eliminate exces-
sive lipids, forming more foam cells (53). CypA is essential to macro-
phage proliferation, which depends on M-CSF. In the early stage of
M-CSF signalling, immunosuppressor sanglifehrin A, a member of the
CypA inhibitor family, is able to inhibit the phosphorylation of Raf-1
and ERK1/2, arresting the G1 phase of the cell cycle. This indicates
that the proliferation of macrophages may be dependent on the activa-
tion of the Raf-1/ MEK/ ERK signal pathway that is regulated by CypA
and its receptor (28).
In addition, on coincubation with platelets, CD34+ progenitor
cells have the potential to differentiate into foam cells (11).
Although no direct evidence regarding influence of CypA on pro-
genitor cell number, size, morphology or the expression of the dif-
ferentiation marker CD68 has been found, it was observed that
inhibition of soluble CypA by its inhibitor N1M811 reduced MMP-9
activity during the CD34+ progenitor cell differentiation process
(11), demonstrating that CypA was an important promoter of
atherogenesis.
Consequently, an increasing number of foam cells accumulate
under the injured endothelium, which is an important component for
atherosclerotic plaques.
effects of cypa on VsMcs
Another important feature of atherosclerosis is the thickening of the
arterial wall. In addition to inducing the proliferation of macro-
phages, CypA is necessary for the multiplication of VSMCs, which
also accumulate in plaques and contribute to the formation of a com-
plicated atheroma. VSMCs secrete CypA in a vesicular manner (7),
and CypA can initiate the ERK1/2 and JAK/STAT signalling path-
ways, which are beneficial to DNA synthesis in VSMCs, and promote
the thickening of the intima and the medial layer (30,31). On stimu-
lation of growth factors and cytokines, such as platelet-derived
growth factor, fibroblast growth factor-b, TNF-α and epidermal
growth factor, masses of VSMCs migrate to the endothelium and alter
their phenotype from contractile to the synthetic type, laying down
an abundant extracellular matrix and various fibres to form fibrous
caps in plaques. CypA also promotes the multiplication of fibroblasts
by inducing excessive production of ROS, which directly stimulates
the migration and proliferation of fibroblasts and contributes to the
remodelling of the vascular wall.
As a large number of foam cells and VSMCs gradually accumulate
under the intima, the lesion will become bulkier until it narrows the
arterial lumen and even hampers blood flow, thus leading to clinical
manifestations such as unstable angina pectoris. MMPs released by
foam cells and VSMCs, which mainly degrade extracellular matrix,
may cause the weakening of plaque stability and even the fracture of
fibrous caps, resulting in acute myocardial infarction.
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Zhang et al

the functions of Th1 (60). In addition, JAK/STAT induces the

production of ROS and the proliferation of VSMCs, contributing to
atherogenesis.
Many other signalling pathways in the development of athero-
sclerosis may also be associated with CypA; therefore, more studies are
required to fully understand the specific mechanisms linking CypA to
atherogenesis.

conclusions anD perspectiVes

CypA is an inflammatory mediator in atherosclerosis. It links various
risk factors such as hyperlipidemia, hypertension and diabetes, which
promote atherogenesis. It also induces endothelial dysfunction, inflam-
mation in vessels, the production of foam cells, the remolding of vas-
cular wall and the weakening of plaque stability. In vivo experiments
show that CypA deficiency leads to a marked reduction in athero-
sclerosis (9,10). All of the evidence discussed, including the biological
functions and signalling pathways that CypA mediates, shows that
CypA serves as an important atherogenic factor in the development of
atherosclerosis, demonstrating that CypA could be a therapeutic tar-
get for the prevention of and intervention in atherosclerosis.
figure 4) Various signalling pathways that cyclophilin A (CypA) mediates. This evidence helps us understand the relationship between CypA
CypA mediates a variety of signalling pathways involving mitogen-activated and atherosclerosis. However, many other specific mechanisms and
protein kinases (MAPK), nuclear factor kappa B (NF-κB) and JAK/STAT biological functions that are induced by CypA in atherogenesis remain
to regulate various pathological processes in atherogenesis unclear. For example, the signalling pathway of EC apoptosis, the
activation mechanisms of ECs and leukocytes, the migration and
adhesion process of inflammatory cells, the details of the formation of
siGnallinG patHWays MeDiateD by cypa in
foam cells and the complicated interaction of various proinflammatory
atHerosclerosis
cytokines and biological signalling pathways all remain unclear.
In atherogenesis, CypA mediates a variety of signalling pathways, such
Studies of these mechanisms may provide more information about
as MAPK, NF-κB and JAK/STAT, to regulate various pathological
how CypA promotes atherogenesis. More research is needed on the
processes (Figure 4) (20,26,28,31,54,55).
specific signalling pathways, such as JNK and p38, that help CypA to
In response to various intracellular and extracellular stimuli,
induce apoptosis in ECs, TLR-associated activation process of ECs, the
including cytokines, hormones, growth factors and cellular stressors,
relationship of CXCR4 and CXCR12 to CypA-mediated chemotaxis
CypA initiates the MAPK signalling pathway via its receptor CD147,
and the influence of CypA to the growth of vascular progenitor cells.
which appears to be at the crossroads of the inflammatory response
However, it is not enough to fully understand atherosclerosis simply at
(56-58). In the MAPK mammalian family, MAPK (ERK1/2) induces
the molecular and cellular level because atherosclerosis is a compli-
many pathological processes of atherosclerosis such as the injury of
cated disease that involves many biological and pathological processes.
ECs, the chemotactic migration and adhesion of leukocytes, the for-
Therefore, many animal experiments and clinical trials are needed to
mation of foam cells, the secretion of MMPs and the proliferation of
objectively and thoroughly study it. Although a few in vivo models
atherosclerosis-related cells. However, MAPK (JNK2) and MAPK
have verified that CypA expression is increased in atherosclerosis and
(P38) contribute to the formation of foam cells and the proliferation
it promotes atherogenesis (9,10), more models will help to explore
of VSMCs (59).
specific biological functions of CypA in atherosclerosis.
NF-κB is another important signalling molecule activated by
Moreover, many new viewpoints about CypA in atherosclerosis
CypA-CD147 that participates in the process of atherogenesis. It regu-
should be considered. Recent publications indicate that CypA is
lates the genes that encode proinflammatory cytokines, adhesion
involved in diseases such as acute lung injury, HIV infection, hepatitis
molecules, chemokines, growth factors and inducible enzymes, fine-
and rheumatoid arthritis by its interplay with its receptor CD147 (21-
tuning the response of the vascular wall to injury and facilitating the
24,32); therefore, we may be able to determine whether these diseases
formation, growth and even rupture of plaques (60,61). For example,
are additional risk factors for atherosclerosis. It may also be valuable to
NF-κB potentiates the production of chemokines such as MCP-1 and
investigate immunological activity of CypA in atherosclerosis. In
IL-8, which induce the migration of inflammatory cells; adhesion mol-
addition, determining which inhibitors can target CypA to block the
ecules such as VCAM-1 and intercellular adhesion molecule-1 that
development of atherosclerosis could be of great significance. Although
facilitate the adhesion of leukocytes to the endothelium and pro-
the immunosuppressant drug CsA has been reported to be able to
inflammtory cytokines such as M-CSF and MMPs, which promote the
inhibit some functions of CypA, it is not a specific ligand, and may
formation of foam cells and the rupture of plaques. NF-κB is a
cause certain side effects. Therefore, a specific inhibitor will be more
heterodimer of p50 and p65, which usually remains inactive by com-
valuable.
bining with IκB in the cytoplasm. When activation signals arrive, IκB
Studies investigating the functions of CypA in atherosclerosis will
will be phosphorylated and consequently degraded by proteasomes.
provide new insights for preventive and therapeutic strategies.
The free NF-κB heterodimer then moves into the nucleus, inducing
various biological activities (54,62). Some studies have reported that
ERK inhibitors, not JNK and P38 inhibitors, are able to decrease acKnoWleDGeMent: The authors thank Innovative research
project of Shanghai Education Committee (09YZ80, to Dr Zhang).
NF-κB activation, demonstrating that ERK may be the upstream path-
way leading to NF-κB activation (4).
CypA also activates JAK/STAT, which participates in the develop-
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