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Cellular Aging

28.e29

Cutting Gordian Knots: Salvaging Misfolded Proteins

Misfolded proteins are increasingly recognized as the root cause of a wide array of human diseases. Clearly, mutations in the primary amino acid sequence can cause loss of enzyme, or of structural function, as catalytic sites or motifs for protein-protein interactions are disrupted; in some cases, misfolded proteins are recognized as defective and even degraded through endoplasmic reticulum (ER) or ubiquitin-proteasome pathways. Cystic fibrosis, Marfan syndrome, Fabry disease, muscular dystrophy, and retinitis pigmentosa all fall into this general category; misfolded tumor suppressor gene products such as p53 can even contribute to malignancy. In other cases, misfolded proteins cause pathology by accumulating. Excessive intracellular accretion can trigger ER stress responses that culminate in apoptotic suicide; diseases in this group include 1-antitrypsin deficiency, amyotrophic lateral sclerosis, Huntington disease, and diabetes. Conversely, excess misfolded extracellular proteins can cause cell death or dysfunction through the formation of amyloid aggregates, as in Alzheimer disease and Creutzfeld-Jakob spongiform encephalopathy (prion disease). Gaucher disease (GD) is the most common of the lysosomal storage disorders; it also is an excellent candidate for therapeutic approaches that influence protein folding. GD results from a variety of recessive genetic mutations (more than 150!) leading to misfolded -gluocerebrosidase enzymes that are either inactive or are prematurely degraded in theER. In most cell types, low-level residual enzyme activity is sufficient to prevent cellular dysfunction. Cells responsible for catabolizing large amounts of glucocerebroside, however, are overwhelmed. Consequently, macrophages progressively accumulate nondegraded glucosylceramide from the membranes of senescent leukocytes and red cells. Besides causing organomegaly, the macrophages also are activated by their glycolipid burden, elaborating pro-inflammatory cytokines. Thus, GD causes bone destruction, thrombocytopenia due to hypersplenism, and central nervous system (CNS) dysfunction attributed to microglial cell cytokine production. Worse, in type II disease, a complete absence of enzyme activity leads to infantile neuronal dysfunction and death consequent to the inability to recycle critical membrane constituents. The treatment option currently in widest use is somewhat less than ideal. Enzyme replacement therapy (ERT), using recombinant enzymes, takes advantage of the fact that terminal mannose-6-phosphate glycosylation of glucocerebrosidase allows the protein to be bound to surface mannose receptors, endocytosed, and specifically targeted to the lysosomal compartment. Because defective macrophages are the central pathologic problem, ERT restores enzyme activity precisely to where it needs to go. Unfortunately, this therapy is extremely expensive ($300,000 annually) and requires regular intravenous administration, and the enzymes do not cross the blood-brain barrier for treating CNS deficiency. To the rescue comes the class of pharmacologic chaperones, small molecules that stabilize or reactivate improperly folded glucocerebrosidase. Studies show that if only 10% of normal enzyme activity can be restored, the vast majority of GD-associated pathologic effects can be ameliorated. These agents (isofagomine, N-octyl--valienamine) are orally available and inexpensive and cross the blood-brain barrier, making them potentially valuable in therapy for all forms of GD. If the molecular chaperones become as successful as their advance press suggests, regimens based on such agents also may become therapeutic paradigms for the treatment of other lysosomal storage disordersas well as the myriad illnesses (such as cystic fibrosis) that result from defective protein folding.

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