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Integrative Physiology/Experimental Medicine

Serum-Glucocorticoid Regulated Kinase 1 Regulates Alternatively Activated Macrophage Polarization Contributing to Angiotensin II–Induced Inflammation and Cardiac Fibrosis

Min Yang, Jiao Zheng, Yanjv Miao, Ying Wang, Wei Cui, Jun Guo, Shulan Qiu, Yalei Han, Lixin Jia, Huihua Li, Jizhong Cheng, Jie Du
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https://doi.org/10.1161/ATVBAHA.112.248732
Arteriosclerosis, Thrombosis, and Vascular Biology. 2012;32:1675-1686
Originally published June 13, 2012
Min Yang
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Jiao Zheng
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Yanjv Miao
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Ying Wang
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Wei Cui
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Jun Guo
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Shulan Qiu
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Yalei Han
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Lixin Jia
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Huihua Li
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Jizhong Cheng
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Jie Du
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Abstract

Objective—Inflammatory responses play a pivotal role in the pathogenesis of hypertensive cardiac remodeling. Macrophage recruitment and polarization contribute to the development of cardiac fibrosis. Although serum-glucocorticoid regulated kinase 1 (SGK1) is a key mediator of fibrosis, its role in regulating macrophage function leading to cardiac fibrosis has not been investigated. We aimed to determine the mechanism by which SGK1 regulates the cardiac inflammatory process, thus contributing to hypertensive cardiac fibrosis.

Methods and Results—After angiotensin II infusion in mice, cardiac hypertrophy and fibrosis developed in wild-type but not SGK1 knockout mice, with equal levels of hypertension in both groups. Compared with wild-type hearts, SGK1 knockout hearts showed less infiltration of leukocytes and macrophages. Importantly, SGK1 deficiency led to decreased proportion of alternatively activated (M2) macrophages and increased levels of profibrotic cytokines. Angiotensin II infusion induced phosphorylation and nuclear localization of signal transducer and activator of transcription 3 (STAT3) whereas SGK1 knockout hearts showed this effect attenuated. In a 3-dimensional peptide gel culture, inhibition of STAT3 suppressed differentiation into M2 macrophages. Coculture of macrophages with cardiac fibroblasts in 3-dimensional peptide gel stimulated the expression of α-smooth muscle actin and collagen in cardiac fibroblasts. However, SGK1 knockout mice with macrophage deficiency showed reduced fibroblast-to-myofibroblast transition.

Conclusion—SGK1 may play an important role in macrophage recruitment and M2 macrophage activation by activating the STAT3 pathway, which leads to angiotensin II–induced cardiac fibrosis.

  • angiotensin II
  • fibrosis
  • inflammation
  • macrophage
  • serum-glucocorticoid regulated kinase

Introduction

Hypertensive cardiac remodeling, characterized by left ventricular (LV) hypertrophy and cardiac fibrosis, is a major risk factor for cardiovascular morbidity and a leading cause of chronic heart failure.1,2 The activation of the renin-angiotensin system plays an important pathophysiological role in hypertensive cardiac remodeling. This finding is supported by blockade of the renin-angiotensin system, with angiotensin-converting enzyme inhibitors or its type 1 receptor blockers, which significantly improves cardiac function and ameliorates cardiac remodeling in patients with hypertension.3 Our data and others have demonstrated that early infiltration of proinflammatory cells in the heart is a key event in angiotensin II (Ang II)–induced hypertensive cardiac remodeling.4–9 This inflammatory component includes macrophages,4–6 mast cells,7,8 and T cells,9 which are associated with released cytokines, disruption of normal cardiac structures, and extracellular matrix deposition promoting cardiac fibrosis. However, the underlying molecular mechanisms for Ang II–induced cardiac inflammation and fibrosis are still uncertain.

Serum-glucocorticoid regulated kinase 1 (SGK1) is a downstream effector of the phosphoinositide-3 kinase cascade. SGK1 belongs to the AGC family of serine-threonine kinases, and shares ≈45% to 55% homology with Akt in its catalytic domain.10 SGK1 transcript levels are upregulated in several fibrotic diseases, including diabetic nephropathy, glomerulonephritis, lung fibrosis, liver cirrhosis, and fibrosing pancreatitis.11 Recent studies have demonstrated that SGK1 plays a critical role in cardiomyocyte apoptosis, inflammatory cytokine expression, and vascular remodeling. SGK1 is dynamically regulated during acute biomechanical stress in the heart and controls cardiomyocyte survival and hypertrophic response.12 Moreover, SGK1 plays a decisive role in mineralocorticoid-induced connective tissue growth factor (CTGF) expression and cardiac fibrosis.13 We recently reported that mechanical stretch–activated SGK1 could be an essential intracellular signal contributing to vascular remodeling in vein grafting.14 Thus, SGK1 is considered 1 of the key molecules participating in the pathophysiological features of various cardiovascular diseases. However, the role of SGK1 in Ang II–induced hypertensive cardiac remodeling remains unclear.

We investigated the mechanism by which SGK1 activation regulates Ang II–induced cardiac fibrosis. SGK1 deficiency in mice significantly attenuated cardiac inflammation and fibrosis after Ang II infusion. This attenuation was associated with inhibition of activation of signal transducer and activator of transcription 3 (STAT3) and reduced differentiation to M2 macrophages and profibrotic cytokine expression, thereby leading to decreased fibroblast-to-myofibroblast transition and cardiac fibrosis. We provide new evidence for a potential molecular mechanism linking SGK1 required for macrophage polarization to the pathogenesis of hypertensive cardiac remodeling.

Materials and Methods

Antibodies and Reagents

The antibodies for phospho-STAT1, STAT1, phospho-STAT3, and STAT3 were from Cell Signaling Technology (Beverly, MA); the antibodies for F4/80, cardiac myosin heavy chain, α-smooth muscle actin (α-SMA), and SGK1 were from Abcam (Cambridge, MA); and the antibodies for Mac-2, CD206, CTGF, transforming growth factor-β (TGF-β), interleukin-10 (IL-10), IL-13, GAPDH, and IgG were from Santa Cruz Biotechnology (Santa Cruz, CA). ChemMate TM EnVision System/DAB Detection Kits were from Dako (Glostrup, Denmark). Antibodies for PerCP/Cy5.5-conjugated CD45.2, phycoerythrin (PE)-conjugated F4/80, fluorescein isothiocyanate (FITC)-conjugated F4/80, PE-conjugated CD11b, FITC-conjugated CD206, PE-conjugated CD3, FITC-conjugated CD4, FITC-conjugated CD8, and isotype control were from Biolegend (San Diego, CA). Ang II was from Sigma (Sigma-Aldrich, St.Louis, MO). Penicillin, streptomycin, DMEM, and fetal bovine serum were from Invitrogen (Carlsbad, CA). The protein assay kit was from Bio-Rad (Hercules, CA).

Animals and Treatment

The SGK1 knockout (SGK1−/−) mouse strain was backcrossed onto the genetic background of wild-type (WT) B6/129S mice for >10 generations, and littermates were used as controls. Mice were 10 to 12 weeks old at the beginning of the experiments and matched for age and sex with WT mice. We infused 10- to 12-week-old male mice (n=6–10 per group) for 7 days with vehicle (saline) or a pressor dose of Ang II (1500 ng.kg−1.min−1) by osmotic minipumps (ALZET Model 1007D, DURECT, Cupertino, CA) implanted subcutaneously. Systolic blood pressure was measured by tail-cuff plethysmography (Visitech Systems, Apex, NC) as a control for efficient Ang II infusion; in this setting, the tail-cuff method is comparable with the telemetry method and is sufficient as we and other investigators reported.15–17

After the study period, Ang II– and saline-treated mice were anesthetized, and the LV was flushed by puncture with 20-mL saline to remove blood from systemic circulation. The hearts were removed and prepared for further histological and molecular analyses. Mouse protocols were approved by the Institutional Animal Care and Use and Committee of the Capital University of Medical Science (Beijing, China).

Echocardiography

Mice were killed with 2% to 4% isoflurane. Echocardiography involved use of a Vevo 770 High-Resolution Imaging System (VisualSonics Inc) as described.18 All measurements were averaged for 5 consecutive cardiac cycles and determined by an experienced technician blinded to treatment group.

Histology and Immunohistochemistry

Heart tissues were fixed in 4% paraformaldehyde, embedded in paraffin and sectioned at 5-μm intervals. Hematoxylin-eosin and Masson trichrome staining involved standard procedures. Picrosirius red staining was used for the histological assessment of collagen types I and III accumulation by polarization microscopy. Wheat germ agglutinin staining was used to evaluate myocyte cross-sectional area. Heart sections were deparaffinized and incubated with 100-μg/mL FITC-labeled wheat germ agglutinin (Sigma) for 90 minutes. The cell area was calculated by measuring at least 200 cells per slide.

Immunohistochemistry of paraffin sections involved the Dako ChemMate TM EnVision System (Dako) with primary antibodies for SGK1 (1:200), α-SMA (1:200), CTGF (1:200), Mac-2 (1:200), TGF-β (1:300), IL-13 (1:300), and IL-10 (1:300). Negative controls were omission of the primary antibody, goat nonimmune IgG, rabbit nonimmune IgG, rat nonimmune IgG, or secondary antibody only; in all cases, negative controls showed insignificant staining. To verify the genotype and treatment, quantitative histology involved standard procedures, and results were confirmed by independent pathologists blinded to genotype or treatment group. Images were viewed and captured using a Nikon Labophot 2 microscope equipped with a Sony CCD-IRIS/RGB color video camera attached to a computerized imaging system and analyzed by Image Pro Plus 3.0 (ECLIPSE 80i/90i; Nikon, Tokyo, Japan). The expression of collagen, α-SMA, CTGF, macrophage markers, or cytokines was calculated as proportion of positive area to total tissue area for all measurements of the section.

Cells and frozen heart sections (7 μm) were incubated with the primary antibodies for F4/80 (1:100), cardiac myosin heavy chain (1:100), SGK1 (1:200), CD206 (1:200), phospho-STAT3, and α-SMA (1:200) at 4°C overnight and then with FITC- or tetramethylrhodamine isothiocyanate–conjugated secondary antibodies (Jackson ImmunoResearch Laboratories) at room temperature for 1 hour. Sections were viewed with a confocal laser scanning microscope (TCS 4D; Leica, Heidelberg, Germany) and a Nikon Labophot 2 microscope equipped with a Sony CCD-IRIS/RGB color video camera.

Flow Cytometry

The content of inflammatory cells was quantified by flow cytometry as described.19 Briefly, heart tissues were cut into multiple small cubes and digested in an enzyme mixture containing collagenase type I (0.05 mg/mL) and type IV (0.05 mg/mL) and hyaluronidase (0.025 mg/mL), and DNase I (0.01 mg/mL) and soybean trypsin inhibitor (0.01 mg/mL) dissolved in DMEM for 45 minutes at 37°C. The cell suspension was centrifuged and preincubated with fragment crystallizable-γ block antibody (anti-mouse CD16/32; PharMingen, San Diego, CA) to prevent nonspecific binding. Cell staining involved different combinations of fluorochrome-coupled antibodies to CD45.2, F4/80, CD11b, CD206, CD3, CD4, or CD8 for 30 minutes at 4°C in the dark. Fluorescence data were collected using an EPICS XL Flow Cytometer (Beckman Coulter), and analyzed using CellQuest (Beckman). Total cell population was recorded by cell size (forward scatter) and internal complexity (side scatter), and showed even distribution in a representative cell suspension prepared from heart tissues. Leukocytes were stained with monoclonal anti-CD45.2 and gated with CD45.2 fluorescence versus side scatter. To determine the viability of leukocytes, we used double staining analysis of uptake of propidium iodide (PI, Sigma-Aldrich) in CD45+ cells. Heart infiltrating myeloid cells (CD11b), macrophages (F4/80 or CD206), and CD4+ and CD8+ T lymphocytes were further gated on CD45+ cells. Appropriate isotype controls of irrelevant specificity were included (rat IgG2a-PerCP as control for CD45.2-PerCP, rat IgG2a-PE for F4/80-PE, rat IgG2a-FITC for CD206-FITC). Fluorescence minus one controls were included to determine the level of nonspecific staining and autofluorescence associated with subsets of cells in each fluorescence channel.

Cell Culture and Peptide Gel Coculture

Bone marrow–derived macrophages (BMDMs) were isolated from tibias and femurs of 3-month-old WT and SGK1−/− mice as described.20 Briefly, BM was flushed from the femur and tibia and purified through Ficoll-Paque gradient (Amersham Biosciences, Freiburg, Germany). Cells were then incubated in complete culture medium supplemented with 50-ng/mL recombinant murine cerebral spinal fluid for 5 days.

Cardiac fibroblasts were prepared from the hearts of adult male WT B6/129S mice as described.21 Briefly, the LVs were isolated, minced, and placed in a solution of 100-U/mL collagenase type I and 0.1% trypsin, and underwent sequential 10-minute periods of digestion with constant stirring at 37°C. After a 30-minute attachment to uncoated culture plates, cells were rinsed and amplified by trypsinization. All studies involved cardiac fibroblasts (passages 2 through 4) grown to subconfluence in serum-containing media and then growth-arrested for 24 hours in serum-free medium before treatment.

Three-dimensional peptide gel coculture was as described.22,23 Briefly, macrophages and cardiac fibroblasts were mixed with peptide gel suspended in PBS (K2(QL)6K2; Beijing Seajet Scientific, Beijing, China) at a final concentration of 1.3 mg peptide/mL DMEM. The mixture of peptide gel with cells distributed well at the center of the cell culture. Polymerization of the gel was initiated by adding 1 to 2 volumes of medium to the side of each well, followed by gentle agitation, then incubation at 37°C for 1 hour to allow the gel to form. Peptide gel coculture was maintained in DMEM containing 10% fetal bovine serum at 37°C in a humidified atmosphere containing 5% CO2 with Ang II treatment (1 μmol/L) for 48 hours.

RNA Analysis

Total RNA was extracted by the Trizol reagent method (Invitrogen), and first strand cDNA was synthesized with SuperScript II (Invitrogen). The transcript levels of SGK1, α-SMA, and collagen I and III were detected by semiquantitative polymerase chain reaction (PCR) or real-time PCR analysis. The primer sequences were for SGK1, 5’-TCCAGAATGAGGGGAATGGTAGCGA-3’, 5’-AGATGAGTAGAAGCGAGCCCGTGGT-3’; β-actin, 5’-TCATCACTATTGGCAACGAGC-3’, 5’-AACAGTCCGCCTAGAAGCAC-3’; α-SMA, 5’-ACTCTCTTCCAGCCATCTTTCA-3’, 5’-ATAGGTGGTTTCGTGGATGC-3’; collagen I, 5’-CATGTTCAGCTTTGTGGACCT-3’, 5’-GCAGCTGACTTCAGGGATGT-3’; collagen III, 5’-TCCCCTGGAATCTGTGAATC-3’, 5’-TGAGTCGAATTGGGGAGAAT-3’; and tubulin, 5’-TCTAACCCGTTGCTATCATGC-3’, 5’-GCCATGTTCCAGGCAGTAG-3’. PCR products were electrophoresed through 1.5% agarose gels containing ethidium bromide. Quantitative real-time PCR involved the iCycler iQ system (Bio-Rad).

Western Blotting Analysis

Western blotting analysis was performed as described.24 Briefly, protein extracts were obtained from LV samples using cell lysis buffer (20-mmol/L Tris, 1% Triton X-100, 0.05% SDS, 5-mg sodium deoxycholate, 150-mmol/L NaCl, and 1-mmol/L phenylmethylsulfonyl fluoride) containing protease/phosphatase inhibitor cocktail (Roche Diagnostics, Indianapolis, IN). Cell lysates were separated by electrophoresis on 8% to 10% SDS-polyacrylamide gels before transfer to nitrocellulose membranes (Bio-Rad), which were incubated with the primary antibodies phospho-STAT1 (1:1000), STAT1 (1:1000), phospho-STAT3 (1:1000), STAT3 (1:1000), and GAPDH (1:1000) at 4°C overnight, then secondary antibodies (1:5000, Alexa Fluor 680 or IRDye 800; Rockland Immunochemicals, Gilbertsville, PA) at room temperature for 1 hour. Images were obtained by the Odyssey Infrared Imaging System (LI-COR Biosciences) and Odyssey software.

STAT3 Small Interfering RNA Transfection and Lentivirus Infection

Because small interfering RNAs (siRNAs) target many genes, a rescue experiment was performed to establish specificity. BMDMs were transfected with siRNA targeting mouse STAT3 or nonsilencing siRNA according to the manufacturer’s instructions (Santa Cruz Biotechnology). The mouse coding sequence for STAT3 was inserted into pBOBI with Flag-tag fused with its N terminal. The Flag-STAT3 lentivirus was packed in 293T cells by the calcium phosphate precipitation method. At the end of siRNA transfection, cells were infected with 100 multiplicity of infection of lentivirus expressing STAT3 or green fluorescent protein as a control. At 24 hours, the medium was replaced, and cells were cultured in 3-dimensional peptide gels with Ang II (1 μmol/L) for 48 hours as described.25

Cytokine Production

The amount of active and latent TGF-β in the supernatant was measured with Quantikine TGF-β ELISA Kit (MB100B; R&D Systems, Minneapolis, MN). For measurement of total TGF-β in the supernatant, latent TGF-β was converted into the activated form by acidification, followed by a neutralization step. Supernatants were assessed for content of IL-10, IL-12p70, and IL-6 using FACSCalibur with BD cytometry bead array Flex Set bead assays (BD Biosciences). Sample files were analyzed using FCAP Array (version 1.0.1 software, Soft Flow).

Statistical Analysis

Data analysis involved use of GraphPad software (GraphPad Prism version 5.00 for Windows, GraphPad Software). Results are expressed as mean±SEM. Differences were analyzed by t test or ANOVA, and results were considered significant at P<0.05.

Results

Ang II Infusion Increases SGK1 Expression in Mouse Cardiac Tissues

To investigate the role of SGK1 in hypertensive mice hearts, we examined SGK1 expression in mice in response to Ang II infusion. The mRNA level of SGK1 was time-dependently upregulated in cardiac tissue of WT mice infused with Ang II for 5 to 14 days (Figure 1A). Immunohistochemistry revealed the number of SGK1-positive cells in WT hearts greater with Ang II than saline infusion, with no change in SGK1 levels in SGK1−/− hearts with Ang II or saline infusion (Figure 1B). Frozen sections were immunostained with the cardiomyocyte marker myosin heavy chain and anti-SGK1 antibodies to assess SGK1 expression in cardiomyocytes. SGK1 was expressed in cardiomyocytes, and its expression was markedly induced after Ang II infusion (Figure IV in the online-only Data Supplement). SGK1−/− cardiomyocytes showed no expression of SGK1. Thus, SGK1 expression and activation may play a critical role in cardiac fibrosis in response to Ang II.

Figure 1.
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Figure 1.

Angiotensin II (Ang II) induces serum-glucocorticoid regulated kinase 1 (SGK1) expression in mouse cardiac tissue. A, Semiquantitative polymerase chain reaction (PCR) of mRNA level of SGK1 in wild-type (WT) hearts after 5, 7, and 14 days of Ang II infusion. β-actin was a loading control. Data are mean±SEM for n=6 mice. *P<0.05, **P<0.01 vs saline control. B, Immunohistochemical analysis of SGK1 expression in heart sections of WT and SGK1 knockout (SGK1−/−) mice with saline infusion or Ang II infusion for 7 days. (n=6 mice per group). Magnification, ×400.

SGK1−/− Inhibits Ang II–Induced Cardiac Hypertrophy

Given that SGK1 was upregulated in the WT mouse heart after Ang II stimulation, we sought to determine the effect of SGK1 deficiency on Ang II–induced hypertension. Both WT and SGK1−/− mice were infused with Ang II for 7 days. Ang II infusion markedly increased systolic blood pressure in both WT and SGK1−/− mice compared with nontreated mice (Figure 2A), with no difference between the groups, so SGK1 is not involved in Ang II–induced hypertension.

Figure 2.
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Figure 2.

Serum-glucocorticoid regulated kinase 1 (SGK1) knockout protects against angiotensin II (Ang II) infusion–induced cardiac hypertrophy in mice. A, Blood pressure in wild-type (WT) littermates and SGK1 knockout (SGK1−/−) mice before and during 7 days of Ang II infusion. Data are mean±SEM for a group of 10 mice. NS indicates not significant. **P<0.01. B, Wheat germ agglutinin staining to evaluate tissue morphology and cardiomyocyte size in heart sections of WT and SGK1−/− mice with saline or Ang II infusion for 7 days (magnification, ×400). Quantitative analysis of cardiomyocyte cross-sectional area. Data are mean±SEM for n=6 mice with 200 cells per animal. **P<0.01 vs WT Ang II infusion. (C, Table) Representative M-mode echocardiography of the left ventricle in WT and SGK1−/− mice with saline infusion or Ang II infusion for 7 days. Data are mean±SEM for n=6 mice. *P<0.05, **P<0.01 vs Ang II–infused WT mice.

To further assess the role of SGK1 in regulating cardiac hypertrophy and function, we used histology with wheat germ agglutinin staining to evaluate myocyte size. WT and SGK1−/− mice did not differ in myocyte size after saline infusion (Figure 2B). Ang II infusion significantly increased myocyte size in LV tissues of WT mice, which was largely blocked in SGK1−/− mice (Figure 2B). On echocardiography, WT and SGK1−/− hearts did not differ in LV wall thickness, diameter, or fractional shortening after saline infusion (Figure 2C and Table), but anterior wall thickening and LV mass were smaller in SGK1−/− than WT hearts after Ang II infusion. Thus, SGK1 deletion may reduce Ang II–induced cardiac hypertrophy but not affect hypertension and cardiac function.

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Table 1.

Results of Echocardiography in Ang Il–Infused WT and SGK1–/– mice

SGK1−/− Inhibits Ang II–Induced Cardiac Fibrosis

To determine whether SGK1 activation contributes to Ang II–induced cardiac remodeling, we examined cardiac fibrosis of WT and SGK1−/− hearts after Ang II infusion by Masson trichrome staining. WT and SGK1−/− hearts did not differ in fibrosis in cardiac tissues with saline treatment (Figure 3A). Ang II infusion significantly increased collagen deposition in LV tissues of WT hearts, particularly in the interstitial and perivascular areas. In contrast, SGK1−/− hearts showed attenuated cardiac fibrosis with Ang II infusion. Picrosirius red staining was used for analysis of total collagen content on bright field microscopy, and collagen fibers were detected by polarized light microscopy. WT and SGK1−/− hearts showed little collagen deposition with saline treatment (Figure 3B). However, collagen accumulation in the interstitial and perivascular sites was greater in WT than SGK1−/− hearts after Ang II infusion. Collagen I and III fiber content was lower in SGK1−/− than WT hearts after Ang II infusion. Moreover, immunohistochemistry confirmed that cardiac expression of α-SMA and CTGF protein was significantly lower in SGK1−/− than WT hearts after Ang II but not saline infusion (Figure 3C). Thus, SGK1 deletion reduces Ang II–induced cardiac fibrosis.

Figure 3.
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Figure 3.

Serum-glucocorticoid regulated kinase 1 (SGK1) knockout reduces interstitial and perivascular fibrosis in the mouse heart. A, Collagen deposition in the heart after 7 days saline or angiotensin II (Ang II) infusion by Masson trichrome staining. Quantitative analysis of fibrotic area (Masson trichrome-stained area in light blue normalized to total myocardial area; magnification, ×100). B, Histology of collagen type I (orange) and III (green) content in wild-type (WT) and SGK1 knockout (SGK1−/−) hearts after 7 days of saline or Ang II infusion by Sirius red staining on light microscopy (magnification, ×200) and polarized light microscopy (magnification, ×400). Data are mean±SEM for n=6 mice with 10 fields per animal. C, Immunohistochemisty of α-smooth muscle actin (SMA)- and connective tissue growth factor (CTGF)–positive cells in WT and SGK1−/− mice after 7 days of saline or Ang II infusion (magnification, ×400). Quantitative analysis of α-SMA– and CTGF-positive cells in heart sections. Data are mean±SEM for n=6 mice with 10 fields per animal.*P<0.05, **P<0.01 vs WT Ang II infusion.

SGK1−/− Inhibits Ang II–Induced Cardiac Inflammation

To examine whether SGK1 affects Ang II–induced cardiac inflammation, we analyzed proinflammatory cell infiltration in WT and SGK1−/− hearts. Ang II infusion significantly increased the infiltration of proinflammatory cells in WT hearts, primarily localizing to the perivascular and interstitial areas (Figure 4A), with lower infiltration in SGK1−/− than WT hearts (Figure 4A). Furthermore, immunohistochemical staining of myocardial sections demonstrated the expression of Mac-2 (macrophage marker) markedly lower in SGK1−/− than WT hearts after Ang II infusion, with no significant difference between WT and SGK1−/− hearts after saline infusion (Figure 4A).

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Figure 4.

Serum-glucocorticoid regulated kinase 1 (SGK1) knockout prevents angiotensin II (Ang II)–induced macrophage infiltration in cardiac tissues. A, Macrophage infiltration in wild-type (WT) and SGK1 knockout (SGK1−/−) mice after saline or Ang II infusion by hematoxylin-eosin (H&E) and immunohistochemical staining of Mac-2 expression (magnification, ×200). Quantitative analysis of Mac-2–positive cells in heart sections. Data are mean±SEM for n=6 mice with 10 fields per animal. **P<0.01 vs Ang II–infused WT mice. B, Scatter plots gated on CD45+ cells, heart infiltrating myeloid cells (CD45+CD11b+cells), macrophages (CD45+CD11b+F4/80+cells), and CD4+ (CD45+CD3+CD4+cells) and CD8+ (CD45+CD3+CD8+cells) T lymphocytes analyzed in WT and SGK1−/− hearts after 7 days of Ang II infusion. Fluorescence minus one (FMO) indicates controls, where 1 staining fluorescence is omitted to set the negative gate. Data are mean±SEM for n=6 mice. NS indicates not significant. *P<0.05, **P<0.01 vs Ang II–infused WT.

Cardiac tissue consists of several types of inflammatory cells, including macrophages, T helper cells, and cytotoxic T lymphocytes, essential for adipose tissue inflammation. Therefore, we analyzed the cell populations in collagenase-digested WT and SGK1−/− hearts by flow cytometry. To determine the viability of leukocytes, we assayed PI uptake in CD45+ population cells by double staining. Gates were set on the CD45+ population, and the gated cell population was separated into viable leukocytes (CD45+PI− cells) and necrotic leukocytes (CD45+PI+ cells). The number of total viable cells was stabilized to 91.71±3.80%, and CD45+PI− cells in total leukocytes reached 81.54±2.93% in single cell suspensions of WT heart tissues after 7 days of Ang II infusion (Figure II in the online-only Data Supplement). To analyze leukocytes, we excluded PI+ nonviable cells and compared the relative proportions of macrophages (CD11b, F4/80), T helper cells (CD3, CD4), and cytotoxic T lymphocytes (CD3, CD8) in WT and SGK1−/− hearts after Ang II infusion. Macrophages were identified as positive for CD11b and F4/80, gated on CD45+ population cells. The proportion of infiltrating CD45+CD11b+ cells, CD45+F4/80+ cells, and CD45+CD11b+F4/80+ cells in cardiac tissue was significantly lower in SGK1−/− than WT hearts (57.19±3.79% versus 71.48±3.81% for CD45+CD11b+ cells; 38.03±5.37% versus 58.98±2.03% for CD45+F4/80+ cells; and 19.65±6.02% versus 55.05±3.92% for CD45+CD11b+F4/80+ cells, P≤ 0.05; Figure 4B). In contrast, SGK1−/− and WT hearts did not differ in proportion of CD4+ or CD8+ T cells. Thus, SGK1 selectively promotes recruitment of macrophages to cardiac tissues.

SGK1−/− Blocks M2 Macrophage Transition in Cardiac Tissue With Ang II Infusion

Because macrophages have been categorized as M1 (classically activated) and M2 (alternatively activated), we then analyzed macrophage phenotype in SGK1−/− hearts. Immunofluorescence staining showed that Ang II infusion significantly increased the expression of macrophage marker F4/80 and SGK1 in WT hearts whereas this effect was markedly attenuated in SGK1−/− hearts (Figure 5A). Moreover, the levels of TGF-β, IL-13, and IL-10 expression were markedly elevated in cardiac tissues of Ang II–treated WT littermates compared with saline-treated WT mice, with the increased expression significantly lower in SGK1−/− mice than in WT littermates after Ang II infusion. The protein expression of TGF-β, IL-13, and IL-10 did not differ between WT littermates and SGK1−/− mice with saline treatment (Figure 5B). To further establish whether SGK1 was necessary for macrophage phenotype in the heart after Ang II infusion, we assessed cell surface expression of CD206, a marker of M2 macrophages. Immunofluorescence analysis revealed double-positive F4/80 and CD206 viable macrophages strongly expressed in WT hearts but not in SGK1−/− hearts (Figure 5C). We further analyzed macrophage phenotype in hearts by flow cytometry. Leukocytes derived from Ang II–treated WT and SGK1−/− hearts were stained with anti-CD45.2, scatter plots were gated for CD45+ population cells, and number of M2 macrophages (CD45+F4/80+CD206+ cells) was analyzed in cardiac tissues. The proportion of infiltrating CD45+ cells into cardiac tissue was significantly lower in SGK1−/− than WT hearts (1.51±0.86% versus 4.03±0.97%; P≤ 0.05; Figure 5D). Moreover, flow cytometry revealed an increased proportion of macrophages (CD45+F4/80+ cells) also positive for CD206 expression in WT mice but lower in SGK1−/− than WT hearts (31.38±1.50% versus 55.90±2.38%). Thus, SGK1 is responsible for driving macrophages toward the M2 phenotype in cardiac tissue after Ang II infusion.

Figure 5.
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Figure 5.

Serum-glucocorticoid regulated kinase 1 (SGK1) knockout reduces M2 macrophage infiltration in mouse cardiac tissue. A, Double immunofluorescence analysis of macrophage (anti-F4/80) and SGK1 expression in wild-type (WT) and SGK1 knockout (SGK1−/−) hearts after 7 days of angiotensin II (Ang II) infusion. Bar=10 μm. B, Immunohistochemical analysis of cytokine expression in heart sections with saline or Ang II infusion in WT and SGK1−/− mice. Cytokine expression detected by anti–transforming growth factor-β (TGF-β), anti–interleukin-10 (IL-10), and anti–IL-13 immunostaining. Data are mean±SEM for n=6 mice with 10 fields per animal. **P<0.01 vs Ang II–infused WT. C, Double immunofluorescence analysis of M2 macrophages (anti-F4/80 and anti-CD206) in WT and SGK1−/− hearts after 7 days of Ang II infusion. Bar=7.5 μm. D, Leukocytes were gated with CD45 fluorescence vs side angle scatter (SS). Scatter plots are gated on CD45+ population cells. M2 macrophage activity (CD45+F4/80+CD206+ cells) was analyzed in WT and SGK1−/− hearts after 7 days of Ang II infusion. Data are mean±SEM for n=6 mice. **P<0.01 vs Ang II–infused WT. DAPI indicates 4',6-diamidino-2-phenylindole.

SGK1−/− Inhibits Activation of M2 Macrophages Through the STAT3 Pathway

To investigate the mechanism by which SGK1 regulates M2 macrophage activation, we analyzed the Janus kinase/STAT pathway, particularly STAT3, which plays a central role in macrophage polarization. STAT3 phosphorylation was similar in cardiac tissues of WT and SGK1−/− mice after saline infusion (Figure 6A). However, Ang II infusion significantly enhanced STAT3 phosphorylation in WT hearts, which was greatly reduced in SGK1−/− hearts (Figure 6A). WT and SGK1−/− hearts did not differ in phosphorylation of STAT1 after Ang II infusion. Furthermore, immunofluorescence staining showed phosphorylated STAT3 localized primarily in the nucleus of F4/80-positive macrophages in WT hearts but mostly in cytoplasm of SGK1−/− hearts (Figure 6B), so SGK1 can activate STAT3 in macrophages after Ang II infusion.

Figure 6.
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Figure 6.

Serum-glucocorticoid regulated kinase 1 (SGK1)–induced macrophage polarization is mediated by signal transducer and activator of transcription 3 (STAT3) pathway. A, Western blotting analysis of phosphorylation levels of STAT1 and STAT3 in wild-type (WT) and SGK1 knockout (SGK1−/−) hearts. Data are mean±SEM for n=6 mice. NS indicates not significant. *P<0.05 vs Ang II–infused WT. B, Double immunofluorescence analyses of STAT3 activation of macrophages (anti-F4/80) in WT and SGK1−/− hearts after 7 days of angiotensin II (Ang II) infusion. Bar=10 μm. C, Effect of STAT3 on macrophage polarization in 3-dimensional culture. WT bone marrow–derived macrophages (BMDMs) were transiently transfected with STAT3-specific or control small interfering RNA (siRNA) before infection with lentivirus expressing STAT3 or green fluorescent protein (GFP) as indicated. BMDMs were then seeded in 3-dimensional nanogels with or without Ang II for 48 hours. Western blotting analysis was used to verify siRNA-mediated STAT3 knockdown and lentivirus infection for rescue experiments in macrophages. ELISA was used to analyze active and latent transforming growth factor-β (TGF-β) and flow cytometry for levels of interleukin-10 (IL-10), IL-12, and IL-6 with a Cytometric Bead Array Flex Set Kit. **P<0.01; *P<0.05 vs STAT3 siRNA-treated. DAPI indicates 4',6-diamidino-2-phenylindole.

To further confirm that SGK1 plays an important role in macrophage polarization via the STAT3 pathway, STAT3-specific siRNA was used to knock down endogenous STAT3 expression in BMDMs, and we performed recombinant STAT3 lentivirus-mediated rescue experiments to measure cytokine production by BMDMs. Western blotting analysis revealed that STAT3 siRNA reduced STAT3 protein levels by ≈75%, with STAT3 lentivirus leading to significant upregulation of STAT3 protein levels. Ang II treatment significantly increased levels of TGF-β and IL-10 (M2-type cytokines), and STAT3-specific siRNA markedly attenuated these levels (Figure 6C). Moreover, infection of recombinant lentivirus rescued production of TGF-β and IL-10 by reexpression of STAT3. To determine whether SGK1-activated STAT3 pathway is linked to M1 polarization of macrophages, we measured secretion of IL-12 or IL-6. Levels of IL-12 and IL-6 did not differ with alteration of STAT3 activation (Figure 6C). Therefore, STAT3 activation is necessary for SGK1-mediated M2-type polarization of macrophages.

SGK1-Deficient Macrophages Inhibit Cardiac Fibroblast Transformation

To investigate the role of SGK1 activation of macrophages in cardiac fibrosis, we cocultured BMDMs from WT and SGK1−/− mice with mouse cardiac fibroblasts in 3-dimensional peptide gels, as an in vitro model of macrophage-mediated fibroblast-to-myofibroblast differentiation. Immunofluorescence analysis revealed the level of α-SMA, a major marker for myofibroblasts, strongly expressed by fibroblasts after coculture with WT BMDMs in response to Ang II (Figure 7A). In contrast, the protein level of α-SMA was markedly suppressed on coculture with SGK1−/− BMDMs in response to Ang II (Figure 7A). Real-time PCR further confirmed that coculture of fibroblasts with WT BMDMs significantly unregulated the mRNA expression of α-SMA and collagen I and III, whereas incubation with SGK1−/− macrophages attenuated this effect (Figure 7B). Thus, SGK1−/− macrophages show reduced myofibroblast differentiation, thereby inhibiting cardiac fibrosis.

Figure 7.
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Figure 7.

Serum/glucocorticoid-regulated kinase 1 knockout (SGK1−/−) macrophages inhibit cardiac fibroblast-to-myofibroblast differentiation. A, Wild-type (WT) or SGK1−/− macrophages were cocultured with cardiac fibroblasts in nanogels with or without angiotensin II (Ang II), then underwent immunofluorescence analysis of myofibroblast differentiation by staining with α-smooth muscle actin (SMA) antibody. Bar=10 μm. B, Quantitative real-time polymerase chain reaction (PCR) analysis of the mRNA expression of α-SMA and collagen I and III in 3-dimensional coculture. Tubulin was a normalization control. Data are mean±SEM of 3 independent experiments. *P<0.05 vs coculture with WT bone marrow–derived macrophages (BMDMs). CF indicates cystic fibrosis; NS not significant.

Discussion

We provide the first evidence for the critical role of SGK1 in Ang II–induced cardiac fibrosis by regulating the inflammation response. Ang II infusion significantly increased the expression of SGK1. Lack of SGK1 activity markedly ameliorated Ang II–induced cardiac macrophage infiltration and proinflammatory cytokine expression. Moreover, SGK1 deficiency inhibited Ang II–induced activation of STAT3, and blocked macrophage differentiation to the M2 phenotype, thereby suppressing myofibroblast activation and cardiac fibrosis in response to Ang II.

SGK1 is a serine-threonine kinase initially identified as transcriptionally induced by glucocorticoids and serum and activated downstream of phosphoinositide-3 kinase in response to growth factors or oxidative stress.10 It shares ≈45% to 55% homology and common downstream substrates with Akt. Increased expression of SGK1 is associated with diabetic nephropathy, glomerulonephritis, hepatic cirrhosis, and pulmonary fibrosis.11 Despite the wide tissue distribution of SGK1 and its sensitivity to various stimuli, its role in cardiac remodeling was not fully defined. SGK1 is highly expressed in the hearts of developing embryos and adult animals26 and plays a crucial role in protecting cardiomyocytes and vascular cells against hypoxia, mechanical, hormonal, and oxidative stresses.11–13 Our recent studies demonstrated that SGK1 activation by mechanical stretch promoted accumulation of vascular cells in vein grafting, thus leading to neointima formation and vein graft failure.14 Importantly, we found SGK1 induced by Ang II and SGK1 deletion in mice decreased the infiltration of proinflammatory cells and cardiac fibrosis. These findings suggest a central role of SGK1 in the regulation of cardiac inflammation and fibrosis in response to Ang II.

Inflammation plays a critical role in the initiation and progression of hypertensive cardiac remodeling. Macrophage recruitment and activation are important in the onset of cardiac remodeling.27–29 Several studies have demonstrated markedly reduced macrophage infiltration and fibrosis in heart and kidney in osteopontin- or monocyte chemoattractant protein 1–null mice.29–31 Furthermore, recent findings suggest that signaling from phosphoinositide-3 kinase γ is crucial for leukocyte recruitment and inflammation but also contributes to cardiac maladaptive remodeling,32 and SGK1 is a phosphoinositide-3 kinase–dependent kinase with structural homology to Akt. Therefore, we focused on whether SGK1 is responsible for Ang II–induced recruitment and activation of macrophages in the mouse heart. Ang II infusion markedly increased perivascular CD45+ leukocytes, especially CD11b+F4/80+ macrophages (Figure 4B). Interestingly, SGK1−/− and WT hearts did not differ in proportion of CD4+ and CD8+ T lymphocytes after Ang II infusion (Figure 4B). Moreover, cardiac macrophage infiltration and inflammation were markedly reduced in SGK1−/− mice, despite Ang II–induced hypertension (Figure 4A). Thus, Ang II–induced activation of cardiac SGK1 may contribute to increased macrophage infiltration to fibrotic deposition, especially in the early development of cardiac fibrosis.

Macrophages are heterogeneous immune cell populations that include classically activated (M1) and alternatively activated (M2) macrophages, which are key inflammatory cells in heart diseases and a strong association with heart failure.33–35 M1 macrophages are classically activated by microbial products and T helper 1 cytokines such as interferon-γ and proinflammatory cytokines, including IL-12 and IL-6,36,37 whereas M2 macrophages are activated by glucocorticoids and the T helper 2 cytokines IL-4, IL-13, IL-18, and upregulation of mannose receptor (CD206), IL-10, and TGF-β.36,37 Increasing evidence suggests that SGK1 plays an important role in inflammatory cytokine expression and vascular remodeling. However, we lack information on SGK1 activation in regulating the macrophage phenotype and function in the hypertensive heart. We found SGK1−/− mice hearts with low expression of CD206 (a marker of M2 macrophages) and M2-type cytokines, including TGF-β, IL-13, and IL-10, in Ang II–treated SGK1−/− hearts (Figure 5B), so SGK1 may be a critical mediator for macrophage recruitment and M2 activation.

Of note, we found reduced TGF-β and IL-10 levels accompanied by reduced inflammation in SGK1−/− mice because both TGF-β and IL-10 are anti-inflammatory cytokines. Inflammation is a critical mechanism of chronic disease that promotes closely interlinked fibrosis and cellular injury, and macrophages are the predominant infiltrating immune cells mediating that inflammatory process. Macrophage infiltration produces various proinflammatory cytokines, including tumor necrosis factor-α (TNF-α) and IL-1β. Moreover, blockade of TNF-α and IL-1β suppresses inflammation and ameliorates organ damage.38,39 However, macrophages that take up apoptotic cells exhibit anti-inflammatory properties and may contribute to resolution of inflammation.40 Indeed, hepatic macrophages are important for resolution of inflammatory scarring.41 Thus, macrophages likely play multiple, and often opposing, roles in tissue repair and fibrosis.

Recent studies demonstrating the diversity of macrophage phenotypes and functionality suggest that the activation state of macrophages may determine their pathogenic or reparative roles in tissue fibrosis. M1 macrophages upregulate proinflammatory cytokines, including TNF-α, IL-6, and IL-12, thus contributing to tissue destruction. In contrast, M2 macrophages secrete anti-inflammatory cytokines, including IL-10 and TGF-β, and downregulate the production of proinflammatory cytokines, thus suppressing immune responses and promoting tissue remodeling.42 Reduced TGF-β and IL-10 levels accompanied by reduced inflammation in SGK1−/− mice hearts may have several explanations:

  1. As we showed in Figure 4, SGK1 deficiency significantly reduced macrophage accumulation (CD45+CD11b+F4/80+) in hearts after Ang II infusion.

  2. We examined the expression of TNF-α (M1 cytokine) and TGF-β, IL-10 (M2 cytokine) at an early time point, and found that in WT mice, Ang II infusion rapidly stimulated macrophage infiltration and mRNA expression of TNF-α (as early as day 1 and reduced at day 7) followed by mRNA expression of M2 cytokines such as TGF-β and IL-10 (at day 7), which suggests a shift in proinflammation to anti-inflammation during cardiac fibrosis in response to Ang II. These results are consistent with recent studies documenting that these subpopulations differentially accumulate over the course of the response to unilateral ureteral obstruction: on days 1 to 4 after unilateral ureteral obstruction, macrophage activation was skewed to the M1 type but at later times was shifted toward the M2 type, which led to enhanced renal fibrosis.43 The cytokine expression profiles and surface phenotypes of macrophages we observed suggest strongly that the cardiac environment (eg, skewed balance toward M2 activation, reduced expression of proinflammatory cytokines, and increased expression of TGF-β and IL-10) early after Ang II infusion (up to day 7) alters inflammatory processes and affects the later fibrotic phenotype.

  3. SGK1 deficiency inhibited STAT3 activation, reduced M2 macrophage infiltration and expression of M2 cytokines TGF-β and IL-10.

  4. As shown in Figure 6C, SGK1 deficiency inhibited STAT3 activation, which failed to regulate M1 macrophage polarization. Taken together, reduced macrophage accumulation and M2 macrophage polarization could be responsible for reduced inflammation and fibrosis.

The Janus kinase/STAT pathway, particularly STAT1, STAT3, and STAT6, have a major role in macrophage polarization.44 STAT1 is activated in response to M1 macrophage-polarizing signals (eg, interferon-γ and lipopolysaccharide) whereas STAT3 and STAT6 are selectively activated by M2 macrophage-polarizing cytokines (eg, IL-10, IL-4, and IL-13).45 We showed that SGK1 deficiency inhibited STAT3 activation but not directly STAT1 activation (Figure 6A and 6B). Moreover, in a 3-dimensional culture system, siRNA silencing of STAT3 in BMDMs significantly decreased the levels of M2-type cytokines IL-10 and TGF-β in response to Ang II, and recombinant STAT3 lentivirus rescued the production of IL-10 and TGF-β (Figure 6C). Therefore, SGK1 may regulate the M2 macrophage phenotype through STAT3 activation in response to Ang II.

Activation of M2 macrophages has an anti-inflammatory effect, which is closely associated with enhanced fibrosis whereas blocking M2 macrophage activation is associated with decreased lung, renal, and adipose tissue fibrosis.46–50 M2 macrophages express high levels of IL-10 and TGF-β, which promote the fibroblast-to-myofibroblast transition characterized by the expression of α-SMA and collagen production.50 Our in vitro coculture system was designed to determine how infiltrated macrophages regulate cardiac fibroblast activation in the hypertensive heart. We used a peptide gel-based 3-dimensional coculture system that consisted of relevant cells (macrophages and cardiac fibroblast) and architecture of tissues, which represents a better model of healthy native tissues compared with cells grown on rigid, 2-dimensional synthetic surfaces with serum. In this 3-dimensional system, we studied the role of SGK1 in macrophages using macrophages from WT or SGK1−/− mice cocultured with cardiac fibroblasts, and investigated the effect of macrophages on cardiac fibroblast activation. Myofibroblast activation and collagen deposition were lower with SGK1−/− than WT BMDMs with Ang II treatment (Figure 7A and 7B). These results are consistent with previous studies showing SGK1 signaling involved in pathological fibrosis of other tissues.51 Thus, our results extend these findings and reveal a novel function of SGK1 in contributing to M2 macrophage-mediated myofibroblast activation and fibrotic remodeling.

In conclusion, we demonstrate that SGK1 is markedly activated in the mouse heart and modulates cardiac inflammation and fibrosis in response to Ang II. Importantly, we demonstrated the role of SGK1 in the heart and its relationship to cardiac fibrosis in in vivo SGK1−/− mouse models. SGK1 primes macrophage polarization toward the M2 phenotype by activating the STAT3 pathway, which could be an attractive strategy for treating hypertensive heart failure and other inflammatory conditions.

Sources of Funding

This study was supported by grants from the Chinese Ministry of Science and Technology (2012CB522205, 2012CB517802), National Science Foundation of China (30888004, 31090363, 81170120), and Beijing Natural Science Foundation (7102024). Dr Cheng is a visiting professor from the Division of Nephrology, Baylor College of Medicine, Houston, TX.

Disclosures

None.

Footnotes

  • The online-only Data Supplement is available with this article at http://atvb.ahajournals.org/lookup/suppl/doi:10.1161/ATVBAHA.112.248732/-/DC1.

  • Received July 18, 2011.
  • Accepted March 14, 2012.
  • © 2012 American Heart Association, Inc.

References

  1. 1.↵
    1. Vakili BA,
    2. Okin PM,
    3. Devereux RB
    Prognostic implications of left ventricular hypertrophy. Am Heart J. 2001;141:334–341.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Hsu CY,
    2. McCulloch CE,
    3. Darbinian J,
    4. Go AS,
    5. Iribarren C
    Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Arch Intern Med. 2005;165:923–928.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Klingbeil AU,
    2. Schneider M,
    3. Martus P,
    4. Messerli FH,
    5. Schmieder RE
    A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med. 2003;115:41–46.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Ren J,
    2. Yang M,
    3. Qi G,
    4. Zheng J,
    5. Jia L,
    6. Cheng J,
    7. Tian C,
    8. Li H,
    9. Lin X,
    10. Du J
    Proinflammatory protein CARD9 is essential for infiltration of monocytic fibroblast precursors and cardiac fibrosis caused by Angiotensin II infusion. Am J Hypertens. 2011;24:701–707.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Kuwahara F,
    2. Kai H,
    3. Tokuda K,
    4. Takeya M,
    5. Takeshita A,
    6. Egashira K,
    7. Imaizumi T
    Hypertensive myocardial fibrosis and diastolic dysfunction: another model of inflammation? Hypertension. 2004;43:739–745.
    OpenUrlAbstract/FREE Full Text
  6. 6.↵
    1. Kagitani S,
    2. Ueno H,
    3. Hirade S,
    4. Takahashi T,
    5. Takata M,
    6. Inoue H
    Tranilast attenuates myocardial fibrosis in association with suppression of monocyte/macrophage infiltration in DOCA/salt hypertensive rats. J Hypertens. 2004;22:1007–1015.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Levick SP,
    2. McLarty JL,
    3. Murray DB,
    4. Freeman RM,
    5. Carver WE,
    6. Brower GL
    Cardiac mast cells mediate left ventricular fibrosis in the hypertensive rat heart. Hypertension. 2009;53:1041–1047.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Levick SP,
    2. Murray DB,
    3. Janicki JS,
    4. Brower GL
    Sympathetic nervous system modulation of inflammation and remodeling in the hypertensive heart. Hypertension. 2010;55:270–276.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Yu Q,
    2. Horak K,
    3. Larson DF
    Role of T lymphocytes in hypertension-induced cardiac extracellular matrix remodeling. Hypertension. 2006;48:98–104.
    OpenUrlAbstract/FREE Full Text
  10. 10.↵
    1. Webster MK,
    2. Goya L,
    3. Ge Y,
    4. Maiyar AC,
    5. Firestone GL
    Characterization of sgk, a novel member of the serine/threonine protein kinase gene family which is transcriptionally induced by glucocorticoids and serum. Mol Cell Biol. 1993;13:2031–2040.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Lang F,
    2. Böhmer C,
    3. Palmada M,
    4. Seebohm G,
    5. Strutz-Seebohm N,
    6. Vallon V
    (Patho)physiological significance of the serum- and glucocorticoid-inducible kinase isoforms. Physiol Rev. 2006;86:1151–1178.
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. Aoyama T,
    2. Matsui T,
    3. Novikov M,
    4. Park J,
    5. Hemmings B,
    6. Rosenzweig A
    Serum and glucocorticoid-responsive kinase-1 regulates cardiomyocyte survival and hypertrophic response. Circulation. 2005;111:1652–1659.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Vallon V,
    2. Wyatt AW,
    3. Klingel K,
    4. Huang DY,
    5. Hussain A,
    6. Berchtold S,
    7. Friedrich B,
    8. Grahammer F,
    9. Belaiba RS,
    10. Görlach A,
    11. Wulff P,
    12. Daut J,
    13. Dalton ND,
    14. Ross J Jr.,
    15. Flögel U,
    16. Schrader J,
    17. Osswald H,
    18. Kandolf R,
    19. Kuhl D,
    20. Lang F
    SGK1-dependent cardiac CTGF formation and fibrosis following DOCA treatment. J Mol Med. 2006;84:396–404.
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Cheng J,
    2. Wang Y,
    3. Ma Y,
    4. Chan BT,
    5. Yang M,
    6. Liang A,
    7. Zhang L,
    8. Li H,
    9. Du J
    The mechanical stress-activated serum-, glucocorticoid-regulated kinase 1 contributes to neointima formation in vein grafts. Circ Res. 2010;107:1265–1274.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Ortiz RM,
    2. Graciano ML,
    3. Seth D,
    4. Awayda MS,
    5. Navar LG
    Aldosterone receptor antagonism exacerbates intrarenal angiotensin II augmentation in ANG II-dependent hypertension. Am J Physiol Renal Physiol. 2007;293:F139–F147.
    OpenUrlAbstract/FREE Full Text
  16. 16.↵
    1. Chen S,
    2. Law CS,
    3. Grigsby CL,
    4. Olsen K,
    5. Hong TT,
    6. Zhang Y,
    7. Yeghiazarians Y,
    8. Gardner DG
    Cardiomyocyte-specific deletion of the vitamin D receptor gene results in cardiac hypertrophy. Circulation. 2011;124:1838–1847.
    OpenUrlAbstract/FREE Full Text
  17. 17.↵
    1. Kassan M,
    2. Galan M,
    3. Partyka M,
    4. Trebak M,
    5. Matrougui K
    Interleukin-10 released by CD4(+)CD25(+) natural regulatory T cells improves microvascular endothelial function through inhibition of NADPH oxidase activity in hypertensive mice. Arterioscler Thromb Vasc Biol. 2011;31:2534–2542.
    OpenUrlAbstract/FREE Full Text
  18. 18.↵
    1. Dewald O,
    2. Frangogiannis NG,
    3. Zoerlein M,
    4. Duerr GD,
    5. Klemm C,
    6. Knuefermann P,
    7. Taffet G,
    8. Michael LH,
    9. Crapo JD,
    10. Welz A,
    11. Entman ML
    Development of murine ischemic cardiomyopathy is associated with a transient inflammatory reaction and depends on reactive oxygen species. Proc Natl Acad Sci USA. 2003;100:2700–2705.
    OpenUrlAbstract/FREE Full Text
  19. 19.↵
    1. Gelderblom M,
    2. Leypoldt F,
    3. Steinbach K,
    4. Behrens D,
    5. Choe CU,
    6. Siler DA,
    7. Arumugam TV,
    8. Orthey E,
    9. Gerloff C,
    10. Tolosa E,
    11. Magnus T
    Temporal and spatial dynamics of cerebral immune cell accumulation in stroke. Stroke. 2009;40:1849–1857.
    OpenUrlAbstract/FREE Full Text
  20. 20.↵
    1. Goodridge HS,
    2. Simmons RM,
    3. Underhill DM
    Dectin-1 stimulation by Candida albicans yeast or zymosan triggers NFAT activation in macrophages and dendritic cells. J Immunol. 2007;178:3107–3115.
    OpenUrlAbstract/FREE Full Text
  21. 21.↵
    1. Gustafsson AB,
    2. Brunton LL
    beta-adrenergic stimulation of rat cardiac fibroblasts enhances induction of nitric-oxide synthase by interleukin-1beta via message stabilization. Mol Pharmacol. 2000;58:1470–1478.
    OpenUrlPubMed
  22. 22.↵
    1. Su G,
    2. Blaine SA,
    3. Qiao D,
    4. Friedl A
    Shedding of syndecan-1 by stromal fibroblasts stimulates human breast cancer cell proliferation via FGF2 activation. J Biol Chem. 2007;282:14906–14915.
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Dong H,
    2. Paramonov SE,
    3. Aulisa L,
    4. Bakota EL,
    5. Hartgerink JD
    Self-assembly of multidomain peptides: balancing molecular frustration controls conformation and nanostructure. J Am Chem Soc. 2007;129:12468–12472.
    OpenUrlCrossRefPubMed
  24. 24.↵
    1. Cheng J,
    2. Du J
    Mechanical stretch simulates proliferation of venous smooth muscle cells through activation of the insulin-like growth factor-1 receptor. Arterioscler Thromb Vasc Biol. 2007;27:1744–1751.
    OpenUrlAbstract/FREE Full Text
  25. 25.↵
    1. Cheng P,
    2. Corzo CA,
    3. Luetteke N,
    4. Yu B,
    5. Nagaraj S,
    6. Bui MM,
    7. Ortiz M,
    8. Nacken W,
    9. Sorg C,
    10. Vogl T,
    11. Roth J,
    12. Gabrilovich DI
    Inhibition of dendritic cell differentiation and accumulation of myeloid-derived suppressor cells in cancer is regulated by S100A9 protein. J Exp Med. 2008;205:2235–2249.
    OpenUrlAbstract/FREE Full Text
  26. 26.↵
    1. Biondi RM,
    2. Kieloch A,
    3. Currie RA,
    4. Deak M,
    5. Alessi DR
    The PIF-binding pocket in PDK1 is essential for activation of S6K and SGK, but not PKB. EMBO J. 2001;20:4380–4390.
    OpenUrlAbstract
  27. 27.↵
    1. Brown NJ
    Aldosterone and vascular inflammation. Hypertension. 2008;51:161–167.
    OpenUrlFREE Full Text
  28. 28.↵
    1. Nakamura T,
    2. Kataoka K,
    3. Fukuda M,
    4. Nako H,
    5. Tokutomi Y,
    6. Dong YF,
    7. Ichijo H,
    8. Ogawa H,
    9. Kim-Mitsuyama S
    Critical role of apoptosis signal-regulating kinase 1 in aldosterone/salt-induced cardiac inflammation and fibrosis. Hypertension. 2009;54:544–551.
    OpenUrlAbstract/FREE Full Text
  29. 29.↵
    1. Rickard AJ,
    2. Morgan J,
    3. Tesch G,
    4. Funder JW,
    5. Fuller PJ,
    6. Young MJ
    Deletion of mineralocorticoid receptors from macrophages protects against deoxycorticosterone/salt-induced cardiac fibrosis and increased blood pressure. Hypertension. 2009;54:537–543.
    OpenUrlAbstract/FREE Full Text
  30. 30.↵
    1. Persy VP,
    2. Verhulst A,
    3. Ysebaert DK,
    4. De Greef KE,
    5. De Broe ME
    Reduced postischemic macrophage infiltration and interstitial fibrosis in osteopontin knockout mice. Kidney Int. 2003;63:543–553.
    OpenUrlCrossRefPubMed
  31. 31.↵
    1. Dewald O,
    2. Zymek P,
    3. Winkelmann K,
    4. Koerting A,
    5. Ren G,
    6. Abou-Khamis T,
    7. Michael LH,
    8. Rollins BJ,
    9. Entman ML,
    10. Frangogiannis NG
    CCL2/Monocyte Chemoattractant Protein-1 regulates inflammatory responses critical to healing myocardial infarcts. Circ Res. 2005;96:881–889.
    OpenUrlAbstract/FREE Full Text
  32. 32.↵
    1. Damilano F,
    2. Franco I,
    3. Perrino C,
    4. Schaefer K,
    5. Azzolino O,
    6. Carnevale D,
    7. Cifelli G,
    8. Carullo P,
    9. Ragona R,
    10. Ghigo A,
    11. Perino A,
    12. Lembo G,
    13. Hirsch E
    Distinct effects of leukocyte and cardiac phosphoinositide 3-kinase γ activity in pressure overload-induced cardiac failure. Circulation. 2011;123:391–399.
    OpenUrlAbstract/FREE Full Text
  33. 33.↵
    1. Fairweather D,
    2. Frisancho-Kiss S,
    3. Njoku DB,
    4. Nyland JF,
    5. Kaya Z,
    6. Yusung SA,
    7. Davis SE,
    8. Frisancho JA,
    9. Barrett MA,
    10. Rose NR
    Complement receptor 1 and 2 deficiency increases coxsackievirus B3-induced myocarditis, dilated cardiomyopathy, and heart failure by increasing macrophages, IL-1beta, and immune complex deposition in the heart. J Immunol. 2006;176:3516–3524.
    OpenUrlAbstract/FREE Full Text
  34. 34.↵
    1. van Amerongen MJ,
    2. Harmsen MC,
    3. van Rooijen N,
    4. Petersen AH,
    5. van Luyn MJ
    Macrophage depletion impairs wound healing and increases left ventricular remodeling after myocardial injury in mice. Am J Pathol. 2007;170:818–829.
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Kaya Z,
    2. Göser S,
    3. Buss SJ,
    4. Leuschner F,
    5. Ottl R,
    6. Li J,
    7. Völkers M,
    8. Zittrich S,
    9. Pfitzer G,
    10. Rose NR,
    11. Katus HA
    Identification of cardiac troponin I sequence motifs leading to heart failure by induction of myocardial inflammation and fibrosis. Circulation. 2008;118:2063–2072.
    OpenUrlAbstract/FREE Full Text
  36. 36.↵
    1. Pollard JW
    Trophic macrophages in development and disease. Nat Rev Immunol. 2009;9:259–270.
    OpenUrlCrossRefPubMed
  37. 37.↵
    1. Biswas SK,
    2. Mantovani A
    Macrophage plasticity and interaction with lymphocyte subsets: cancer as a paradigm. Nat Immunol. 2010;11:889–896.
    OpenUrlCrossRefPubMed
  38. 38.↵
    1. Kluth DC,
    2. Erwig LP,
    3. Rees AJ
    Multiple facets of macrophages in renal injury. Kidney Int. 2004;66:542–557.
    OpenUrlCrossRefPubMed
  39. 39.↵
    1. Li DJ,
    2. Evans RG,
    3. Yang ZW,
    4. Song SW,
    5. Wang P,
    6. Ma XJ,
    7. Liu C,
    8. Xi T,
    9. Su DF,
    10. Shen FM
    Dysfunction of the cholinergic anti-inflammatory pathway mediates organ damage in hypertension. Hypertension. 2011;57:298–307.
    OpenUrlAbstract/FREE Full Text
  40. 40.↵
    1. Tabas I
    Macrophage death and defective inflammation resolution in atherosclerosis. Nat Rev Immunol. 2010;10:36–46.
    OpenUrlCrossRefPubMed
  41. 41.↵
    1. Duffield JS,
    2. Forbes SJ,
    3. Constandinou CM,
    4. Clay S,
    5. Partolina M,
    6. Vuthoori S,
    7. Wu S,
    8. Lang R,
    9. Iredale JP
    Selective depletion of macrophages reveals distinct, opposing roles during liver injury and repair. J Clin Invest. 2005;115:56–65.
    OpenUrlCrossRefPubMed
  42. 42.↵
    1. Mosser DM,
    2. Edwards JP
    Exploring the full spectrum of macrophage activation. Nat Rev Immunol. 2008;8:958–969.
    OpenUrlCrossRefPubMed
  43. 43.
    1. Fujiu K,
    2. Manabe I,
    3. Nagai R
    Renal collecting duct epithelial cells regulate inflammation in tubulointerstitial damage in mice. J Clin Invest. 2011;121:3425–3441.
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. O’Shea JJ,
    2. Pesu M,
    3. Borie DC,
    4. Changelian PS
    A new modality for immunosuppression: targeting the JAK/STAT pathway. Nat Rev Drug Discov. 2004;3:555–564.
    OpenUrlCrossRefPubMed
  45. 45.↵
    1. Sica A,
    2. Bronte V
    Altered macrophage differentiation and immune dysfunction in tumor development. J Clin Invest. 2007;117:1155–1166.
    OpenUrlCrossRefPubMed
  46. 46.↵
    1. Endo M,
    2. Oyadomari S,
    3. Terasaki Y,
    4. Takeya M,
    5. Suga M,
    6. Mori M,
    7. Gotoh T
    Induction of arginase I and II in bleomycin-induced fibrosis of mouse lung. Am J Physiol Lung Cell Mol Physiol. 2003;285:L313–L321.
    OpenUrlAbstract/FREE Full Text
  47. 47.↵
    1. Grasemann H,
    2. Schwiertz R,
    3. Matthiesen S,
    4. Racké K,
    5. Ratjen F
    Increased arginase activity in cystic fibrosis airways. Am J Respir Crit Care Med. 2005;172:1523–1528.
    OpenUrlCrossRefPubMed
  48. 48.↵
    1. Sun L,
    2. Louie MC,
    3. Vannella KM,
    4. Wilke CA,
    5. LeVine AM,
    6. Moore BB,
    7. Shanley TP
    New concepts of IL-10-induced lung fibrosis: fibrocyte recruitment and M2 activation in a CCL2/CCR2 axis. Am J Physiol Lung Cell Mol Physiol. 2011;300:L341–L353.
    OpenUrlAbstract/FREE Full Text
  49. 49.↵
    1. Spencer M,
    2. Yao-Borengasser A,
    3. Unal R,
    4. Rasouli N,
    5. Gurley CM,
    6. Zhu B,
    7. Peterson CA,
    8. Kern PA
    Adipose tissue macrophages in insulin-resistant subjects are associated with collagen VI and fibrosis and demonstrate alternative activation. Am J Physiol Endocrinol Metab. 2010;299:E1016–E1027.
    OpenUrlAbstract/FREE Full Text
  50. 50.↵
    1. Wang Y,
    2. Harris DC
    Macrophages in renal disease. J Am Soc Nephrol. 2011;22:21–27.
    OpenUrlAbstract/FREE Full Text
  51. 51.↵
    1. BelAiba RS,
    2. Djordjevic T,
    3. Bonello S,
    4. Artunc F,
    5. Lang F,
    6. Hess J,
    7. Görlach A
    The serum- and glucocorticoid-inducible kinase Sgk-1 is involved in pulmonary vascular remodeling: role in redox-sensitive regulation of tissue factor by thrombin. Circ Res. 2006;98:828–836.
    OpenUrlAbstract/FREE Full Text
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    Serum-Glucocorticoid Regulated Kinase 1 Regulates Alternatively Activated Macrophage Polarization Contributing to Angiotensin II–Induced Inflammation and Cardiac Fibrosis
    Min Yang, Jiao Zheng, Yanjv Miao, Ying Wang, Wei Cui, Jun Guo, Shulan Qiu, Yalei Han, Lixin Jia, Huihua Li, Jizhong Cheng and Jie Du
    Arteriosclerosis, Thrombosis, and Vascular Biology. 2012;32:1675-1686, originally published June 13, 2012
    https://doi.org/10.1161/ATVBAHA.112.248732

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    Serum-Glucocorticoid Regulated Kinase 1 Regulates Alternatively Activated Macrophage Polarization Contributing to Angiotensin II–Induced Inflammation and Cardiac Fibrosis
    Min Yang, Jiao Zheng, Yanjv Miao, Ying Wang, Wei Cui, Jun Guo, Shulan Qiu, Yalei Han, Lixin Jia, Huihua Li, Jizhong Cheng and Jie Du
    Arteriosclerosis, Thrombosis, and Vascular Biology. 2012;32:1675-1686, originally published June 13, 2012
    https://doi.org/10.1161/ATVBAHA.112.248732
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