American Journal of Respiratory and Critical Care Medicine

Rationale: Patients with idiopathic pulmonary fibrosis (IPF), a progressive disease with a dismal prognosis, exhibit an unexplained disparity of increased alveolar epithelial cell (AEC) apoptosis but reduced fibroblast apoptosis.

Objectives: To examine whether the failure of patients with IPF to up-regulate cyclooxygenase (COX)-2, and thus the antifibrotic mediator prostaglandin (PG)E2, accounts for this imbalance.

Methods: Fibroblasts and primary type II AECs were isolated from control and fibrotic human lung tissue. The effects of COX-2 inhibition and exogenous PGE2 on fibroblast and AEC sensitivity to Fas ligand (FasL)-induced apoptosis were assessed.

Measurements and Main Results: IPF lung fibroblasts are resistant to FasL-induced apoptosis compared with control lung fibroblasts. Inhibition of COX-2 in control lung fibroblasts resulted in an apoptosis-resistant phenotype. Administration of PGE2 almost doubled the rate of FasL-induced apoptosis in fibrotic lung fibroblasts compared with FasL alone. Conversely, in primary fibrotic lung type II AECs, PGE2 protected against FasL-induced apoptosis. In human control and, to a greater extent, fibrotic lung fibroblasts, PGE2 inhibits the phosphorylation of Akt, suggesting that regulation of this prosurvival protein kinase is an important mechanism by which PGE2 modulates cellular apoptotic responses.

Conclusions: The observation that PGE2 deficiency results in increased AEC but reduced fibroblast sensitivity to apoptosis provides a novel pathogenic insight into the mechanisms driving persistent fibroproliferation in IPF.

Scientific Knowledge on the Subject

Excess epithelial cell apoptosis and fibroblast resistance to apoptosis are believed to contribute to the fibroproliferation that characterizes idiopathic pulmonary fibrosis (IPF). The mechanism underlying this imbalance in apoptosis is unknown.

What This Study Adds to the Field

The diminished capacity of patients with IPF to produce prostaglandin (PG)E2 results in increased sensitivity of alveolar epithelial cells to Fas ligand–induced apoptosis but induces fibroblast resistance to the same stimulus.

Idiopathic pulmonary fibrosis (IPF) is postulated to develop as a consequence of an aberrant wound healing response after recurrent alveolar injury (1, 2). Prostaglandin (PG)E2, the major prostanoid in the lung, is an important antifibrotic lipid mediator (35). PGE2 is found in reduced levels in the lungs of patients with IPF (6). This reduction, due to a failure of patients with IPF to up-regulate the expression of the key inducible enzyme in the PGE2 biosynthetic pathway cyclooxygenase (COX)-2, has been demonstrated to contribute to increased proliferation and collagen production by fibroblasts from IPF lung after transforming growth factor (TGF)-β stimulation when compared with control lung fibroblasts (4, 7). In the murine bleomycin model of pulmonary fibrosis, COX-2–deficient animals develop worse fibrosis than wild-type littermates (4, 8).

Apoptosis is important in the resolution phase of the normal wound healing response (9). In healthy peripheral human lung only sporadic cells undergo apoptosis. In IPF, however, widespread epithelial apoptosis is observed (1012). In contrast to epithelial cells, fibroblasts derived from IPF lung are more resistant to apoptosis than control lung fibroblasts (1316). A number of mechanisms have been proposed for this imbalance in fibroblast and epithelial cell apoptosis. Fibroblasts from IPF lungs induce alveolar epithelial cell (AEC) apoptosis in vitro, at least in part through the paracrine secretion of angiotensin II (17). Resistance of fibroblasts to apoptosis in IPF has been suggested to be due, in part, to altered responses to IL-6 (14). A number of other mediators, including TGF-β, tumor necrosis factor (TNF)-α, IL-1β and FIZZ1 (found in inflammatory zone) have been demonstrated to play a role in modulating either fibroblast or AEC apoptosis (1822). However, none of these mechanisms has been shown in humans to explain the increased epithelial cell but decreased fibroblast apoptosis observed in IPF.

Outside the lung, COX-2 and PGE2 play integral roles in regulating the apoptosis of both epithelial cells and fibroblasts. COX-2 overexpression plays an important part in the development of a range of epithelial-derived tumors through inhibition of epithelial apoptosis (23). In a murine model of radiation-induced gastric epithelial injury, exogenous PGE2 protects epithelial cells from apoptosis (24). In contrast, apoptosis of both human synovial fibroblasts and colonic fibroblasts is promoted by PGE2 (25, 26).

This study tested the hypothesis that the limited expression of COX-2 and PGE2 observed in patients with IPF contributes to both enhanced epithelial apoptosis and reduced fibroblast apoptosis. Our results demonstrate that PGE2 promotes AEC survival but sensitizes fibroblasts to Fas ligand (FasL)-induced apoptosis via a mechanism involving phosphorylation of Akt. Furthermore, we have shown that in patients with IPF, deficient PGE2 production results, at least in part, in increased AEC but reduced fibroblast apoptosis. Some of the data in this paper have previously been reported in abstract form (27, 28).

Patient Population

Fibrotic lung tissue was obtained at transplant surgery (n = 3, aged 52 ± 10.6 yr, two men, two IPF, one scleroderma fibrotic nonspecific interstitial pneumonia [29]) and from patients undergoing surgical lung biopsy (n = 6, aged 60.8 ± 20.0 yr, two men, six IPF). Control lung tissue was obtained from histologically normal areas of peripheral lung removed at lung cancer resection (n = 6, aged 52 ± 17.3 yr, three men). Additional samples of paraffin-embedded lung tissue were from the pathology archive of the Royal Brompton Hospital (10 IPF, aged 57.6 ± 3.6 yr and 6 control subjects, aged 58.2 ± 7.6 yr). All tissue was obtained with appropriate consent and its use approved by the relevant local research ethics committee.

Tissue Culture

Primary human lung fibroblasts were isolated as previously described (4). Type II AECs were isolated from lung tissue obtained at lung transplantation using the technique described by Thorley and colleagues (30). Additional experiments were performed using the A549 type II AEC cell line. Further information is provided in the online supplement.

Induction and Detection of Apoptosis

Fibroblasts and AECs were incubated as necessary with COX inhibitors or exogenous PGE2 for 16 hours before being exposed to FasL (Calbiochem, CA) (50 ng/ml for 24 h unless otherwise stated). Experimental agents were added at doses and times indicated in the figure legends and text, and are described in more detail in the online supplement. Apoptosis was detected by Annexin V/propidium iodide staining and analyzed by flow cytometry. Verification of results was performed by morphological assessment of cell nuclei as described by Uhal and colleagues (31). These methods are described in more detail in the online supplement.


Immunohistochemical staining was performed on formalin-fixed, paraffin-embedded sections of human lung tissue using the avidin-biotin antibody complexing method, as previously described (32).

Terminal Deoxynucleotidyl Transferase dUTP Nick End Labeling

Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining (Roche TUNEL kit; Roche Applied Science, Burgess Hill, UK) was performed on paraffin sections according to the manufacturer's instructions. Binding of labeled nucleotides was visualized with NBT/BCIP solution (Roche). Sections were counterstained with nuclear fast red.

PGE2 Quantification

PGE2 quantification was performed, according to manufacturer's instructions, using a Biotrak Enzymeimmunoassay (GE Healthcare, Amersham, UK).

Western Blotting

Sodium dodecyl sulfate polyacrylamide gel electrophoresis and Western blot were performed as previously described (8) with further detail in the online supplement.


Statistical analyses were performed using GraphPad Prism version 5.02 for Windows (GraphPad Software, San Diego, CA). Data for individual experiments are reported as mean ± SEM. Group data are presented as the median. Parametric data were tested using either a Student t test or analysis of variance with Tukey multiple comparison test. Nonparametric data were analyzed using a Mann-Whitney U test.

Apoptosis of Epithelial Cells but Not Fibroblasts Is Frequently Observed in IPF Lung Tissue

To assess apoptosis in vivo in IPF, paraffin-embedded sections of lung tissue were TUNEL stained and immunohistochemically stained for active caspase 3 and cleaved poly(ADP-ribose) polymerase (Figure 1). All three methods are considered to demonstrate cells that have terminally activated the apoptotic cascade and are in the process of undergoing apoptosis. In keeping with previous studies that have used either TUNEL or active caspase 3 staining (10, 11, 13) we found evidence, by all three methods, of frequent epithelial cell apoptosis. Epithelial apoptosis was seen most often in regions of hyperplastic epithelium, especially in areas overlying fibroblastic foci, and was also seen in bronchial epithelium and in areas of apparently normal alveolar epithelium. By contrast, fibroblast-like cells and cells within regions of fibrosis were rarely seen to be apoptotic. In normal lung sections apoptosis was very rarely seen, with there often being no apoptotic cells detectable across whole tissue sections (data not shown).

IPF Lung Fibroblasts Are Resistant to FasL-induced Apoptosis When Compared with Control Lung Fibroblasts

FasL, through binding of Fas (CD95), is a potent activator of the extrinsic apoptotic pathway. Both control and fibrotic lung fibroblasts have been demonstrated in vitro to express membrane-bound Fas (16). Preliminary experiments confirmed that human recombinant FasL induces apoptosis of primary human lung fibroblasts in a concentration- and time-dependent manner (see online data supplement for more detail). We and others have previously reported that fibroblasts from fibrotic lung are resistant to FasL-induced apoptosis when compared with fibroblasts from control lung (1416). To confirm this was the case for this current collection of primary fibroblast lines, we exposed cells to 50 ng/ml FasL for 24 hours and then measured apoptosis by annexin V/propidium iodide staining and fluorescence-activated cell sorter (FACS) analysis (Figure 2). Fibroblasts from six control patients and nine patients with pulmonary fibrosis were assessed. The median increase in FasL-induced apoptosis compared with untreated cells for fibrotic lung fibroblasts was more than fivefold lower than for control lung fibroblasts (P < 0.005).

COX-2 Inhibition Increases Control Lung Fibroblast Resistance to FasL-induced Apoptosis

To assess the role of COX-2 in modulating the apoptotic response of fibroblasts to FasL-induced apoptosis, control lung fibroblasts were incubated with the nonspecific COX-1/-2 inhibitor indomethacin (1μg/ml) or the selective COX-2 inhibitor NS398 (5 μg/ml) before exposure to FasL. Apoptosis was assessed morphologically by fluorescence microscopy after propidium iodide staining of fixed cells and by annexin V/propidium iodide staining and FACS analysis (Figure 3). COX-2 inhibition significantly increased control lung fibroblast resistance to FasL-induced apoptosis but did not affect apoptosis in the absence of FasL. When assessed morphologically in a representative control fibroblast line (Figures 3A–3C), apoptosis decreased from 55.3 ± 9.0% to 29.8 ± 9.35% in cells incubated with indomethacin (P < 0.001) and to 23.8 ± 3.2% for cells incubated with NS398 (P < 0.001 compared with control; nonsignificant compared with indomethacin). Five separate lines of primary control lung fibroblasts were tested by FACS analysis. For each of these lines, COX-2 inhibition with either indomethacin or NS398 increased resistance to FasL-induced apoptosis (Figure 3D). The median percentage change compared with control in FasL-induced apoptosis for the five lines was 63.8%; this decreased to 24.4% in the presence of indomethacin (P < 0.01 compared with control) and 31.8% with NS398 (P < 0.001 compared with control). There was no significant difference in FasL-induced apoptosis between indomethacin- and NS398-exposed fibroblasts.

PGE2 Increases the Sensitivity of Fibrotic Lung Fibroblasts to FasL-induced Apoptosis

Fibrotic fibroblasts, as noted, are resistant to FasL-induced apoptosis. As illustrated in data from a representative fibroblast cell line, COX-2 inhibition with either indomethacin or NS398 had no further effect on this resistance (Figure 4A). Administration of exogenous PGE2 at a dose of 10−7 M significantly increased the sensitivity of the same fibroblast line to FasL by approximately 2.5-fold (P < 0.001). Exogenous PGE2 had no significant effect on apoptosis in fibroblasts not exposed to FasL. Phase contrast microscopy of fibroblasts incubated with FasL demonstrated a reduction in cell number compared with untreated cells and clear morphological evidence of apoptosis (Figures 4B−4C). Many of the fibroblasts treated with FasL were shrunken or rounded up. Detached fibroblasts floating in the media were observed in the FasL-exposed but not the untreated control cells. Exogenous PGE2 in addition to FasL dramatically increased apoptosis, resulting in a clearly discernible increase in the number of both shrunken, rounded-up fibroblasts and of detached fibroblasts (Figure 4D). Overall, PGE2 increased the rate of FasL-induced apoptosis in each of six lines of fibrotic lung fibroblasts tested (Figure 4E). The fibroblasts from scleroderma lung did not differ from the IPF lung fibroblasts in either their resistance to apoptosis or their response to exogenous PGE2. The median rate of apoptosis for fibrotic lung fibroblasts exposed to FasL alone was 8.2%. This increased to 34.9% after PGE2 administration (P < 0.01). The PGE2-mediated increase in FasL-induced apoptosis in fibrotic lung fibroblasts, as measured in a representative cell line, was concentration dependent (Figure 5A). The rate of apoptosis increased from 52.7 ± 11.2% to 78.5 ± 19.9% after incubation with 10−7 M PGE2 (P < 0.05) and increased further to 102.0 ± 14.7% with 10−5 M PGE2 (P < 0.001). Fibrotic lung fibroblasts exposed to PGE2 without FasL did not show any increase in apoptosis even at the maximum PGE2 concentration tested of 10−5 M (Figure 5A). By contrast to fibrotic lung fibroblasts, fibroblasts from control lung showed no significant change in the rate of FasL-induced apoptosis at any of the concentrations of PGE2 tested (Figure 5B). However, when control fibroblast COX-2 was inhibited by pretreatment for 16 hours with indomethacin (1 μg/ml), exogenous PGE2 resulted in a concentration-dependent increase in FasL-induced apoptosis (Figure 5C).

FasL Induces Fibroblast PGE2 Production

PGE2 levels in media were measured after 24 hours of exposure of fibroblasts to FasL (50 ng/ml). Interestingly, FasL stimulated the production of PGE2 by fibroblasts. PGE2 levels in media from untreated control lung fibroblasts were 328.2 ± 83.68 pg/ml (n = 6) and this increased significantly to 1,256 ± 580.2 pg/ml after FasL (P < 0.0001). For fibrotic lung fibroblasts, untreated PGE2 levels were 143.4 ± 33.91 pg/ml (n = 9), and this also increased significantly after FasL to 271.8 ± 58.0 pg/ml (P < 0.01). The FasL-induced increase in PGE2 levels was significantly greater in control as compared with fibrotic lung fibroblasts (P < 0.05). As expected, COX-2 inhibition with either indomethacin or NS398 significantly reduced the levels of PGE2 detectable in cell culture media after FasL exposure. For control fibroblasts exposed to FasL, PGE2 levels after indomethacin were 69.0 ± 34.8 pg/ml (P < 0.0001 compared with FasL alone) and with NS398 levels were 260.7 ± 123.6 pg/ml (P < 0.0001). The corresponding PGE2 levels for fibrotic fibroblasts were: indomethacin 14.4 ± 8.1 pg/ml (P < 0.0001) and NS398 84.4 ± 22.7 (P < 0.001).

The Sensitivity of Fibroblasts to FasL-induced Apoptosis Correlates with Their Capacity to Induce COX-2 and Thus PGE2 Synthesis

In previous work we have shown that fibroblasts from control lung induce COX-2 expression and thus PGE2 synthesis in response to TGF-β stimulation (4). By contrast, fibrotic lung fibroblasts exhibit a reduced capacity to increase COX-2 expression in response to TGF-β. The capacity for individual fibroblast lines to induce PGE2 synthesis was assessed by measuring PGE2 concentrations in the culture media of cells exposed to 1 ng/ml of TGF-β in media containing 0.2% FCS for 24 hours. The sensitivity of fibroblasts to FasL-induced apoptosis, as determined by increase in apoptosis compared with untreated cells after FACs analysis of annexin V/propidium iodide–stained cells, was compared with baseline and TGF-β–stimulated levels of PGE2. There was no correlation between fibroblast apoptosis and basal PGE2 levels (Figure 5D). However, there was a marked positive correlation between TGF-β–induced PGE2 levels and FasL-induced fibroblast apoptosis (r2 = 0.5699, P = 0.0029) (Figure 5E). Fibroblast FasL-induced PGE2 levels correlated with TGF-β–induced induction of PGE2 expression (r2 = 0.34, P = 0.038). TGF-β–induced levels of PGE2 are presented in preference to FasL-induced levels of PGE2 as we believe that these more accurately represent the cells' capacity to produce PGE2. FasL-induced levels of PGE2 are likely to be less comparable between cell lines because of varying degrees of cell death and thus PGE2 production.

PGE2 Protects AECs from Fas-induced Apoptosis

Experiments to assess the role of COX-2 and PGE2 in modulating the apoptotic response of AECs to FasL were performed using the A549 immortalized human type II AEC cell line with verification of key findings performed in primary type II AECs isolated from fibrotic lung tissue. A549 cells were sensitive to FasL (Figure 6A) with apoptosis increasing by 69.9 ± 6.6% compared with media control (P < 0.01). COX-2 inhibition with either indomethacin or NS398 resulted in a significant increase in apoptosis in response to FasL when compared with FasL exposure alone (both P < 0.001). COX-2 inhibition in the absence of FasL had no effect on AEC apoptosis. Administration of PGE2 to A549 cells exposed to indomethacin and FasL resulted in a concentration-dependent reduction in apoptosis to levels observed with FasL alone (Figure 6B).

Primary type II AECs isolated from IPF lung were induced to undergo apoptosis by exposure to FasL (Figure 6C). Apoptosis was determined by annexin V/propidium iodide staining and FACS analysis. In contrast to fibroblasts derived from the same patient, type II AECs readily underwent FasL-induced apoptosis, with apoptosis increasing by 61.8 ± 3.2% compared with media control (P < 0.001). The addition of exogenous PGE2 partially protected the fibrotic lung AECs from FasL-induced apoptosis, reducing the rate of apoptosis by 29.2% compared with FasL treatment alone (P < 0.01).

A549 cells produced 118.5 ± 7.1 pg/ml PGE2 at baseline and 142.8 ± 13.1 pg/ml after FasL (P < 0.05 compared with baseline). Both indomethacin (48.29 ± 7.29 pg/ml, P < 0.001 compared with FasL alone) and NS398 (25.08 ± 1.34 pg/m, P < 0.001 compared with FasL alone) effectively inhibited PGE2 production by FasL-exposed A549 cells. Primary type II AECS produced 170.3 ± 29.3 pg/ml of PGE2 basally and 139.0 ± 13.9 pg/ml after FasL exposure (nonsignificant compared with basal levels). Because of the limited numbers of primary type II AECs available it was not possible to assess the effects of COX-2 inhibition on FasL-induced apoptosis.

COX-2/PGE2 Modulate the Phosphorylation of the Prosurvival Protein Kinase Akt

Akt (protein kinase B) is a serine/threonine kinase that plays a central role in regulating a variety of signal transduction pathways involved in cell proliferation and apoptosis. Activation of Akt occurs through phosphorylation, a process that may be triggered by a variety of growth factors. To assess the effect of PGE2 on Akt phosphorylation, control and fibrotic lung fibroblasts were serum starved overnight before incubation with either FasL alone or in combination with PGE2. A549 AECs were incubated with either FasL alone or in combination with indomethacin. Cells were lysed in RIPA buffer at time intervals between 30 minutes and 12 hours after FasL exposure. As determined by Western blotting, Akt is only partially phosphorylated in basal untreated control and fibrotic fibroblasts (Figures 7A and 7C). PGE2 almost totally abolishes Akt phosphorylation in both control and fibrotic lung fibroblasts (Figures 7B and 7C). In both control and fibrotic lung fibroblasts the degree of Akt phosphorylation increases dramatically within 30 minutes of exposure to FasL. PGE2, however, markedly attenuates FasL-induced phosphorylation of Akt. PGE2-induced attenuation of Akt phosphorylation was most prominent at 30 minutes and 1 hour after FasL treatment but persisted over the whole 12-hour time course. The magnitude of change in Akt phosphorylation after FasL exposure and thus the relative effect of PGE2 in inhibiting this phosphorylation was markedly higher in fibrotic as compared with control lung fibroblasts (Figure 7D). In keeping with the presented data on the effect of PGE2 on FasL-induced fibroblast apoptosis, levels of cleaved caspase 3 were higher in PGE2-exposed cells at both 6 and 12 hours after FasL treatment (Figure 7A). Western blotting for phosphorylated AKT (p-Akt) in A549 cells demonstrates that basal levels of p-Akt are high but gradually diminish at 1 through 12 hours after FasL exposure (Figure 7E). The level of p-Akt, however, returns to baseline in A549 cells by 24 hours after FasL exposure. The phosphorylation of Akt is not affected in A549s by COX-2 inhibition.

PGE2 Down-Regulates X-linked Inhibitor of Apoptosis Protein in Fibroblasts

X-linked inhibitor of apoptosis protein (XIAP) is the most potent apoptosis inhibitor in the inhibitor of apoptosis protein family. XIAP has been shown to be protected from breakdown by p-Akt–regulated phosphorylation (33). Both fibrotic and control lung fibroblasts express XIAP in the basal state (Figures 7A and 7C). After treatment with FasL, Western blotting for XIAP demonstrates that XIAP levels increase after 1 hour in fibroblasts exposed to FasL alone and that this increase is inhibited by the addition of PGE2. In keeping with this finding, immunohistochemistry for XIAP shows no staining in control lung tissue (Figure 7F) but marked staining in IPF, with predominant localization to fibroblasts within both fibroblastic foci and within regions of dense mature fibrosis (Figures 7G and 7H). Epithelium in IPF shows only limited staining for XIAP.

In normal wound healing, the restitution of epithelial integrity and the apoptosis of fibroblasts/myofibroblasts are important steps in the resolution of injury and the restoration of tissue structure and function (1, 34). In IPF, excess epithelial apoptosis combined with fibroblast resistance to apoptosis appears to be an important mechanism underlying the development of progressive fibrosis (11, 13, 14). Our data confirm the previously observed imbalance of increased epithelial but reduced fibroblast apoptosis in IPF. We have demonstrated that PGE2 has opposing effects on the sensitivity of primary lung fibroblasts and alveolar epithelial cells to FasL-induced apoptosis. In fibrotic lung fibroblasts, we have shown that PGE2 inhibits the phosphorylation of the prosurvival protein kinase Akt, suggesting that this is an important mechanism by which PGE2 exerts its proapoptotic effect on fibroblasts. Furthermore, we have demonstrated, using patient-derived primary cells, that the failure of patients with IPF to up-regulate COX-2 and thus PGE2 contributes to the observed paradox of reduced fibroblast apoptosis but increased AEC apoptosis in the lungs of patients with IPF.

PGE2 is a key antifibrotic mediator that plays an important role in wound resolution. Deficiency of PGE2 in the lungs of patients with IPF has important profibrotic consequences (4, 8). PGE2 has been shown outside the lung to play an important role in regulating the sensitivity of different cell types to apoptotic stimuli (23, 24). A recent study by Huang and colleagues demonstrates that PGE2 induces fibroblast apoptosis and enhances the fibrotic response of fibroblasts to a combination of FasL and cycloheximide (35). Using both murine lung fibroblasts and the fetal lung fibroblast line IMR-90, Huang and colleagues were able to show that PGE2 promotes apoptosis via a number of mechanisms, including decreased Akt phosphorylation, down-regulation of the prosurvival protein survivin, and up-regulation of Fas. Our observation that COX-2 inhibition increases the resistance of control lung fibroblasts to FasL-induced apoptosis and that exogenous PGE2 restores the sensitivity of fibrotic lung fibroblasts to FasL-induced apoptosis is consistent with these findings and with previous observations made in synovial and colonic fibroblasts (25, 26). The variability in sensitization of different fibrotic lung fibroblast lines to FasL after exposure to PGE2 is similar to the reported heterogeneous responses in fibroblast proliferation and collagen production induced by PGE2 (36). In keeping with our findings in A549 cells, PGE2 has previously been demonstrated to protect A549 cells from staurosporine-induced apoptosis (37). Our work is, as far as we are aware, novel in demonstrating that PGE2 is protective against FasL-induced apoptosis in primary type II AECs derived from IPF lung. Because isolating primary AECs requires the availability of a significant quantity of lung tissue we have been limited in the experiments we have been able to perform in primary fibrotic lung AECs.

Apoptosis plays a crucial role in normal tissue homeostasis and is an important mechanism by which the body clears infected or terminally damaged cells. Dysregulated apoptosis has been shown to play a role in the development of a range of diseases, including many tumors, systemic lupus erythematosus, and Alzheimer disease (38, 39). In mice, induction of extensive alveolar epithelial apoptosis is sufficient, in itself, to induce pulmonary fibrosis (40). Conversely, bleomycin-induced fibrosis can be attenuated in mice by the administration of caspase inhibitors (41). Evidence in humans that aberrant apoptosis, in the form of excess AEC but reduced fibroblast apoptosis, is important in the evolution of IPF is, although circumstantial, compelling (11, 13, 14). A wide range of mediators, including IL-6, angiotensin II, TNF-α, and IL-1β (14, 17, 20, 22), have been shown to modulate the apoptotic response of a number of cell types in the lung; however, we believe that we are the first to demonstrate a single mediator that has differing effects on fibroblast and AEC apoptosis in human fibrotic lung. Another mediator that might also have opposing effects on fibroblast and AEC apoptosis in IPF is the profibrotic cytokine TGF-β. Although not investigated in IPF, TGF-β has been shown to increase resistance to apoptosis in rat lung fibroblasts, in the human fetal fibroblast line IMR-90, and in alveolar mesenchymal cells isolated from patients with acute lung injury (21, 42, 43). TGF-β has also been shown to sensitize human bronchiolar epithelial cells to Fas-induced apoptosis (18). TGF-β is an important stimulus for the up-regulation of COX-2, and thus PGE2, by lung fibroblasts (4). Our data suggest that in the normal lung, after injury, PGE2 opposes the effects of TGF-β, thus promoting AEC resistance to apoptosis and favoring fibroblast/myofibroblast apoptosis and by so doing promoting wound resolution. In IPF the failure of patients to up-regulate COX-2, combined with increased levels of TGF-β, may be sufficient to drive the paradox of fibroblast resistance to apoptosis and excess AEC apoptosis.

Our work has thrown up a number of as-yet unanswered questions. Interestingly, we have shown that FasL stimulates the production of PGE2 by both control and fibrotic lung fibroblasts. This hitherto undescribed phenomenon may underlie the intrinsic differences in fibrotic and control lung fibroblast sensitivity to FasL-induced apoptosis. We have previously reported that fibrotic lung fibroblasts have a reduced capacity to up-regulate COX-2 and therefore PGE2 in response to TGF-β stimulation (4). Although we have found that fibrotic fibroblasts increase PGE2 release in response to FasL stimulation, the magnitude of increase is far less than that seen in control lung fibroblasts. Further to the observation of increased PGE2 synthesis after FasL exposure, our data show that the sensitivity of individual fibroblast cell lines to FasL-induced apoptosis correlates with the capacity of the individual lines to induce PGE2. It seems likely that this intrinsic difference in control and fibrotic lung fibroblasts explains our observation that fibrotic, but not control, lung fibroblasts showed a concentration-dependent increase in their sensitivity to FasL-induced apoptosis when exposed to exogenous PGE2. Similarly, in fibrotic lung fibroblasts, cells that exhibit a reduced capacity to induce COX-2, COX-2 inhibition had relatively little additional effect on PGE2 levels and also had no further effect on resistance to FasL-induced apoptosis. Interestingly, our data demonstrate that in both control and fibrotic lung fibroblasts, but not AECs, FasL acts as a trigger for the phosphorylation of the prosurvival kinase Akt. FasL stimulation of Fas has been previously reported to induce phosphorylation of Akt in murine epidermal cells (44).

The mechanisms by which FasL stimulates PGE2 production and induces Akt phosphorylation are unclear. Fas is part of the TNF superfamily of receptors and TNF-α is known to promote COX-2 up-regulation (45). It is increasingly being recognized that Fas mediates not only apoptosis but also diverse nonapoptotic functions, depending on the tissue and the conditions under which the receptor is expressed (46). Our observation that fibrotic lung fibroblasts are both resistant to apoptosis and produce less PGE2 in response to FasL than control fibroblasts suggests that alterations in both the apoptotic and nonapoptotic functions of Fas signaling are important in the pathogenesis of IPF.

Our data suggest that a mechanism by which PGE2 increases the sensitivity of fibrotic lung fibroblast to FasL-induced apoptosis is by inhibiting phosphorylation, and thus activation, of the prosurvival kinase Akt. In our experiments, FasL-induced phosphorylation of Akt was greater in fibrotic than control lung fibroblasts. Consequently, the inhibitory effect of PGE2 on Akt phosphorylation was magnified in fibrotic lung fibroblasts. Interestingly, in view of this observation, Xia and colleagues have recently shown that fibroblasts from fibrotic lung display aberrant activation of the phosphoinositide 3-kinase–Akt signal pathway when compared with control lung fibroblasts (47).

Because of the large amount of tissue required to isolate relatively few type II AECs from fibrotic lung, we have been limited in the number of experiments that we have been able to perform with these cells. We have therefore been unable to assess the effect of PGE2 on Akt phosphorylation in primary AECs. The A549 cell line is immortalized; it is likely that this has an impact on the activation of prosurvival pathways in these cells. This may therefore explain the failure of COX-2 inhibition to alter Akt phosphorylation in these cells. In gut epithelium, however, PGE2, acting on the EP2 and EP4 receptors, reduces radiation-induced apoptosis by increasing Akt phosphorylation (48). PGE2 may have additional beneficial effects on AECs beyond inhibiting apoptosis. In kidney epithelial cells PGE2 is a key inhibitor of epithelial to mesenchymal cell transition (EMT) (49). EMT has been shown to play an important pathogenetic role in the development of pulmonary fibrosis in mice (50). Further work is required to explore whether PGE2 prevents AECs transforming into fibroblasts via EMT.

In conclusion, we have demonstrated that, in addition to its previously described actions, PGE2 exerts an important antifibrotic effect by promoting the survival of AECs but increasing the sensitivity of fibroblasts/myofibroblasts to apoptosis. Furthermore, we provide evidence that in patients with IPF, deficiency of PGE2 is, at least in part, responsible for the observed paradox of increased epithelial but reduced fibroblast apoptosis. These findings further substantiate the notion that the consequence of reduced PGE2 in the lungs of patients with IPF is to perpetuate fibroproliferation (Figure 8). Our results provide further support for the idea that IPF arises as a result of an aberrant wound healing response in the lung that is characterized by an imbalance between pro- and antifibrotic mediators. Overall, our findings suggest that PGE2-mediated signaling pathways offer a potentially attractive target for therapeutic drug development in IPF.

1. Selman M, King TE, Pardo A. Idiopathic pulmonary fibrosis: prevailing and evolving hypotheses about its pathogenesis and implications for therapy. Ann Intern Med 2001;134:136–151.
2. Maher TM, Wells AU, Laurent GJ. Idiopathic pulmonary fibrosis: multiple causes and multiple mechanisms? Eur Respir J 2007;30:835–839.
3. McAnulty RJ, Hernandez-Rodriguez NA, Mutsaers SE, Coker RK, Laurent GJ. Indomethacin suppresses the anti-proliferative effects of transforming growth factor-beta isoforms on fibroblast cell cultures. Biochem J 1997;321:639–643.
4. Keerthisingam CB, Jenkins RG, Harrison NK, Hernandez-Rodriguez NA, Booth H, Laurent GJ, Hart SL, Foster ML, McAnulty RJ. Cyclooxygenase-2 deficiency results in a loss of the anti-proliferative response to transforming growth factor-beta in human fibrotic lung fibroblasts and promotes bleomycin-induced pulmonary fibrosis in mice. Am J Pathol 2001;158:1411–1422.
5. Kolodsick JE, Peters-Golden M, Larios J, Toews GB, Thannickal VJ, Moore BB. Prostaglandin E2 inhibits fibroblast to myofibroblast transition via E. prostanoid receptor 2 signaling and cyclic adenosine monophosphate elevation. Am J Respir Cell Mol Biol 2003;29:537–544.
6. Borok Z, Gillissen A, Buhl R, Hoyt RF, Hubbard RC, Ozaki T, Rennard SI, Crystal RG. Augmentation of functional prostaglandin E levels on the respiratory epithelial surface by aerosol administration of prostaglandin E. Am Rev Respir Dis 1991;144:1080–1084.
7. Wilborn J, Crofford LJ, Burdick MD, Kunkel SL, Strieter RM, Peters-Golden M. Cultured lung fibroblasts isolated from patients with idiopathic pulmonary fibrosis have a diminished capacity to synthesize prostaglandin E2 and to express cyclooxygenase-2. J Clin Invest 1995;95:1861–1868.
8. Hodges RJ, Jenkins RG, Wheeler-Jones CP, Copeman DM, Bottoms SE, Bellingan GJ, Nanthakumar CB, Laurent GJ, Hart SL, Foster ML, et al. Severity of lung injury in cyclooxygenase-2-deficient mice is dependent on reduced prostaglandin E(2) production. Am J Pathol 2004;165:1663–1676.
9. Desmouliere A, Badid C, Bochaton-Piallat ML, Gabbiani G. Apoptosis during wound healing, fibrocontractive diseases and vascular wall injury. Int J Biochem Cell Biol 1997;29:19–30.
10. Barbas-Filho JV, Ferreira MA, Sesso A, Kairalla RA, Carvalho CR, Capelozzi VL. Evidence of type II pneumocyte apoptosis in the pathogenesis of idiopathic pulmonary fibrosis (IFP)/usual interstitial pneumonia (UIP). J Clin Pathol 2001;54:132–138.
11. Uhal BD, Joshi I, Hughes WF, Ramos C, Pardo A, Selman M. Alveolar epithelial cell death adjacent to underlying myofibroblasts in advanced fibrotic human lung. Am J Physiol 1998;275:L1192–L1199.
12. Plataki M, Koutsopoulos AV, Darivianaki K, Delides G, Siafakas NM, Bouros D. Expression of apoptotic and antiapoptotic markers in epithelial cells in idiopathic pulmonary fibrosis. Chest 2005;127:266–274.
13. Lappi-Blanco E, Soini Y, Paakko P. Apoptotic activity is increased in the newly formed fibromyxoid connective tissue in bronchiolitis obliterans organizing pneumonia. Lung 1999;177:367–376.
14. Moodley YP, Misso NL, Scaffidi AK, Fogel-Petrovic M, McAnulty RJ, Laurent GJ, Thompson PJ, Knight DA. Inverse effects of interleukin-6 on apoptosis of fibroblasts from pulmonary fibrosis and normal lungs. Am J Respir Cell Mol Biol 2003;29:490–498.
15. Moodley YP, Caterina P, Scaffidi AK, Misso NL, Papadimitriou JM, McAnulty RJ, Laurent GJ, Thompson PJ, Knight DA. Comparison of the morphological and biochemical changes in normal human lung fibroblasts and fibroblasts derived from lungs of patients with idiopathic pulmonary fibrosis during FasL-induced apoptosis. J Pathol 2004;202:486–495.
16. Buhling F, Wille A, Rocken C, Wiesner O, Baier A, Meinecke I, Welte T, Pap T. Altered expression of membrane-bound and soluble CD95/Fas contributes to the resistance of fibrotic lung fibroblasts to FasL induced apoptosis. Respir Res 2005;6:37.
17. Wang R, Zagariya A, Ang E, Ibarra-Sunga O, Uhal BD. Fas-induced apoptosis of alveolar epithelial cells requires ANG II generation and receptor interaction. Am J Physiol 1999;277:L1245–L1250.
18. Hagimoto N, Kuwano K, Inoshima I, Yoshimi M, Nakamura N, Fujita M, Maeyama T, Hara N. TGF-beta 1 as an enhancer of Fas-mediated apoptosis of lung epithelial cells. J Immunol 2002;168:6470–6478.
19. Chung MJ, Liu T, Ullenbruch M, Phan SH. Antiapoptotic effect of found in inflammatory zone (FIZZ)1 on mouse lung fibroblasts. J Pathol 2007;212:180–187.
20. Frankel SK, Cosgrove GP, Cha SI, Cool CD, Wynes MW, Edelman BL, Brown KK, Riches DW. TNF-alpha sensitizes normal and fibrotic human lung fibroblasts to Fas-induced apoptosis. Am J Respir Cell Mol Biol 2006;34:293–304.
21. Zhang HY, Phan SH. Inhibition of myofibroblast apoptosis by transforming growth factor beta(1). Am J Respir Cell Mol Biol 1999;21:658–665.
22. Zhang HY, Gharaee-Kermani M, Phan SH. Regulation of lung fibroblast alpha-smooth muscle actin expression, contractile phenotype, and apoptosis by IL-1beta. J Immunol 1997;158:1392–1399.
23. Jabbour HN, Kelly RW, Boddy SC. Autocrine/paracrine regulation of apoptosis in epithelial cells by prostaglandin E2. Prostaglandins Leukot Essent Fatty Acids 2002;67:357–363.
24. Houchen CW, Sturmoski MA, Anant S, Breyer RM, Stenson WF. Prosurvival and antiapoptotic effects of PGE2 in radiation injury are mediated by EP2 receptor in intestine. Am J Physiol Gastrointest Liver Physiol 2003;284:G490–G498.
25. Jovanovic DV, Mineau F, Notoya K, Reboul P, Martel-Pelletier J, Pelletier JP. Nitric oxide induced cell death in human osteoarthritic synoviocytes is mediated by tyrosine kinase activation and hydrogen peroxide and/or superoxide formation. J Rheumatol 2002;29:2165–2175.
26. Kim H, Rhee SH, Pothoulakis C, Lamont JT. Inflammation and apoptosis in Clostridium difficile enteritis is mediated by PGE2 up-regulation of Fas ligand. Gastroenterology 2007;133:875–886.
27. Maher TM, Evans IC, Laurent GJ, McAnulty RJ. Loss of prostaglandin E2 induced inhibition of Akt phosphorylation contributes to fibroblast resistance to apoptosis in idiopathic pulmonary fibrosis (IPF) [abstract]. Am J Respir Crit Care Med 2009;179:A2702.
28. Maher TM, Evans IC, Laurent GJ, McAnulty RJ. Diminished cyclooxygenase-2 mediated PGE2 production in idiopathic pulmonary fibrosis fibroblasts contributes to resistance to apoptosis [abstract]. Am J Respir Crit Care Med 2008;177:A738.
29. Bouros D, Wells AU, Nicholson AG, Colby TV, Polychronopoulos V, Pantelidis P, Haslam PL, Vassilakis DA, Black CM, du Bois RM. Histopathologic subsets of fibrosing alveolitis in patients with systemic sclerosis and their relationship to outcome. Am J Respir Crit Care Med 2002;165:1581–1586.
30. Thorley AJ, Goldstraw P, Young A, Tetley TD. Primary human alveolar type II epithelial cell CCL20 (macrophage inflammatory protein-3alpha)-induced dendritic cell migration. Am J Respir Cell Mol Biol 2005;32:262–267.
31. Uhal BD, Joshi I, True AL, Mundle S, Raza A, Pardo A, Selman M. Fibroblasts isolated after fibrotic lung injury induce apoptosis of alveolar epithelial cells in vitro. Am J Physiol 1995;269:L819–L828.
32. Reinhardt AK, Bottoms SE, Laurent GJ, McAnulty RJ. Quantification of collagen and proteoglycan deposition in a murine model of airway remodelling. Respir Res 2005;6:30.
33. Dan HC, Sun M, Kaneko S, Feldman RI, Nicosia SV, Wang HG, Tsang BK, Cheng JQ. Akt phosphorylation and stabilization of X-linked inhibitor of apoptosis protein (XIAP). J Biol Chem 2004;279:5405–5412.
34. McAnulty RJ. Fibroblasts and myofibroblasts: their source, function and role in disease. Int J Biochem Cell Biol 2007;39:666–671.
35. Huang SK, White ES, Wettlaufer SH, Grifka H, Hogaboam CM, Thannickal VJ, Horowitz JC, Peters-Golden M. Prostaglandin E(2) induces fibroblast apoptosis by modulating multiple survival pathways. FASEB J 2009;23:4317–4326.
36. Huang S, Wettlaufer SH, Hogaboam C, Aronoff DM, Peters-Golden M. Prostaglandin E(2) inhibits collagen expression and proliferation in patient-derived normal lung fibroblasts via E prostanoid 2 receptor and cAMP signaling. Am J Physiol Lung Cell Mol Physiol 2007;292:L405–L413.
37. Schnitzer SE, Schmid T, Zhou J, Brune B. Hypoxia and HIF-1[alpha] protect A549 cells from drug-induced apoptosis. Cell Death Differ 2006;13:1611–1613.
38. Sigal LH. Basic science for the clinician 42: handling the corpses: apoptosis, necrosis, nucleosomes and (quite possibly) the immunopathogenesis of SLE. J Clin Rheumatol 2007;13:44–48.
39. Culmsee C, Landshamer S. Molecular insights into mechanisms of the cell death program: role in the progression of neurodegenerative disorders. Curr Alzheimer Res 2006;3:269–283.
40. Hagimoto N, Kuwano K, Miyazaki H, Kunitake R, Fujita M, Kawasaki M, Kaneko Y, Hara N. Induction of apoptosis and pulmonary fibrosis in mice in response to ligation of Fas antigen. Am J Respir Cell Mol Biol 1997;17:272–278.
41. Kuwano K, Kunitake R, Maeyama T, Hagimoto N, Kawasaki M, Matsuba T, Yoshimi M, Inoshima I, Yoshida K, Hara N. Attenuation of bleomycin-induced pneumopathy in mice by a caspase inhibitor. Am J Physiol Lung Cell Mol Physiol 2001;280:L316–L325.
42. Horowitz JC, Rogers DS, Sharma V, Vittal R, White ES, Cui Z, Thannickal VJ. Combinatorial activation of FAK and AKT by transforming growth factor-beta1 confers an anoikis-resistant phenotype to myofibroblasts. Cell Signal 2007;19:761–771.
43. Horowitz JC, Lee DY, Waghray M, Keshamouni VG, Thomas PE, Zhang H, Cui Z, Thannickal VJ. Activation of the pro-survival phosphatidylinositol 3-kinase/AKT pathway by transforming growth factor-beta1 in mesenchymal cells is mediated by p38 MAPK-dependent induction of an autocrine growth factor. J Biol Chem 2004;279:1359–1367.
44. Lu B, Wang L, Stehlik C, Medan D, Huang C, Hu S, Chen F, Shi X, Rojanasakul Y. Phosphatidylinositol 3-kinase/Akt positively regulates Fas (CD95)-mediated apoptosis in epidermal Cl41 cells. J Immunol 2006;176:6785–6793.
45. Chen CC, Sun YT, Chen JJ, Chiu KT. TNF-alpha-induced cyclooxygenase-2 expression in human lung epithelial cells: involvement of the phospholipase C-gamma 2, protein kinase C-alpha, tyrosine kinase, NF-kappa B-inducing kinase, and I-kappa B kinase 1/2 pathway. J Immunol 2000;165:2719–2728.
46. Peter ME, Budd RC, Desbarats J, Hedrick SM, Hueber AO, Newell MK, Owen LB, Pope RM, Tschopp J, Wajant H, et al. The CD95 receptor: apoptosis revisited. Cell 2007;129:447–450.
47. Xia H, Diebold D, Nho R, Perlman D, Kleidon J, Kahm J, Avdulov S, Peterson M, Nerva J, Bitterman P, et al. Pathological integrin signaling enhances proliferation of primary lung fibroblasts from patients with idiopathic pulmonary fibrosis. J Exp Med 2008;205:1659–1672.
48. Tessner TG, Muhale F, Riehl TE, Anant S, Stenson WF. Prostaglandin E2 reduces radiation-induced epithelial apoptosis through a mechanism involving AKT activation and bax translocation. J Clin Invest 2004;114:1676–1685.
49. Zhang A, Wang MH, Dong Z, Yang T. Prostaglandin E2 is a potent inhibitor of epithelial-to-mesenchymal transition: interaction with hepatocyte growth factor. Am J Physiol Renal Physiol 2006;291:F1323–F1331.
50. Kim KK, Kugler MC, Wolters PJ, Robillard L, Galvez MG, Brumwell AN, Sheppard D, Chapman HA. Alveolar epithelial cell mesenchymal transition develops in vivo during pulmonary fibrosis and is regulated by the extracellular matrix. Proc Natl Acad Sci USA 2006;103:13180–13185.
Correspondence and requests for reprints should be addressed to Robin J. McAnulty, Ph.D., Centre for Respiratory Research, University College London, Rayne Building, 5 University Street, London, WC1E 6JJ, UK. E-mail:


No related items
American Journal of Respiratory and Critical Care Medicine

Click to see any corrections or updates and to confirm this is the authentic version of record