Published ahead of print on July 10, 2003, doi:10.1165/rcmb.2003-0050OC
© 2004 American Thoracic Society DOI: 10.1165/rcmb.2003-0050OC Regulation of Proteoglycan Synthesis by Leukotriene D4 and Epidermal Growth Factor in Bronchial Smooth Muscle CellsThe Hope Heart Institute and Departments of Pathology and Medicine, Division of Allergy and Infectious Diseases, and School of Nursing, University of Washington, School of Medicine, Seattle, Washington Address correspondence to: Thomas N. Wight, Ph.D., Department of Vascular Biology, The Hope Heart Institute, 1124 Columbia Street, Seattle, WA 98104. E-mail: twight{at}hopeheart.org
Extracellular matrix (ECM) expansion contributes to airway remodeling in asthma. This study examines the effect of leukotriene D4 (LTD4), combined with epidermal growth factor (EGF), on proteoglycan synthesis by cultured human bronchial smooth muscle cells (BSMCs). LTD4 plus EGF stimulated proliferation of BSMCs with increased versican synthesis. Further, versican mRNA splice variants, V0 and V1, were differently regulated in BSMCs by LTD4 plus EGF. Synthesis of [35S]-methionine labeled versican V0, as a percentage of total versican, was doubled. This upregulation was confirmed by Western analysis. Synthetic changes were paralleled by alterations in versican V0 mRNA. The effects of LTD4 and EGF on proteoglycan synthesis were inhibited by montelukast. Similar upregulation of versican V0 was observed in arterial smooth muscle cells (ASMCs) stimulated with LTD4 plus EGF as measured by western and reverse transcriptasepolymerase chain reaction analyses. Changes in ECM in the asthmatic airway may parallel those in atherosclerotic lesions where proliferating ASMCs synthesize a versican-rich expanded ECM. Inhibition of these processes could lead to reduced tissue expansion in the early phases of asthma progression.
Abbreviations: arterial smooth muscle cell, ASMC bronchial smooth muscle cell, BSMC Dulbecco's modified Eagle's medium, DMEM extracellular matrix, ECM epidermal growth factor, EGF epidermal growth factor receptor, EGF-R fetal calf serum, FCS fibroblast growth factor, FGF leukotriene D4, LTD4 reverse transcriptasepolymerase chain reaction, RT-PCR sodium dodecyl sulfatepolyacrylamide gel electrophoresis, SDS-PAGE
Asthma is characterized by airway wall thickening and obstruction. Part of this thickening is due to airway smooth muscle hyperplasia and hypertrophy (1, 2) and part is due to deposits of connective tissue in the extracellular matrix (ECM) (312). Recent studies have shown an increase in lung proteoglycans and hyaluronan, two components of the ECM, in lung fibrosis (1316) and in mild forms of asthma (3, 12, 16, 17). Also, bronchial fibroblasts from patients with asthma synthesize increased amounts of proteoglycans (18), suggesting that the deposition of these molecules may be an early remodeling response. These events precede the deposition of collagens in later stages of fibrosis (8, 9). ECM enriched in proteoglycans tends to favor cellular proliferative responses, whereas ECM enriched in collagen tends to suppress proliferation (19). It may be that targeting processes that are involved in early matrix remodeling can prevent those processes involved in late fibrotic events. Epidermal growth factor (EGF) has been identified as a significant contributor to changes in the airway wall in asthma (20). EGF and the EGF receptor (EGF-R) have been found in bronchial smooth muscle cells (BSMCs) in the developing rat lung (21), and they are markedly increased in BSMCs in the asthmatic human airway (22). Leukotriene D4 (LTD4) and other leukotrienes are potent bronchoconstrictors that contribute significantly to acute and chronic components of asthma (23, 24), and these mediators have been shown to stimulate the proliferation of smooth muscle cells (2527). EGF alone stimulates the proliferation of cultured BSMC, and this stimulation is synergistically increased by the addition of LTD4 (28); however, the effects of LTD4 and EGF on ECM synthesis have not been examined. In other cell types, including arterial smooth muscle cells (ASMCs) and fibroblasts, proliferative stimuli cause qualitative and quantitative alterations in ECM composition (19). In addition, BSMCs cultured in atopic serum show increased deposition of ECM components (29). Our goal was to determine if the proliferative effects of EGF and LTD4 on BSMCs were correlated with changes in ECM synthesis. Increased expression and synthesis of versican concomitant with stimulation of proliferation in other cell types is well known (30, 31); however, a causal link between the two phenomena has not been proved. In this article we have characterized the major proteoglycans synthesized by cultured BSMCs and compared them to the well-characterized proteoglycans synthesized by ASMCs. These studies show that BSMCs synthesize the same major proteoglycans as ASMCs but in different relative amounts. In addition, we have studied the proliferation of BSMCs induced by LTD4 and EGF, and found that this event is temporally correlated with specific changes in the synthesis of isoforms of versican as well as other ECM components. Finally, we examined the effect of montelukast, an antagonist of CysLT1, an LTD4 receptor, (32) on these events and found that it partially inhibited the response of BSMCs to LTD4 plus EGF.
Cell Culture and Proteoglycan Isolation Human BSMCs were obtained from Clonetics (BioWhittaker, Walkersville, MD). Samples from each cell line were immunostained by Clonetics and found to be negative for Factor VIII, a marker for endothelial cells, and positive for -actin, a marker for smooth muscle cells. Because the phenotypes of smooth muscle cells and myofibroblasts are not distinct (33), the identification of these cells as smooth muscle also relies on their tissue source, the normal bronchial wall. The cells were maintained and grown in Clonetics proprietary medium (Smooth Muscle Cell Basal Medium) supplemented with 0.5 ng/ml human EGF, 5 µg/ml insulin, 2 ng/ml human fibroblast growth factor (FGF), 50 µg/ml Gentamicin, 50 ng/ml Amphotericin-B, and 5% fetal bovine serum (FBS). For experiments, cells were seeded at 6,300 cells per cm2 in 100-mm-diameter dishes or 15,000 cells per cm2 in 24-well tissue culture dishes and maintained in growth medium for 34 d until determined by visual inspection to be 8090% confluent. They were then cultured for another 48 h in growth arrest medium, which was basal medium with FBS reduced to 0.1% and no added EGF or FGF. Treatments, including controls, were then added in fresh growth arrest medium. Montelukast was added 10 min before the addition of LTD4 and EGF. Montelukast was a generous gift from Merck and Co. (Whitehouse Station, NJ). EGF was purchased from Sigma (St. Louis, MO) and LTD4 from Biomol (Plymouth Meeting, PA). To investigate the effect of EGF and LTD4 on proteoglycan synthesis by BSMC, we first determined the optimal concentrations for interaction of these two agents for stimulation of total proteoglycan synthesis (data not shown). These were 1 ng/ml EGF and 0.5 µM LTD4, and all of the subsequent experiments reported here were performed using these concentrations. Human ASMCs (a generous gift from Elaine Raines, Department of Pathology, University of Washington, Seattle, WA) were grown and maintained in Dulbecco's modified Eagle's medium (DMEM) with 10% FBS and growth-arrested in DMEM with 0.1% FBS (34). To obtain radiolabeled proteoglycans, cells were metabolically labeled with 100 µCi/ml Na2[35S]-sulfate or 40 µCi/ml [35S]-methionine. The medium was then combined with protease inhibitors (5 mM benzamidine, 100 mM 6-aminohexanoic acid, and 50 mM phenylmethylsulfonyl fluoride). The cell layer was rinsed with phosphate-buffered saline and solubilized in 8 M urea buffer (8M urea, 2 mM EDTA, 0.25 M NaCl, 50 mM Tris-HCl, and 0.5% Triton-X 100 detergent, pH 7.4) containing protease inhibitors (31, 35). Aliquots were taken for determination of total [35S]-sulfate incorporation into proteoglycans by cetylpryidinium chloride precipitation (36). Medium and cell layer extracts were concentrated and purified by ion exchange chromatography on diethylaminoethyl Sephacel in 8 M urea buffer and eluted with 8 M urea buffer containing 3 M NaCl (31, 35). Aliquots containing 30,000 dpm [35S]-sulfate or 100,000 dpm [35S]-methionine were precipitated in 80% ethanol and 1.3% potassium acetate before sodium dodecyl sulfatepolyacrylamide gel electrophoresis (SDS-PAGE) analysis and some were digested with 2.3 U/ml chondroitin ABC lyase (Sigma) in 300 mM TRIS-buffered solution (300 mM TRIS, 0.06 mg/ml bovine serum albumin, 18 mM sodium acetate, pH 8.0) for 3 h at 37°C (37). SDS-PAGE was performed using a 412% gradient resolving gel and a 3.5% stacking gel.
Northern Blot Analysis
Reverse TranscriptasePolymerase Chain Reaction Conditions for PCR amplification were optimized for MgCl2 concentration and temperature using the PTC-200 gradient thermal cycler (MJ Research, Waltham, MA). PCR reactions were performed using 12 µl single-strand synthesis product, 250 mM dNTP, 1x Amplitaq Gold Buffer, 5 pmol of each primer, 0.75 U Amplitaq Gold Enzyme (PE Biosystems, Foster City, CA), and 1.5 mM MgCl2 in a 20-µl reaction volume. After a 10-min initial enzyme activation step at 95°C for the Amplitaq Gold, denaturation was done for 1 min at 95°C, annealing at 61° for 1 min, and extension at 72°C for 50 s. Identical samples were taken out at different cycles to ensure linearity. Linearity was obtained at 35 and 37 cycles. For comparison of expression levels of the two different splice variants, PCR was performed on samples of reverse-transcribed RNA incubated in parallel under conditions resulting in a linear time course. They were then scanned and quantitated and expressed as a ratio of the two splice variant bands. A single band was obtained with each primer set.
Western Blotting
DNA Assay
To characterize proteoglycan expression, BSMCs and ASMCs were grown to confluence, arrested in low serum medium for 48 h, and total RNA was harvested for Northern blot analysis. BSMCs and ASMCs contain mRNA for the matrix molecules decorin, collagen type I, versican, and perlecan, but in different relative amounts. In BSMCs, decorin, and collagen type I transcripts accounted for a larger portion of the total mRNA than in ASMCs. ASMCs, on the other hand, contained relatively more mRNA for versican and perlecan (Figure 1). Little or no versican message was found in growth-arrested BSMCs. Longer exposure of autoradiograms from growth-arrested cells was required to reveal mRNA for versican in the BSMCs and for decorin in the ASMCs.
To characterize the proteoglycans synthesized by these cells, BSMCs and ASMCs were grown to confluence, arrested in low serum medium for 48 h, and labeled for another 24 h with [35S]-sulfate in fresh growth-arrest medium. Proteoglycans in the cell culture medium were isolated and purified by ion exchange chromatography and applied to SDS-PAGE. It was observed that BSMCs and ASMCs synthesized and secreted the same proteoglycans but in different relative amounts. Versican and decorin were identified in medium from BSMCs by analogy to previous SDS-PAGE analysis of ASMCs (46). The predominant proteoglycan in medium from BSMCs was decorin, whereas that found in ASMC medium was versican (Figure 2A). These differences are consistent with those found by mRNA analysis (Figure 1). The identities of versican and decorin in BSMC cultures were also confirmed by Western blot analysis (Figure 2B) (38, 39).
It has previously been shown that EGF and LTD4 stimulate [3H]-thymidine incorporation in BSMCs (28). We obtained similar results. To determine the time course of the proliferative response of BSMCs to LTD4 plus EGF, cells were grown to confluence, growth arrested, and stimulated with the combination of these two activators. DNA was harvested from parallel wells on each day from Days 04 after stimulation (Figure 3A). The maximum effect was observed on Day 3. Controls had grown 42% above Day 0, whereas EGF plus LTD4treated cells had grown 88% above the Day 0 level, or about twice as much as control (P 0.05). When the cells were grown to a greater, postconfluent density before addition of EGF and LTD4, they did not respond to these stimuli (not shown). Thus, cell density is clearly an important determinant of BSMC growth regulation by EGF and LTD4.
A study to determine the effect of montelukast on EGF plus LTD4stimulated proliferation of BSMCs demonstrated partial inhibition. To first determine appropriate concentrations of montelukast for these studies, growth-arrested cells were stimulated to proliferate by addition of 10% FBS with different added concentrations of montelukast. Cell growth was not altered by 100 nM montelukast, although it was reduced 20% by 500 nM montelukast (data not shown). It was therefore concluded that any effect of montelukast at 100 nM would be specific and mediated through the LTD4 receptor. Arrested BSMC were then grown in the presence of EGF and LTD4 with or without 100 nM montelukast and harvested for DNA analysis after 3 d in culture (Figure 3B). EGF alone stimulated proliferation above control, whereas LTD4 did not. EGF plus LTD4 stimulated proliferation more than EGF alone, and addition of montelukast produced a small reduction in the amount of DNA that was not statistically significant. To determine if stimulation by EGF and LTD4 had an effect on proteoglycan mRNA expression, growth-arrested BSMCs were cultured with EGF plus LTD4 and total RNA was harvested at 1, 2, and 3 d after stimulation. Maximal effects were observed at Day 3. Figure 4A shows representative Northern blots for ECM components on Day 3. Both control and LTD4 plus EGF media were made in fresh growth-arrest medium, which by itself provides some stimulation of proliferation (Figure 3A) and causes an increase in versican mRNA levels in comparison to growth-arrested cells (Figures 1 and 4A). In Figure 4B, mRNA for each day is expressed as a percent of control level for each matrix molecule. The average of two different experiments is presented. On Day 3, mRNA for versican V0 from EGF plus LTD4stimulated cells was increased to 1.90-fold control, and that for decorin was reduced to 0.38-fold control. Fibronectin transcripts increased to 1.29-fold control and collagen type I mRNA decreased to 0.57-fold control. Transcripts for versican V1, perlecan, and biglycan showed little change in comparison to control levels. In other experiments, versican V1 was slightly upregulated in comparison to controls, but not to the same extent as versican V0 (data not shown). As a result of the marked increase observed in V0 mRNA levels at Day 3, all further studies focused on versican expression and synthesis at this time point after stimulation with EGF and LTD4.
To examine the effect of LTD4 plus EGF on the synthesis and secretion of versican or decorin, growth-arrested BSMCs were cultured with the activators, labeled with [35S]-sulfate between 48 and 72 h thereafter, and proteoglycan production determined on SDS-PAGE. In EGF plus LTD4activated cells, [35S]-sulfate labeled versican, which includes versican V0 and versican V1, was increased (Figure 5A). Western analysis, using an antibody specific for the -GAG domain of versican V0, demonstrated a 46% increase in synthesis of versican V0 above control when determined on a per-volume basis (Figure 5B). In cells treated with EGF and LTD4, SDS-PAGE analysis showed that decorin synthesis was reduced when expressed as a percent of the total synthesized (by analysis with NIH Image) from 6252%. Although the synthesis of 35S-sulfatelabeled decorin was reduced as a percent of the total proteoglycans made, overall proteoglycan synthesis was increased. Moreover, the decorin band ran at a larger apparent molecular weight than the control, indicating that there may be longer glycosaminoglycan chains and hence more sulfation per decorin molecule. Previous studies in ASMC have shown increased glycosaminoglycan chain size to be responsible for such shifts in response to proliferative stimuli (35). Consequently, there was no net change in the 35S-sulfatelabeled decorin production on a per-cell basis.
Next, core protein synthesis was measured. Growth-arrested BSMCs were labeled with [35S]-methionine from 4872 h after stimulation with fresh growth-arrest medium with or without EGF and LTD4. The assumption was made that the specific activity of the methionine pool was identical in the two experimental conditions. Proteoglycans secreted into the culture medium were isolated by ion exchange, digested with chondroitin ABC lyase, and applied to SDS-PAGE (Figure 5C). Lanes were loaded with material from equal volumes of medium to demonstrate the net change in proteoglycan synthesis. Total [35S]-material was increased by 100% in the LTD4 plus EGFstimulated cells in comparison to the control. The increase in total synthesis was partially a consequence of an increase in cell number (Figure 3A). When normalized to cell number, the increase is 50% above control. Labeled material in cells treated only with montelukast was similar to that from controls; however, cells treated with LTD4, EGF, and montelukast contained an intermediate amount of material, indicating that montelukast partially inhibited the combined effect of the two activators. The lanes were scanned vertically with NIH Image software to quantify the relative synthesis of the two versican splice variants, versican V0 and versican V1, and decorin resulting from each treatment. [35S]-methioninelabeled decorin comprised 49% of the total label in the control cells but only 36% of the total in the LTD4 plus EGFstimulated cells (Figure 5C). This reduction in decorin core protein as a percent of the total labeled material is consistent with the reduction we observed in decorin mRNA from similarly treated cultures (Figure 4). On the other hand, there was no change in the amount of decorin core synthesis on a per-cell basis. Wells cultured with EGF, LTD4, and 100 or 500 nM montelukast contained 43 and 42% decorin, values intermediate between the control and stimulated values of 49 and 36%, respectively. Thus, montelukast partially inhibited the change in decorin synthesis as a percent of the total proteoglycans due to stimulation with EGF and LTD4. The relative intensity of versican V0 and versican V1 bands was also determined within each lane (Figure 5C). EGF and LTD4 altered synthesis of the proteoglycan core proteins, revealing differential regulation of the versican splice variants V0 and V1. Versican V0 as a percent of the total versican was 8.4% in the control cells and more than doubled at 20.3% in the LTD4 plus EGFstimulated cells. When normalized to cell number, V0 production was increased 180% above controls, whereas V1 was increased 50% above control cells. This preferential increase in versican V0 relative to versican V1 after stimulation with these activators is consistent with the changes observed in mRNA levels for those two splice variants (Figure 4). In cells treated with 100 and 500 nM montelukast, versican V0 comprised 12.1 and 10.0% of the total versican, whereas in cells treated with LTD4 plus EGF and 100 or 500 nM montelukast, it was 18.9 and 15.6% of the total versican, a level intermediate between control and activated cells.
Montelukast inhibits the increase in versican V0 core protein synthesis relative to versican V1 in a dose-dependent fashion. In these experiments, cells were treated as for Figure 5C. Arrested cells were stimulated with EGF plus LTD4, and different concentrations of montelukast from 0500 nM were added to the stimulated cells. [35S]-methionine was added after 48 h and the medium was collected at 72 h after stimulation. The ratio of versican V0 to versican V1, as revealed by SDS-PAGE, was more than doubled by treatment with EGF plus LTD4. No reduction was detected with the addition of 50 nM montelukast; 100 nM montelukast reduced the effect by
To determine if the selective upregulation of versican V0 in stimulated BSMCs was unique to those cells or if it is a more general phenomenon in smooth muscle cells, low serum arrested ASMCs were stimulated with LTD4 and EGF for 24 h and assayed for versican V0 mRNA and protein synthesis. Cell number did not change over 24 h, so that normalization of results to cell number was not necessary. Western analysis of medium proteoglycans demonstrated increased versican V0 synthesis in comparison to controls (Figure 6A). Total RNA was subjected to RT-PCR. This analysis showed that versican V0 mRNA was increased with respect to versican V1 mRNA, from a versican V0 to versican V1 ratio of 0.40 in unstimulated control cells to 0.72 in LTD4 and EGFtreated cells (P
Airway remodeling in chronic asthma may be viewed as a consequence of inflammation, resulting in release of cytokines and growth factors causing, in turn, activation of fibroblasts and smooth muscle cells in the vicinity of the injury. Activated smooth muscle cells can change into a proliferative and/or migratory state (47) with the elaboration of increased levels of matrix metalloproteinases, other proteases (48), and an altered complement of ECM molecules (49, 50). The presence of large amounts of versican in fibroproliferative lesions is a constant feature of all of the major fibrotic lung diseases and has been observed in fatal asthma (16). Also, the spatial association of versican with proliferating and migrating myofibroblasts in the diseased lung suggests a significant contribution of this molecule to the phenomenon of remodeling in chronic lung diseases (16). However, the regulation of BSMCs' expression and synthesis of versican splice variants in the lung has not been studied. Increased proliferation and versican V0 synthesis by BSMCs in response to EGF and LTD4, as we describe, are consistent with previous in vivo (16) and in vitro observations (28). To our knowledge, the preferential increase of the V0 splice variant, in comparison to V1, has not previously been shown. Our studies show increased synthesis of total proteoglycans and versican V0 by BSMCs in response to EGF and LTD4. Although versican V0 mRNA and protein synthesis were increased by the combined addition of LTD4 and EGF, versican V1 production showed little or no change. This differential regulation of the two splice variants was also found in ASMCs, suggesting that it occurs in various smooth muscle cell types. Variation of versican V0 and V1 expression with cell proliferation has also been observed in tissue from aortic aneurisms where downregulation of versican V0 in comparison to versican V1 has been found along with loss of ASMCs (51). In our studies of LTD4- and EGF-induced BSMC proliferation, 100 nM montelukast reduced the effect of these activators but did not reduce it to the effect of EGF alone. This is not surprising because the affinity of LTD4 for the LTD4 receptor, CysLT1, is greater than that of montelukast (IC50 = 0.91.0 nM versus 2.34.5nM [32]) and LTD4 was added in a 5-fold excess, on a molar basis, above the concentration of montelukast. In addition, CysLT2, LTD4 receptors, are present on BSMCs, and these receptors are not inhibited by montelukast (52). LTD4 plus EGF stimulation of proteoglycan synthesis was completely inhibited by 200 nM montelukast. The success of this inhibition may be partly due to the fact that montelukast was added to the cultures before addition of LTD4. mRNA for collagen type I was reduced and that for fibronectin was increased in BSMCs exposed to EGF and LTD4. Decorin expression was reduced as a percentage of the total proteoglycans at the protein and mRNA levels, suggesting that it is regulated differently from the other proteoglycans by EGF and LTD4. Co-regulation of decorin and collagen type I synthesis has been described in other cell systems (53) where decorin has been implicated in the regulation of size and abundance of collagen fibrils (54). In addition, conditions that stimulate proliferation of fibroblasts, epithelial cells, and endothelial cells induce downregulation of collagen type I synthesis and upregulation of fibronectin synthesis (55). In studies similar to ours with ASMCs, versican synthesis increased in response to proliferative stimuli, and it is also known that versican accumulates in atherosclerotic plaque where the population of ASMCs has increased (50). Consistent with these phenomena, our data show that changes in proteoglycan synthesis by BSMCs are temporally coordinated with increased levels of DNA. In addition, increased expression of glycosaminoglycan synthases in LTD4 and EGFactivated BSMCs is suggested by the greater apparent molecular weight of decorin made by these cells. This increase is also found in ASMCs, which have been stimulated to proliferate by platelet-derived growth factor (31).
Growth-arrested BSMCs and ASMCs express collagen type I and predominant proteoglycans versican and decorin but in different relative amounts, corresponding to differences in the ECM found in the airway wall and in the human aorta. Collagen type I and decorin are expressed at a higher level in BSMCs than in ASMCs and are major components in the normal airway wall and in lung fibrosis (3, 4, 79). Versican, the predominant proteoglycan found in ASMCs, is also highly expressed in normal arterial tissue and especially in atherosclerotic intima (49, 50). The molecular composition of proteoglycans secreted by BSMCs is similar to that found in fibroblast cultures (56) in that relatively less versican is produced than in ASMCs. This suggests that the BSMCs used in our study may be similar to myofibroblasts. Myofibroblasts have been shown to originate from both fibroblasts and smooth muscle cells and cannot be distinguished from smooth muscle cells by any exclusive set of characteristics (33). Therefore, the Cell migration and elaboration of ECM in atherosclerosis has been explained by the "Response to Injury" model, in which an early response includes ASMC migration, proliferation, and proteoglycan secretion. Versican and hyaluronan are major ECM components involved in vascular remodeling in atherosclerosis. These molecules have been shown to accompany cell proliferation and result in expansion of the extracellular space (58). The original function of this expansion may be the provision of a loose, hydrated matrix in which cells can migrate and divide. Collagen type I and decorin are usually coordinately regulated and their synthesis is inversely regulated with proliferation (19) as we have observed in these studies. Later stages of the atherosclerotic response can include deposition of collagen in this space to form a strong and antiproliferative matrix that is similar to that found in the fibrotic lung ECM (79). The proliferative, versican-synthesizing phase of BSMC activity may be chronically maintained in severe pulmonary fibrosis, where high levels of versican are found (13), whereas in asthma it may occur briefly after each asthmatic event, followed by a return to the normal, nonproliferating cell type that synthesizes primarily decorin and collagen components of the ECM. An understanding of the sequence of BSMC responses to activation by inflammatory agents will help to illuminate the asthmatic sequellae in vivo. Each asthmatic event could result in a small increase in the total number of BSMCs and amount of ECM. The greater tendency of BSMCs to synthesize an ECM rich in collagen and decorin and with less versican than ASMCs may explain the different consequence of chronic injury in the lung, where gradual fibrosis is predominant, and in the aorta, where accumulation of a proteoglycan-rich luminal ECM leads to accumulation of lipids and thrombus formation.
The authors thank the Merck Medical School Grant Program for financial assistance and Ellen Briggs for editing the manuscript. Received in original form February 11, 2003 Received in final form June 25, 2003
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