PCSK9 单克隆抗体作用机制与临床研究进展

前蛋白转化酶枯草溶菌素9(PCSK9)是前蛋白转化酶家族成员之一,它通过与肝细胞表面低密度脂蛋白受体(LDLR)结合,使体内低密度脂蛋白水平升高,引发高血脂。PSCK9抑制剂可以达到降低血脂的临床效果并已经成为重要的减少冠心病发病率的药物靶点。尤其是单克隆抗体药物,作为目前唯一的具有降脂功能的单克隆抗体,在临床试验上的表现对于家族遗传性高血脂的治疗及冠心病的防治都具有重要意义。本文将主要对PCSK9的作用机制及其单克隆抗体的研发现状、临床试验进展进行总结,旨在对降脂单抗药物研发与临床应用作为参考。     

前蛋白转化酶枯草溶菌素9的生物学功能

前蛋白转化酶枯草溶菌素9(proprotein convertase subtilisin/kexin type 9,PCSK9)基因属于前蛋白转化酶(PC)家族,是一个新发现不久的与胆固醇代谢相关基因.近年来,PCSK9在其生物学效应及疾病中的作用越来越受到重视.大量的研究表明,除通过调节低密度脂蛋白受体(LDLR)影响胆固醇代谢外,PCSK9还参与细胞凋亡,促进肝发育、再生,促进神经系统发育,影响神经系统分化并且与炎症过程以及糖尿病相关.本文对PCSK9功能方面最新研究进展进行了综述。     

氧化低密度脂蛋白通过PCSK9/LRP1信号途径促神经细胞凋亡的双向调节

目的 阿尔茨海默病（Alzheimer’s disease, AD）是多种危险因素引起的中枢神经系统退行性疾病,其中神经细胞凋亡是其主要病理基础之一。高脂血症是AD发生的高危因素,可导致脑组织内氧化低密度脂蛋白（oxidized lowdensity lipoprotein,ox-LDL）水平增高。前蛋白转化酶枯草溶菌素9(proprotein convertase subtilisin kexin type 9,PCSK9)是一个与血脂代谢密切相关的蛋白酶,但有研究显示其与AD发生可能相关。本研究旨在探索PCSK9在介导ox-LDL促神经细胞凋亡中的作用及其机制,进一步阐述高脂血症导致AD等神经退行性疾病的发生机制。方法 首先用不同浓度ox-LDL(0、25、50、75、100 mg/L)处理PC12细胞24 h,油红O染色检测PC12细胞脂质蓄积,Hoechst33258染色和流式细胞术检测PC12细胞凋亡,ELISA检测PC12分泌的β淀粉样肽（amyloid β-peptide,Aβ）含量,蛋白质印迹（Western blot）法检测SREBP2、PCSK9和LRP1的表达。然...     

在真核细胞表达制备重组人前蛋白转化酶枯草溶菌素9

分别优化、合成和构建了在毕赤酵母和哺乳动物细胞表达人前蛋白转化酶枯草溶菌素9(proprotein convertase subtilisin/kexin type 9,PCSK9)的PCSK9-p PICZαA和PCSK9-pcDNA4.0重组质粒,将重组质粒转化至GS115细胞和转染至中国仓鼠卵巢(chinese hamster ovary,CHO)细胞,诱导细胞表达包含his标签的PCSK9重组蛋白。通过SDS-PAGE电泳和Western-blot分析两种系统表达重组蛋白的能力,发现GS115表达的重组蛋白相对分子质量大于人天然PCSK9蛋白且容易发生降解,而CHO细胞能够高表达与人天然PCSK9蛋白相对分子质量相同的、稳定的、易于纯化的特异重组蛋白。采用His/Ni2+亲和层析柱纯化重组蛋白,获得纯度达90%以上的PCSK9重组蛋白;用纯化的重组蛋白免疫小鼠制备了高效价特异性PCSK9多克隆抗体。所建立的CHO细胞表达体系PCSK9的平均表达量为5.6 mg/L,为开发PCSK9抑制剂和深入研究PCSK9分子结构和功能奠定了基础。     

神经细胞凋亡调节转化酶-1在LDL胆固醇代谢中的作用

人类枯草溶菌素转化酶9（PCSK9）编码神经细胞凋亡调节转化酶-1,是一个属于丝氨酸蛋白酶K亚类的独特前蛋白转化酶。它能切割非碱性氨基酸,其底物特异性不同于许多其它前蛋白转化酶。它的唯一已知底物为前体NARC-1。PCSK9基因有多种序列变异,如错义突变S127R和F216L可引起常染色体显性高胆固醇血症;无义突变Y142X、C679X及错义变异R46L均可降低LDL胆固醇和冠心病发病率。通过研究这些变异和野生型PCSK9,发现PCSK9参与肝再生和神经分化,调节胆固醇代谢、含apoB脂蛋白代谢,并在动脉粥样硬化、冠心病等心血管疾病的发生发展和防治中发挥重要作用。     

pcsk9基因突变与胆固醇血症

  常染色体显性高胆固醇血症（ADH）是家族早发性动脉粥样硬化的最主要的危险因素.在与ADH有关的基因突变中,LDL-R、apoB100基因突变导致ADH的机制已经比较明确,而pcsk9基因突变与ADH相关是最近发现的.pcsk9基因编码神经凋亡调节转化酶即NARC-1, 它通过在蛋白水平降低肝细胞上LDL受体的数量,使血液中LDL不能被清除,从而与高胆固醇血症相关联.研究pcsk9与LDL之间的关系,探索pcsk9在高胆固醇血症以及动脉粥样硬化发生中的作用及机制,将有助于高胆固醇血症和动脉粥样硬化发病机制的研究,也能为防治高胆固醇血症和动脉粥样硬化提供新思路.     

pcsk9 siRNA对oxLDL诱导的THP-1源性巨噬细胞凋亡的影响

为研究pcsk9基因沉默后对氧化型低密度脂蛋(oxLDL)诱导THP-1源性巨噬细胞凋亡的影响,用不同浓度oxLDL处理THP-1源性巨噬细胞48 h,Hoechst33258染色检测细胞凋亡,RT-PCR、Western blot分别检测pcsk9 mRNA、NARC-1蛋白的表达.应用Lipofectamine2000转染3对pcsk9 siRNAs进THP-1源性巨噬细胞中,筛选出最有效的siRNA再转染入THP-1源性巨噬细胞,24 h后加入oxLDL处理48 h,Hoechst33258染色观察细胞评价细胞凋亡,流式细胞术计数检测细胞凋亡率.结果发现,75 mg/L oxLDL处理THP-1源性巨噬细胞48 h后,Hoechst33258染色可见大量凋亡细胞.同时RT-PCR、Western blot检测发现,pcsk9 mRNA和NARC-1蛋白质表达量均随oxLDL浓度的增加而增加,75 mg/LoxLDL组增加最明显.不同浓度siRNA转染THP-1源性巨噬细胞后,RT-PCR筛选出3对siRNAs的终浓度为80 nmol/L均可出现明显的沉默效应.选取此浓度在蛋白质水平检测基因抑制情况,筛选出最有效的一对siRNA.将筛选出来的siRNA转染细胞24 h后,再用oxLDL处理48 h,Hoechst33258染色及流式细胞计数结果显示,转染siRNA组凋亡明显被抑制.结果表明,在本研究的浓度范围内,随着oxLDL浓度增加pcsk9的表达随之增加,同时,THP-1源性巨噬细胞凋亡也明显增加,75 mg/L oxLDL最明显,pcsk9 mRNA和蛋白质的表达也在该浓度最高.提示pcsk9 siRNA能有效抑制pcsk9基因的表达,从而有效抑制由oxLDL诱导的THP-1源性巨噬细胞的凋亡.     

pcsk9 siRNA对oxLDL诱导的THP-1源性巨噬细胞凋亡的影响

为研究pcsk9基因沉默后对氧化型低密度脂蛋白(oxLDL)诱导THP-1源性巨噬细胞凋亡的影响,用不同浓度oxLDL 处理THP-1源性巨噬细胞48 h,Hoechst33258染色检测细胞凋亡,RT-PCR、Western blot分别检测pcsk9 mRNA、NARC-1蛋白的表达．应用Lipofectamine2000转染3对pcsk9 siRNAs进THP-1源性巨噬细胞中,筛选出最有效的siRNA再转染入THP-1源性巨噬细胞,24 h后加入oxLDL处理 48 h,Hoechst33258染色观察细胞评价细胞凋亡,流式细胞术计数检测细胞凋亡率．结果发现,75 mg/L oxLDL处理THP-1源性巨噬细胞48 h后,Hoechst33258染色可见大量凋亡细胞．同时RT-PCR、Western blot检测发现,pcsk9 mRNA和NARC-1蛋白质表达量均随oxLDL浓度的增加而增加,75 mg/L oxLDL组增加最明显．不同浓度siRNA转染THP-1源性巨噬细胞后,RT-PCR筛选出3对siRNAs的终浓度为80 nmol/L均可出现明显的沉默效应．选取此浓度在蛋白质水平检测基因抑制情况,筛选出最有效的一对siRNA．将筛选出来的siRNA转染细胞24 h后,再用oxLDL处理48 h,Hoechst33258染色及流式细胞计数结果显示,转染siRNA组凋亡明显被抑制．结果表明,在本研究的浓度范围内,随着oxLDL浓度增加pcsk9的表达随之增加,同时,THP-1源性巨噬细胞凋亡也明显增加,75 mg/L oxLDL最明显,pcsk9 mRNA和蛋白质的表达也在该浓度最高．提示pcsk9 siRNA能有效抑制pcsk9基因的表达,从而有效抑制由oxLDL诱导的THP-1源性巨噬细胞的凋亡．     

PCSK9的靶向基因治疗

心血管疾病是全球非传染性疾病致死的主要原因。降低血液低密度脂蛋白胆固醇(low-density lipoprotein cholesterol, LDL-C)是预防和治疗动脉粥样硬化引起的冠状动脉疾病的主要手段。人类遗传学研究发现携带PCSK9功能缺失突变的个体血液LDL-C含量显著降低,对心血管疾病有明显的保护作用。这使得PCSK9成为基因编辑治疗以降低血液胆固醇的理想靶点。当前的研究证明在小鼠和非人灵长类动物中靶向敲除肝脏PCSK9可显著降低血液低密度脂蛋白胆固醇,展现该基因治疗策略的发展前景。该文介绍了PCSK9基因与心血管疾病的关系,并综述了基因组编辑技术的发展及其体内靶向PCSK9基因以降低LDL-C的研究进展。     

PCSK9结构与功能

前蛋白转化酶枯草溶菌素9（PCSK9）基因属于前蛋白转化酶（PC）家族,由信号肽、前结构域、催化结构域和羧基末端结构域组成.大量研究发现,PCSK9能介导低密度脂蛋白受体（LDLR）降解,调节血浆LDL胆固醇（LDL-C）水平;而PCSK9的两类主要突变,功能获得型、功能缺失型可分别导致高胆固醇血症和低胆固醇血症. 因而研究PCSK9对相关心血管疾病的防治有重要意义. PCSK9结构特性与其生化功能密切相关,突变致使其调节胆固醇代谢的机制更为复杂.本文旨在总结PCSK9结构与功能的分子生物学特性,并指出目前研究中存在的问题,以利对PCSK9的进一步探索.     

Secreted PCSK9 downregulates low density lipoprotein receptor through receptor-mediated endocytosis

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a protease that regulates low density lipoprotein receptor (LDLR) protein levels. The mechanisms of this action, however, remain to be defined. We show here that recombinant human PCSK9 expressed in HEK293 cells was readily secreted into the medium, with the prosegment associated with the C-terminal domain. Secreted PCSK9 mediated cell surface LDLR degradation in a concentration- and time-dependent manner when added to HEK293 cells. Accordingly, cellular LDL uptake was significantly reduced as well. When infused directly into C57B6 mice, purified human PCSK9 substantially reduced hepatic LDLR protein levels and resulted in increased plasma LDL cholesterol. When added to culture medium, fluorescently labeled PCSK9 was endocytosed and displayed endosomal-lysosomal intracellular localization in HepG2 cells, as was demonstrated by colocalization with DiI-LDL. PCSK9 endocytosis was mediated by LDLR as LDLR deficiency (hepatocytes from LDLR null mice), or RNA interference-mediated knockdown of LDLR markedly reduced PCSK9 endocytosis. In addition, RNA interference knockdown of the autosomal recessive hypercholesterolemia (ARH) gene product also significantly reduced PCSK9 endocytosis. Biochemical analysis revealed that the LDLR extracellular domain interacted directly with secreted PCSK9; thus, overexpression of the LDLR extracellular domain was able to attenuate the reduction of cell surface LDLR levels by secreted PCSK9. Together, these results reveal that secreted PCSK9 retains biological activity, is able to bind directly to the LDLR extracellular domain, and undergoes LDLR-ARH-mediated endocytosis, leading to accelerated intracellular degradation of the LDLR.     

Functional analysis of sites within PCSK9 responsible for hypercholesterolemia

Mutations within proprotein convertase subtilisin/kexin type 9 (PCSK9) are associated with dominant forms of familial hypercholesterolemia. PCSK9 binds the LDL receptor (LDLR), and addition of PCSK9 to cells promotes degradation of LDLR. PCSK9 mutant proteins associated with hypercholesterolemia (S127R and D374Y) are more potent in decreasing LDL uptake than is wild-type PCSK9. To better understand the mechanism by which mutations at the Ser127 and Asp374 residues of PCSK9 influence PCSK9 function, a limited vertical scanning mutagenesis was performed at both sites. S127R and S127K proteins were more potent in decreasing LDL uptake than was wild-type PCSK9, and each D374 mutant tested was more potent in reducing LDL uptake when the proteins were added exogenously to cells. The potencies of D374 mutants in lowering LDL uptake correlated with their ability to interact with LDLR in vitro. Combining S127R and D374Y was also found to have an additive effect in enhancing PCSK9's ability to reduce LDL uptake. Modeling of PCSK9 S127 and D374 mutations indicates that mutations that enhance PCSK9 function stabilize or destabilize the protein, respectively. In conclusion, these results suggest a model in which mutations at Ser127 and Asp374 residues modulate PCSK9's ability to regulate LDLR function through distinct mechanisms.     

Plasma Membrane Tetraspanin CD81 Complexes with Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) and Low Density Lipoprotein Receptor (LDLR), and Its Levels Are Reduced by PCSK9

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is an important factor in plasma cholesterol regulation through modulation of low density lipoprotein receptor (LDLR) levels. Naturally occurring mutations can lead to hyper- or hypocholesterolemia in human. Recently, we reported that PCSK9 was also able to modulate CD81 in Huh7 cells. In the present study, several gain-of-function and loss-of-function mutants as well as engineered mutants of PCSK9 were compared for their ability to modulate the cell surface expression of LDLR and CD81. Although PCSK9 gain-of-function D374Y enhanced the degradation both receptors, D374H and D129N seemed to only reduce LDLR levels. In contrast, mutations in the C-terminal hinge-cysteine-histidine-rich domain segment primarily affected the PCSK9-induced CD81 degradation. Furthermore, when C-terminally fused to an ACE2 transmembrane anchor, the secretory N-terminal catalytic or hinge-cysteine-histidine-rich domain domains of PCSK9 were able to reduce CD81 and LDLR levels. These data confirm that PCSK9 reduces CD81 levels via an intracellular pathway as reported for LDLR. Using immunocytochemistry, a proximity ligation assay, and co-immunoprecipitation, we found that the cell surface level of PCSK9 was enhanced upon overexpression of CD81 and that both PCSK9 and LDLR interact with this tetraspanin protein. Interestingly, using CHO-A7 cells lacking LDLR expression, we revealed that LDLR was not required for the degradation of CD81 by PCSK9, but its presence strengthened the PCSK9 effect.     

A small molecule inhibitor of PCSK9 that antagonizes LDL receptor binding via interaction with a cryptic PCSK9 binding groove

Proprotein convertase (PC) subtilisin kexin type 9 (PCSK9) inhibits the clearance of low density lipoprotein (LDL) cholesterol from plasma by directly interacting with the LDL receptor (LDLR). As the interaction promotes elevated plasma LDL cholesterol levels and a predisposition to cardiovascular disease (CVD), it has attracted much interest as a therapeutic target. While anti-PCSK9 monoclonal antibodies have been successful in the treatment of hypercholesteremia by decreasing CVD risk, their high cost and a requirement for injection have prohibited widespread use. The advent of an orally bioavailable small molecule inhibitor of the PCSK9-LDLR interaction is an attractive alternative, however efforts have been tempered as the binding interface is unfavourable for binding by small organic molecules. Despite its challenging nature, we report herein the discovery of compound 3f as a small molecule inhibitor of PCSK9. The kinase inhibitor nilotinib emerged from a computational screen that was applied to identify compounds that may bind to a cryptic groove within PCSK9 and proximal to the LDLR-binding interface. A subsequent in vitro PCSK9-LDLR binding assay established that nilotinib was a bona fide but modest inhibitor of the interaction (IC₅₀ = 9.8 µM). Through multiple rounds of medicinal chemistry, 3f emerged as a lead-like molecule by demonstrating disruption of the PCSK9-LDLR interaction at nanomolar levels in vitro (IC₅₀ = 537 nM) with no inhibitory activity (IC₅₀ > 10 µM) against a small panel of kinases. Compound 3f restored LDL uptake by liver cells at sub-micromolar levels and demonstrated excellent bioavailability when delivered subcutaneously in mice. Most significantly, compound 3f lowered total cholesterol levels in the plasma of wild-type mice, thereby providing proof-of-concept that the notion of a small molecule inhibitor against PCSK9 is therapeutically viable.     

PCSK9 inhibition fails to alter hepatic LDLR,circulating cholesterol,and atherosclerosis in the absence of ApoE

LDL cholesterol (LDL-C) contributes to coronary heart disease. Proprotein convertase subtilisin/kexin type 9 (PCSK9) increases LDL-C by inhibiting LDL-C clearance. The therapeutic potential for PCSK9 inhibitors is highlighted by the fact that PCSK9 loss-of-function carriers exhibit 15–30% lower circulating LDL-C and a disproportionately lower risk (47–88%) of experiencing a cardiovascular event. Here, we utilized pcsk9^−/− mice and an anti-PCSK9 antibody to study the role of the LDL receptor (LDLR) and ApoE in PCSK9-mediated regulation of plasma cholesterol and atherosclerotic lesion development. We found that circulating cholesterol and atherosclerotic lesions were minimally modified in pcsk9^−/− mice on either an LDLR- or ApoE-deficient background. Acute administration of an anti-PCSK9 antibody did not reduce circulating cholesterol in an ApoE-deficient background, but did reduce circulating cholesterol (−45%) and TGs (−36%) in APOE*3Leiden.cholesteryl ester transfer protein (CETP) mice, which contain mouse ApoE, human mutant APOE3*Leiden, and a functional LDLR. Chronic anti-PCSK9 antibody treatment in APOE*3Leiden.CETP mice resulted in a significant reduction in atherosclerotic lesion area (−91%) and reduced lesion complexity. Taken together, these results indicate that both LDLR and ApoE are required for PCSK9 inhibitor-mediated reductions in atherosclerosis, as both are needed to increase hepatic LDLR expression.     

Plasma PCSK9 preferentially reduces liver LDL receptors in mice

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a secreted protein that regulates the expression of LDL receptor (LDLR) protein. Gain-of-function mutations in PCSK9 cause hypercholesterolemia, and loss-of-function mutations result in lower plasma LDL-cholesterol. Here, we investigate the kinetics and metabolism of circulating PCSK9 relative to tissue levels of LDLRs. The administration of recombinant human PCSK9 (32 microg) to mice by a single injection reduced hepatic LDLRs by approximately 90% within 60 min, and the receptor levels returned to normal within 6 h. The half-life of the PCSK9 was estimated to be approximately 5 min. Continuous infusion of PCSK9 (32 microg/h) into wild-type mice caused a approximately 90% reduction in hepatic LDLRs within 2 h and no associated change in the level of LDLR in the adrenals. Parallel studies were performed using a catalytically inactive form of PCSK9, PCSK9(S386A), and similar results were obtained. Infusion of PCSK9(D374Y), a gain-of-function mutation, resulted in accelerated clearance of the mutant PCSK9 and a greater reduction in hepatic LDLRs. Combined, these data suggest that exogenously administrated PCSK9 in plasma preferentially reduces LDLR protein levels in liver at concentrations found in human plasma and that PCSK9's action on the LDLR is not dependent on catalytic activity in vivo.     

Berberrubine and its analog,hydroxypropyl-berberrubine,regulate LDLR and PCSK9 expression via the ERK signal pathway to exert cholesterol-lowering effects in human hepatoma HepG2 cells

Berberine (BBR), the major isoquinoline alkaloid in Chinese herb Rhizoma coptidis, has significant lipid-lowering effect by upregulating hepatic low-density lipoprotein receptor (LDLR) expression. In a previous study, we have indicated that berberrubine (M3), a major metabolite of BBR in vivo, displays the most potential hypolipidemic effects via upregulating LDLR expression in human hepatoma (HepG2) cells compared with BBR and 3 other metabolites. Accordingly, 9 M3 analogs (A1-A9) were modified at the C9 position. We aimed to find a new promising agent by evaluating the cholesterol-lowering effect and clarifying the related molecular mechanism. In the current study, the cellular cholesterol content was assayed with a commercial cholesterol assay kit. Real-time polymerase chain reaction and Western blot assay were used to explore the molecular mechanism of M3 and its analogs on the hypolipidemic effect. Among M3 and its analogs, hydroxypropyl-berberrubine (A8) exhibited the highest potential effects on the upregulation of LDLR expression, which was accompanied by a steady decline of proprotein convertase subtilisin/kexin type 9 (PCSK9) messenger RNA and protein levels. Furthermore, inhibition of extracellular signal-regulated kinase (ERK) activity with PD98059 prevented the upregulation of LDLR and downregulation of PCSK9 induced by A8. The current study revealed that M3 and its structurally modified analog, A8, could regulate hepatic LDLR and PCSK9 expression to exert lipid-lowering effects via the ERK signal pathway, while A8 showed a stronger effect and might be a promising drug candidate against hyperlipidemia.     

Function and distribution of circulating human PCSK9 expressed extrahepatically in transgenic mice

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is predominantly expressed in liver and regulates cholesterol metabolism by down regulating liver LDL receptor (LDLR) proteins. Here we report transgenic overexpression of human PCSK9 in kidney increased plasma levels of PCSK9 and subsequently led to a dramatic reduction in liver LDLR proteins. The regulation of LDLR by PCSK9 displayed tissue specificity, with liver being the most responsive tissue. Even though the PCSK9 transgene was highly expressed in kidney, LDLR proteins were suppressed to a lower extent in this tissue than in liver. Adrenal LDLR proteins were not regulated by elevated plasma PCSK9. hPCSK9 transgene expression and subsequent reduction of liver LDLR led to increases in plasma total cholesterol, LDL cholesterol, and ApoB, which were further increased by a high-fat, high-cholesterol diet. We also observed that the size distribution of hPCSK9 in transgenic mouse plasma was heterogeneous. In chow-fed mice, the majority of PCSK9 proteins were in free forms; however, feeding a high-fat, high-cholesterol diet resulted in a shift of hPCSK9 distribution toward larger complexes. PCSK9 distribution in human plasma also exhibited heterogeneity and individual variability in the percentage of PCSK9 in free form and in large complexes. We provide strong evidence to support that human PCSK9 proteins secreted from extrahepatic tissue are able to promote LDLR degradation in liver and increase plasma LDL. Our data also suggest that LDLR protein regulation by PCSK9 has tissue specificity, with liver being the most responsive tissue.