Phosphatidylserine is a global immunosuppressive signal in efferocytosis, infectious disease, and cancer.

Apoptosis is an evolutionarily conserved and tightly regulated cell death modality. It serves important roles in physiology by sculpting complex tissues during embryogenesis and by removing effete cells that have reached advanced age or whose genomes have been irreparably damaged. Apoptosis culminates in the rapid and decisive removal of cell corpses by efferocytosis, a term used to distinguish the engulfment of apoptotic cells from other phagocytic processes. Over the past decades, the molecular and cell biological events associated with efferocytosis have been rigorously studied, and many eat-me signals and receptors have been identified. The externalization of phosphatidylserine (PS) is arguably the most emblematic eat-me signal that is in turn bound by a large number of serum proteins and opsonins that facilitate efferocytosis. Under physiological conditions, externalized PS functions as a dominant and evolutionarily conserved immunosuppressive signal that promotes tolerance and prevents local and systemic immune activation. Pathologically, the innate immunosuppressive effect of externalized PS has been hijacked by numerous viruses, microorganisms, and parasites to facilitate infection, and in many cases, establish infection latency. PS is also profoundly dysregulated in the tumor microenvironment and antagonizes the development of tumor immunity. In this review, we discuss the biology of PS with respect to its role as a global immunosuppressive signal and how PS is exploited to drive diverse pathological processes such as infection and cancer. Finally, we outline the rationale that agents targeting PS could have significant value in cancer and infectious disease therapeutics.

Direct inhibition of phospholipid scrambling activity in erythrocytes by potassium ions.

The exposure of phosphatidylserine (PS) at the cell surface plays a critical role in blood coagulation and serves as a macrophage recognition moiety for the engulfment of apoptotic cells. Previous observations have shown that a high extracellular [K(+)] and selective K(+) channel blockers inhibit PS exposure in platelets and erythrocytes. Here we show that the rate of PS exposure in erythrocytes decreases by approximately 50% when the intracellular [K(+)] increases from 0 to physiological concentrations. Using resealed erythrocyte membranes, we further show that lipid scrambling is inducible by raising the intracellular [Ca(2+)] and that K(+) ions have a direct inhibitory effect on this process. Lipid scrambling in resealed ghosts occurs in the absence of cell shrinkage and microvesicle formation, processes that are generally attributed to Ca(2+)-induced lipid scrambling in intact erythrocytes. Thus, opening of Ca(2+)-sensitive K(+) channels causes loss of intracellular K(+) that results in reduced intrinsic inhibitory effect of these ions on scramblase activity.

Recruitment of beta-2-glycoprotein 1 to cell surfaces in extrinsic and intrinsic apoptosis.

Apoptotic cells and phagocytes have developed a diverse array of distinct ligand-receptor systems that drive the recognition and uptake of dying cells. Phagocytes recognize apoptotic cells either directly, by binding to specific ligands at their cell surface, or indirectly, by binding to bridging proteins that bind these ligands. Previous observations showed that the plasma bridging protein beta2GP1, binds PS containing vesicles, and enhances their binding and engulfment by phagocytes in vitro. In this study we show that apoptotic cells injected intravenously and intraperitonealy into syngeneic mice recruited the PS binding protein, beta2GP1. Examination of peritoneal exudates and spleen thin sections showed that only the injected apoptotic cells picked up endogenous beta2GP1. Recovery of cells from the peritoneum showed that apoptotic cells bearing beta2GP1 were clustered around host peritoneal phagocytes. In addition, tissue sections from mice injected with Fas antibody showed colocalization of beta2GP1 with TUNEL-positive apoptotic cells. These results provide evidence that endogenous beta2GP1 binds apoptotic cells in vivo, suggesting that the protein plays an important physiologic role in the recognition of dying cells.

Binding of annexin V to membrane products of lipid peroxidation.

There is increasing evidence that endogenously generated aldehydes formed as a result of lipid peroxidation are involved in the pathophysiological effects associated with oxidative stress in cells and tissues. Malondialdehyde (MDA), a major product of lipid peroxidation, can modify amines present on the cell surface and thereby introduce negative charges that can affect the interfacial ionic layer. We show that lipid peroxidation of RBC generates MDA adducts that, similar to phosphatidylserine (PS), bind annexin V in a Ca(2+)-dependent manner. Like PS, these adducts also promote the "PS-dependent" prothrombinase assays, albeit to lower levels. These results indicate that annexin V binding cannot be used as an exclusive indicator of cell surface PS and raise the possibility that some phenomenon attributed to PS may, in fact, also involve aldehyde-lipid adducts.

Modulation of the susceptibility of human erythrocytes to snake venom myotoxic phospholipases A(2): role of negatively charged phospholipids as potential membrane binding sites.

Cerrophidion (Bothrops) godmani myotoxins I (CGMT-I) and II (CGMT-II), Asp-49 and Lys-49 phospholipases A(2) (PLA2s), which drastically differ in enzymatic activity, were devoid of direct hemolytic effects on erythrocytes (RBC) from different species despite the fact that enzymatically active CGMT-I was able to hydrolyze RBC membrane phospholipids and disrupt liposomes prepared from RBC lipids. Human RBC did not become susceptible to the toxins after treatment with neuraminidase or after altering membrane fluidity with cholesterol or sublytic concentrations of detergent. Unlike normal RBC, significant hemolysis was induced by CGMT-II and another similar Lys-49 isoform, B. asper MT-II (BAMT-II), in RBC enriched with phosphatidylserine (PS). Hemolysis was greater in RBC preincubated with pyridyldithioethylamine (PDA), a potent inhibitor of aminophospholipid transport. RBC enriched with phosphatidic acid (PA) also became susceptible to the myotoxins but was unaffected by PDA. Cells enriched with phosphatidylcholine (PC) remained resistant to the action of the toxins. BAMT-II also induced damage in black lipid membranes prepared with PS but not PC alone. When RBC binding of BAMT-II was measured by enzyme-linked immunosorbent assay, it was observed that PS- and PA-enriched erythrocytes were always able to capture more toxin than normal and PC-enriched RBC. This effect was significantly improved by PDA (in the case of PS) and it was observed either in the presence or in the absence of calcium in the medium. These data suggest that negatively charged lipids in the outer leaflet of cell membranes constitute myotoxic PLA2 binding sites. The scarcity of anionic phospholipids in the outer leaflet of RBC could explain their resistance to the action of these PLA2s.

beta(2)-glycoprotein I-dependent alterations in membrane properties.

beta(2)-Glycoprotein I (beta(2)GP1), a 50 kDa serum glycoprotein, binds anionic phospholipids and plays a role in phosphatidylserine (PS)-dependent coagulation and apoptotic processes. To characterize the molecular consequences that occur to target membranes upon binding of beta(2)GP1, the interaction between beta(2)GP1 and PS-containing vesicles was investigated by fluorescent spectroscopy. Membranes containing pyrene-labeled lipid showed that binding of beta(2)GP1 induced a decrease in excimer/monomor ratios (E/M) of the target membrane. Although these membrane alterations occurred in isotonic buffer, the effects were greater in low ionic strength buffer and were coincident to membrane precipitation. In contrast, increases in membrane polarization were only seen in low ionic strength buffer. Analysis of beta(2)GP1 binding kinetics by resonance energy transfer between fluorescein-labeled beta(2)GP1 and rhodamine-containing PS vesicles revealed a two-component process: (1) a primary and rapid binding via the C-terminus that occurred <2 s in both isotonic and low ionic strength buffers, and (2) a sequential binding of the N-terminus that was approximately 100-fold slower in low ionic strength solution. Taken together, these data suggest that beta(2)GP1 alters the fluidity and membrane polarization of its target membrane, which in low ionic strength buffer is of sufficient magnitude to induce precipitation.

Phosphatidylserine expression on cell surfaces promotes antibody-dependent aggregation and thrombosis in beta2-glycoprotein I-immune mice.

Beta-2-glycoprotein I (beta2GP1) has been implicated as the primary antigenic target in antiphospholipid syndrome. To study the role beta2GP1 antibodies play in thrombosis associated with this syndrome, the clearance and binding of phosphatidylserine (PS)-containing target membranes were monitored in beta2GP1-immune mice. Clearance in immune mice (T(1/2)4.8 min) was faster than in normal mice (T(1/2)11.0 min). Analysis of PS vesicles recovered from immune mice by sequencing and Western blotting showed the presence of bound beta2GP1 and autologous antibody, respectively. Bleeding times in immune mice were approximately 30% shorter than in control mice. In vitro clotting times, however, were the same in both populations. To determine if the in vivo results could be attributed to the interaction of autoantibodies with the vascular endothelium, the binding of PS-containing target membranes to normal and apoptotic endothelial cells was studied. While endothelial cells bound PS vesicles, beta2GP1 reduced uptake by approximately 50% in both normal and apoptotic endothelium. In the presence of beta2GP1 antibodies, however, uptake in apoptotic cells, but not normal cells, increased by more than two-fold. These results suggest that thrombosis in antiphospholipid syndrome could, in part, be due to antibody-dependent cross-linking of beta2GP1 bound to PS-expressing cells and the vascular endothelium.

Phosphatidylserine externalization during differentiation-triggered apoptosis of erythroleukemic cells.

K562 erythroleukemia cells undergo apoptosis when induced to differentiate along the erythroid lineage with hemin. This event, characterized by DNA fragmentation, correlated with downregulation of the survival protein, BCL-xL, and decrease in mitochondrial transmembrane potential (deltapsi[m]) that ultimately resulted in cell death. Reorientation of phosphatidylserine (PS) from the cells inner-to-outer plasma membrane leaflet and inhibition of the aminophospholipid translocase was observed upon hemin-treatment. Constitutive expression of BCL-2 did not inhibit hemin-induced alterations in lipid asymmetry or decrease in deltapsi[m], and only moderately prevented DNA fragmentation. BCL-2, on the other hand, effectively inhibited actinomycin D-induced DNA fragmentation, the appearance of PS at the cells outer leaflet and the decrease in deltapsi[m]. The caspase inhibitor, z.VAD.fmk, blocked DNA fragmentation by both hemin and actinomycin D, but inhibited PS externalization only in the actinomycin D-treated cells. These results suggest that, unlike pharmacologically-induced apoptosis, PS externalization triggered by differentiation-induced apoptosis occurs by a mechanism that is associated with a decrease in deltapsi[m], but independent of BCL-2 and caspases.

Transbilayer movement of NBD-labeled phospholipids in red blood cell membranes: outward-directed transport by the multidrug resistance protein 1 (MRP1).

The outward movement (flop) of fluorescently labeled analogues of phosphatidylserine (PS) and phosphatidylcholine (PC) in human and murine red blood cells (RBC) was examined. 1-Oleoyl-2-[6(7-nitrobenz-2-oxa-1,3-diazol-4-yl)amino]caproyl (C6-NBD) analogues of PS and PC were incorporated in the inner leaflet of the plasma membrane through the action of aminophospholipid translocase or through equilibration upon prolonged incubation, respectively. After removal of noninternalized probe, externalization of C6-NBD-PS or C6-NBD-PC from the inner to outer leaflet was monitored by continuous incubation of the cells in the presence of bovine serum albumin. Flop rates for both probes in intact human RBC were virtually identical (t1/2 approximately 1.5 h), confirming earlier findings by Bitbol et al. [Bitbol, M., et al. (1988) Proc. Natl. Acad. Sci. U.S.A. 85, 6783-6787] and Connor et al. [Connor, J., et al. (1992) J. Biol. Chem. 267, 19412-19417]. Flop activity in resealed RBC ghosts could only be found upon coinclusion of both ATP and oxidized glutathione (GSSG). Furthermore, flop in intact cells was sensitive to verapamil (IC50 = 5-7 microM), vincristine (IC50 = 20 microM), and indomethacin (IC50 = 50 microM), suggesting the involvement of proteins conferring multidrug resistance (MDR). Experiments with RBC from knock-out mice for multidrug resistance P-glycoproteins (Mdr1a/1b-/- and Mdr2-/-) and multidrug resistance protein 1 (Mrp1-/-) revealed that Mrp1 is responsible for the observed flop of the fluorescent lipid analogues. We found no indications for outward transport of endogenous PS by any of these drug-transporting proteins as measured by a sensitive prothrombinase assay. Neither aminophospholipid translocase nor Ca2+-induced lipid scramblase activities were affected in RBC of these knock-out mice. We conclude that lipid floppase activity, as detected with lipid probes, reflects the activity of MRP1 recognizing the modified lipid analogues as xenobiotics to be expelled from the cell.

Estimation of plasma beta-2-glycoprotein levels by competitive ELISA.

Beta-2-glycoprotein I (beta2GPI), a 50-kDA serum glycoprotein that binds negatively charged phospholipids plays a role in coagulation, thrombosis, and the clearance of phosphatidylserine expressing cells. Because of its recently recognized role in several autoimmune responses, we have developed a method that quantifies plasma beta2GPI levels by using a competitive ELISA assay. When combined with data from a standard ELISA, this method determines the concentration of free beta2GPI and the fraction of antibody-bound beta2GPI thereby facilitating quantification of total antigen in individuals with autoimmune antibodies. Standard competitive inhibition ELISA was compared with this method, which uses known amounts of standard beta2GPI added to the plasma as an internal standard. Identical results were obtained with both methods for plasma samples from normal individuals that did not contain blocking antibodies. Analysis of plasma from antiphospholipid syndrome patients (patients with autoantibodies to beta2GPI) by the internal standard method, however, resulted in significantly lower apparent beta2GPI levels indicating that a substantial fraction of the plasma beta2GPI was bound by antibody.

Characterization of phosphatidylserine-dependent beta2-glycoprotein I macrophage interactions. Implications for apoptotic cell clearance by phagocytes.

The binding and uptake of phosphatidylserine (PS)-expressing cells appears to involve multiple receptor-mediated systems that recognize the lipid either directly or indirectly through intermediate proteins that form a molecular bridge between the cells. Here we show that beta2-glycoprotein I (beta2GPI), a 50-kDa serum glycoprotein, binds PS-containing vesicles and serves as an intermediate for the interaction of these vesicles with macrophages. Chemical modification of lysines and cysteines abolished beta2GPI-dependent PS uptake by inhibiting the binding of PS to beta2GPI and the binding of PS.beta2GPI complex to macrophages, respectively. Recognition was mediated by beta2GPI and not by the lipid because antibodies to beta2GPI inhibited binding of the complex to macrophages. These results indicate that human (THP-1-derived) macrophages bind beta2GPI only after it is bound to its lipid ligand. Competition experiments with monosaccharides that inhibit lectin-dependent interactions, and PS.beta2GPI binding experiments using deglycosylated beta2GPI, suggested that carbohydrate residues were not required for macrophage recognition of the complex. Antibodies to putative macrophage PS receptors (CD36, CD68, and CD14) did not inhibit uptake of the complex. These data suggest that beta2GPI can bind cells that fail to maintain membrane lipid asymmetry and generate a specific bridging moiety that is recognized for clearance by a phagocyte receptor that is distinct from CD36, CD68, and CD14.

Synthesis of disulfide-containing phospholipid analogs for the preparation of head group-specific lipid antigens: generation of phosphatidylserine antibodies.

In this report, we describe a new approach for the production of lipid antigens that elicit specific immune responses against phosphatidylserine (PS). Because phospholipids are small nonimmunogenic haptens, PS analogs containing activated coupling groups were synthesized and covalently attached to carrier proteins. Sulfhydryl-reactive PS was generated by acylation of 1-oleoyl-2-(aminocaproyl)-phosphatidylcholine with N-succinimidyl-3-(2-pyridyldithio) propionate, converted to PS by phospholipase D-catalyzed base exchange with L-serine, and conjugated to carrier proteins by thiol-disulfide exchange. Antisera to these lipid hapten-protein carrier conjugates were developed in rabbits. Antibodies bound PS but not phosphatidylcholine (PC), phosphatidylglycerol, phosphatidic acid, or phosphatidylethanolamine (PE) when presented together with PC. Inhibition studies using water-soluble lipid analogs and sonicated vesicles indicated that antibody specificity was directed toward the lipid's polar head group. These antibodies also inhibited the PS-dependent prothrombinase activity assay by approximately 60%. These data show that the covalent coupling of phospholipid haptens to protein carriers via the lipid's fatty acyl side chains preserves its primary head group moiety for the production of specific lipid antibodies.

Immune clearance of phosphatidylserine-expressing cells by phagocytes. The role of beta2-glycoprotein I in macrophage recognition.

The function of beta2-glycoprotein I (beta2GPI), a 50-kDa serum glycoprotein, is not completely understood but has been suggested to be involved in the regulation of thrombosis (Brighton, T. A., Hogg, P. J., Dai, Y.-P., Murray, B. H., Choing, B. H., and Chesterman, C. N. (1996) Br. J. Haematol. 93, 185-194) and the clearance of phosphatidylserine (PS)-expressing cells (Chonn, A., Semple S. C., and Cullis P. R. (1995) J. Biol. Chem. 270, 25845-25849). To further understand the role of this protein, we characterized the ability of beta2GPI to interact with PS vesicles and influence their uptake by macrophages in vitro. beta2GPI bound to and precipitated vesicles containing anionic but not zwitterionic phospholipids in a gel diffusion assay. beta2GPI also inhibited the procoagulant activity of PS liposomes. In vitro phagocytosis studies showed 20-fold greater uptake of PS liposomes over phosphatidylcholine liposomes. This enhanced uptake was maintained even after PS was "shielded" with beta2GPI and further increased upon the addition of beta2GPI antibodies. Similar to liposomes, PS-expressing apoptotic thymocytes and lipid symmetric red blood cell ghosts bound beta2GPI. Macrophage uptake of these cells was also maintained or enhanced in the presence of beta2GPI and further increased upon the addition of beta2GPI antibodies. It is concluded that beta2GPI can play a critical role in hemostasis by influencing both thrombosis and the clearance of PS-expressing cells.

Membrane phospholipid asymmetry: host response to the externalization of phosphatidylserine.

Membrane phospholipid asymmetry is an important regulator of cellular function and homeostasis. The activities of lipid transporters are contributing factors to the regulation of membrane lipid composition over the lifespan of the cell. Alterations in the activities of these proteins result in the movement of phosphatidylserine to the cell's outer leaflet. This promotes several physiologic responses including initiation of the coagulation cascade and cell recognition by the reticuloendothelial system.

Generation of phenotypically aged phosphatidylserine-expressing erythrocytes by dilauroylphosphatidylcholine-induced vesiculation.

In vitro stored red blood cells (RBC) and RBC artificially induced to vesiculate by incubation with dilauroylphosphatidyl-choline were monitored for age- and vesiculation-dependent changes in cell density, membrane lipid asymmetry, and their ability to be recognized and cleared by reticuloendothelial cells. RBC demonstrated a progressive increase in density on self-forming Percoll gradients upon vesiculation and in vitro "aging." Uptake of vesiculated RBC by in vitro cultivated macrophages was increased threefold over non-vesiculated control RBC. The clearance rate of dense vesiculated RBC was biphasic and contained a rapid component and a slower second component consistent with the clearance rates of normal control populations. Determination of phosphatidylserine (PS) in the outer leaflet of RBC by the PS-dependent prothrombinase assay revealed that PS redistributed to the cell's outer leaflet upon in vitro storage and vesiculation. Inhibition of PS movement by oxidation of membrane sulfhydryls with pyridyldithioethylamine resulted in higher prothrombinase levels and enhanced clearance of vesiculated RBC. These experiments suggest that vesiculation contributes to alterations in membrane lipid asymmetry and cell density characteristic of the aged RBC phenotype.

The complex of phosphatidylinositol 4,5-bisphosphate and calcium ions is not responsible for Ca2+-induced loss of phospholipid asymmetry in the human erythrocyte: a study in Scott syndrome, a disorder of calcium-induced phospholipid scrambling.

Elevation of cytoplasmic Ca2+ levels in human erythrocytes induces a progressive loss of membrane phospholipid asymmetry, a process that is impaired in erythrocytes from a patient with Scott syndrome. We show here that porcine erythrocytes are similarly incapable of Ca2+-induced redistribution of membrane phospholipids. Because a complex of phosphatidylinositol 4,5-bisphosphate (PIP2) and Ca2+ has been proposed as the mediator of enhanced transbilayer movement of lipids (J Biol Chem 269:6347,1994), these cell systems offer a unique opportunity for testing this mechanism. Analysis of both total PIP2 content and the metabolic-resistant pool of PIP2 that remains after incubation with Ca2+ ionophore showed no appreciable differences between normal and Scott erythrocytes. Moreover, porcine erythrocytes were found to have slightly higher levels of both total and metabolic-resistant PIP2 in comparison with normal human erythrocytes. Although loading of normal erythrocytes with exogenously added PIP2 gave rise to a Ca2+-induced increase in prothrombinase activity and apparent transbilayer movement of nitrobenzoxadiazolyl (NBD)-phospholipids, these PIP2-loaded cells were also found to undergo progressive Ca2+-dependent cell lysis, which seriously hampers interpretation of these data. Moreover, loading Scott cells with PIP2 did not abolish their impaired lipid scrambling, even in the presence of a Ca2+-ionophore. Finally, artificial lipid vesicles containing no PIP2 or 1 mole percent of PIP2 were indistinguishable with respect to transbilayer movement of NBD-phosphatidylcholine in the presence of Ca2+. Our findings suggest that Ca2+-induced redistribution of membrane phospholipids cannot simply be attributed to the steady-state concentration of PIP2, and imply that such lipid movement is regulated by other cellular processes.

Colocalization of Rh polypeptides and the aminophospholipid transporter in dilauroylphosphatidylcholine-induced erythrocyte vesicles.

Cytoskeleton-free vesicles released from human red blood cells (RBC) transport exogenously supplied aminophospholipid analogues from the vesicle's outer to inner leaflet at rates comparable to those of normal RBC (Beleznay et al. (1993) Biochemistry 32, 3146-3152). Because polypeptides associated with the Rh blood group system have been implicated in the transbilayer movement of phosphatidylserine (PS), we investigated the relationship and co-localization of the aminophospholipid translocase and Rh in dilauroylphosphatidylcholine-induced RBC vesicles. The transbilayer movement of fluorescent (NBD-PS) and photoactivatable (125I-N3-PS) PS in RBC vesicles was ATP-and temperature-dependent. Inhibition of PS transport by sulfhydryl reagents could be accomplished by direct vesicle treatment or by treating RBC before vesiculation. In the case of diamide- and pyridyldithioethylamine-mediated inhibition, NBD-PS transport could be restored by reduction with dithiothreitol, indicating that the movement of the PS transporter into the emerging vesicle was independent of the oxidative status of membrane sulfhydryls. The presence of Rh polypeptides in the vesicles was verified by direct immunoprecipitation of isotopically-labeled Rh and semi-quantified by antibody adsorption assays. Similar to the movement of the PS transporter, localization of Rh polypeptides in the vesicle membrane was independent of the red cell's oxidative status. These results show that the PS translocase and Rh-related proteins colocalize in RBC vesicles suggesting that these proteins may be members of a multicomponent complex that plays a role in lipid movement and the generation of membrane lipid asymmetry.

Exposure of phosphatidylserine in the outer leaflet of human red blood cells. Relationship to cell density, cell age, and clearance by mononuclear cells.

Human red blood cells (RBC) were separated by density on self-forming Percoll gradients into five distinct populations. The transbilayer movement and equilibrium distribution of 1-oleoyl-2-(N-(7-nitrobenz-2-oxa-1,3-diazol-4- yl)aminocaproyl)phosphatidylserine (NBD-PS) was slower in dense cells and equilibrated in the inner leaflet of these cells to a lesser degree than in light cells. Conversely, the outward movement of the lipid was slower in light cells. Assessment of endogenous PS in the cells' outer leaflet by the prothrombinase activity of externalized PS revealed an increase in its presence at the cell surface with increasing cell density. The presence of PS on the cell surface directly correlated with the propensity of the RBC to bound by autologous monocytes. To determine whether increased cell density is associated with increased cell age, the in vivo clearance of density-separated murine RBC was monitored in syngeneic mice. The T1/2 of circulation of light cells was about twice that of dense cells. The majority of the cleared cells localized in the spleen. Studies carried out in antibody-deficient SCID mice indicated that RBC were cleared via a mechanism that was independent of antibody. These data suggest that cell age is related to cell density and that cells of increasing age and density display higher amounts of PS in their outer leaflet.