Review TRENDS in Cell Biology
2 February 2004
Autophagy: in sickness and in health
Ana Maria Cuervo
Department of Anatomy and Structural Biology, Marion Bessin Liver Research Center, Albert Einstein College of Medicine,
1300 Morris Park Avenue, Ullmann B. 614, Bronx, NY 10461, USA
The degradation of intracellular components in lyso-
somes (autophagy) has recaptured the attention of cell
biologists in recent years. The main reason for this
renewed interest is the dissection of the molecular
machinery that participates in this process, because the
identification of new intracellular elements involved in
autophagy has provided new tools to trace, quantify
and manipulate autophagy in a growing number of
organisms. As a result, a better understanding of the
physiological roles of autophagy, the consequences of
its malfunctioning and its participation in different
pathological processes has emerged. This article
reviews our current knowledge of the role of autophagy
in disease and the efforts to reconcile its proposed dual
function as both a cell protector and a cell killer.
Autophagy (self-eating) is the generic name used for any
intracellular process that results in the degradation of
cytosolic components inside lysosomes. The outcome of
autophagy is always the same – a complete and irrevers-
ible dissociation of the substrate into its essential con-
stituents (e.g. proteins into amino acids or nucleic acids
into nucleotides) by lysosomal enzymes. Although there
are evolutionary variations in the mechanisms by which
substrates are delivered to lysosomes, autophagy itself is a
well-conserved process [1– 4].
The best understood role of autophagy is cellular
housekeeping, a function that extends beyond the simple
removal of damaged or unwanted products [1 – 5]. In fact,
along with other proteolytic systems, lysosomes partici-
pate in the continuous turnover of intracellular constitu-
ents. Not only soluble cytosolic proteins but also
organelles, such as mitochondria and peroxisomes, or
parts of organelles, such as regions of Golgi and endo-
plasmic reticulum and even, as recently shown in yeast,
selective areas of the nucleus, can be removed by
autophagy [6– 8].
In addition to maintaining cellular homeostasis, there
is growing evidence for the participation of autophagy in
processes such as cellular differentiation, tissue remodel-
ing, growth control, cell defense and adaptation to adverse
environments [9– 12]. As research in this field expands,
this list grows accordingly. For example, under specific
conditions in yeast, autophagy can deliver into the vacuole
(equivalent of a lysosome) both the substrates and the
enzymes required for their degradation, replacing the
cytoplasm to vacuole targeting pathway (CVT) [2]. Further
Corresponding author: Ana Maria Cuervo (amcuervo@aecom.yu.edu).
www.sciencedirect.com 0962-8924/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.tcb.2003.12.002
Vol.14 No.
studies will determine whether a similar function is also
present in mammals.
Because the emphasis of this review is on the role of
autophagy in human disease, most of the work discussed
refers to mammalian systems. However, recent advances in
the molecular dissection of autophagy originate from studies
in other species – predominantly yeast but also flies, worms
and protozoa. Readers are encouraged to find out about these
exciting data in more focused reviews [4,13–15].
The different flavors of autophagy
Based on the ways substrates reach the lysosomal lumen,
three major forms of autophagy have been described in
mammalian cells: macroautophagy, microautophagy and
chaperone-mediated autophagy (Figure 1) [1 –4]. As more
is learnt about each of these, variations depending on the
nature of the substrate, cell type or cellular conditions
become evident and consequently some of these processes
have gained their own names; for example, macropex-
ophagy and micropexophagy describe the degradation
of peroxisomes by macro- or microautophagy, respectively
[7,16]. In macroautophagy, the cytosolic elements that
must be degraded are sequestered by an isolating
membrane of nonlysosomal origin that seals, creating an
autophagic vacuole or autophagosome [17,18]. Fusion of
lysosomes with autophagosomes provides the enzymes
required for the degradation of the sequestered com-
ponents. Although still controversial, the isolating
membrane is thought to form from small preformed
membranous structures of unknown origin (autophago-
some precursors or phagophores) [19]. A similar process of
sequestration occurs in microautophagy, but, in this case,
it is the lysosomal membrane itself that deforms to engulf
the cytosolic substrates [3,20]. In both macro- and
microautophagy the membrane of the vesicle that carries
substrates to the lysosomal lumen is rapidly degraded,
granting lysosomal hydrolases access to internalized
substrates. In the third form of autophagy, chaperone-
mediated, soluble cytosolic proteins selectively bind to a
receptor at the lysosomal membrane that mediates their
translocation into the lysosomal lumen [3,4]. Selectivity
depends on the recognition of a targeting signal in the
amino acid sequence of the substrate proteins by a
cytosolic chaperone. The chaperone – substrate complex
then binds to the lysosomal membrane receptor. A second
chaperone located in the lysosomal lumen is required for
substrate translocation [3,4]. Table 1 summarizes simi-
larities and differences among these three main forms of
autophagy.
 Review TRENDS in Cell Biology Vol.14 No.2 February 2004 71

Peroxisome Pre-
autophagosome
Micropexophagy Macropexophagy

Microautophagy Isolating
membrane

Autophagosome

Macroautophagy
Lysosomal
chaperone
Lysosome
Membrane Cytosolic chaperone
receptor and cochaperones

Cytosolic protein
Chaperone-mediated autophagy
(substrate)

TRENDS in Cell Biology

Figure 1. Types of autophagy in mammalian cells. Three main forms of autophagy exist: macroautophagy, microautophagy and chaperone-mediated autophagy. Interna-
lized substrates could be different cytosolic organelles (circles) and/or single proteins (strings). As an example of selective autophagy of organelles, peroxisomes are
shown as they are delivered to the lysosome by peroxisomes-specific macroautophagy (macropexophagy). The arrow with broken line indicates the degradation of peroxi-
somes by microautophagy (micropexophagy), which has only been described in yeast. Note that chaperone-mediated autophagy is shown at higher magnification to eluci-
date the proteins at the lysosomal membrane that participate in the internalization of the substrate proteins.

Table 1. Comparison of the three main forms of autophagy in mammalsa

Characteristic Macroautophagy Microautophagy Chaperone-mediated autophagy
Activation Stress Constitutive Stress
Species
Mammals Yes Yes Yes
Nonmammals Yes Yes ?b
Mechanism
Engulfment Yes Yes No
Sequestering membrane Nonlysosomal Lysosomal –
Receptor mediated No No Yes
Requirementsc
ATP Yes Yes Yes
GTP and GTPases Yes Yes No
Cytoskeleton Yes No ?b
Chaperones ?b ?b Yes
Acidic vacuolar pH Yes Yes No
Membrane potential ?b Yes Yes
PI3 kinases Yes ?b No
Substrates
Organelles All types All types No
Soluble cytosolic proteins All types All types KFERQd-tagged
Targeting signals Ubiquitination?e ?b KFERQd-like motif
Removal of glucose?e
Unfolding No No Yes
Selectivity Some formsf Some formsf Always
a
Data have been compiled from the literature cited throughout the text.
b
Unknown
c
Requirements refers only to the uptake and/or internalization steps, but not to degradation in the lysosomal lumen, which has the same requirements for all three types of
autophagy.
d
One-letter code for amino acids.
e
Although these are not generalized targeting signals, both the ubiquitinization of some cytosolic enzymes [69] and the removal of glucose from N-glycans of glycoproteins
[70] are reported to be necessary for their degradation by macroautophagy.
f
Selective macro- and microautophagy for some organelles have been mainly described in yeast and are not included in this comparison.

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72 Review TRENDS in Cell Biology
Molecular dissection of an ‘old’ process
Morphological evidence for macro- and microautophagy in
mammals was first reported almost forty years ago [21]. A
common method for analyzing the activity of macro- and
microautophagy in tissues is to quantify the number of
autophagic vacuoles and multivesiculated lysosomes in
their cells. However, an increase in the number of
autophagic structures does not always mean activation
of autophagy. Not only the increased formation of
autophagic vacuoles but also a decrease in their ability
to fuse with lysosomes, and thereby be eliminated from the
cytosol, can result in their accumulation inside cells. To
differentiate between these two possibilities, dynamic
studies, such as measurement of protein turnover or
autophagosome clearance, should accompany morphologi-
cal data. Indeed, studies combining morphological and
dynamic assays have provided valuable information about
the regulation of autophagy and the changes in autophagic
activity under different physiological and pathological
conditions [1,5,22]. However, a lack of both information
about the molecular players in autophagy and selective
markers for each autophagic pathway was the common
limitation for the researchers in this area.
Fortunately, during the past decade, systematic screen-
ings of yeast mutants, carried out simultaneously in
several laboratories worldwide, have led to a molecular
dissection of macro- and microautophagy and their
variations [13,17,23]. Orthologs of many of the yeast
genes have been rapidly identified in different species,
from amoebae to mammals, supporting the conserved
nature of these types of autophagy [19,23,24]. The
identification of genes involved in macro- and microauto-
phagy – recently unified under the term ATG (autophagy
related) [23] – has provided the necessary markers for
these forms of autophagy and the chance to manipulate
these processes genetically [25].
Chaperone-mediated autophagy has not benefited from
the genetic screenings in yeast because its occurrence in
nonmammalian cells has not been demonstrated. How-
ever, recently a lysosomal receptor for the substrates of
this pathway was identified [3,4], the levels of which were
found to determine the rates of internalization of sub-
strates into lysosomes by chaperone-mediated autophagy.
This allows the manipulation of the activity of chaperone-
mediated autophagy by modifying the expression of
this receptor.
Autophagy and pathology: a guardian angel or the touch
of death?
The molecular dissection of autophagy and the growing
number of physiological functions attributed to this process
are leading to a better understanding of the role of autophagy
in disease. In fact, since the term autophagy was linked to
devastating human pathologies, such as Alzheimer’s dis-
ease, Parkinson’s disease and different forms of cancer,
research in this topic has grown exponentially.
When analyzing the role of autophagy in disease,
independent of the specific details of each disorder, a
common challenge is to determine whether autophagy
protects or contributes to cell damage. Autophagy is
crucial for cell adaptation and survival under extreme
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Vol.14 No.2 February 2004
conditions. Degradation of intracellular macromolecules
provides the energy required for minimal cell functioning
when nutrients are scarce [2,3]. Specific toxins and
pathogens are sequestered and degraded through auto-
phagy [26,27]. In addition, autophagy-mediated elimin-
ation of altered cytosolic constituents, such as aggregated
proteins or damaged organelles, preserves cells from
further damage [6,28]. Consequently, the activation of
autophagy could play a protective role in early stages of
several diseases.
There is also extensive number of studies reporting a
role for autophagy in programmed cell-death (PCD) type
II, or nonapoptotic death [29– 31]. Morphological features
distinguish this form of PCD from the classical type I, or
apoptosis. In autophagic PCD, Golgi cisterna, polyribo-
somes and endoplasmic reticulum are degraded before
nuclear destruction, and in contrast to apoptosis, the
cytoskeleton is largely preserved [29]. However, the two
forms of PCD also have common aspects. Some of the
intracellular signals that activate or block apoptosis have
similar effects on autophagy [6,32]. Certain proteins are
required for the formation of both apoptotic nuclear blebs
and autophagic vacuoles [33]. Sometimes, both forms of
PCD can coexist in the same cell [29,32]. Inhibiting the
sequestration of cytosolic elements inside autophagosomes
delays apoptosis; however, inhibiting the later autophagic
steps, such as the fusion between autophagosomes and
lysosomes or the degradation by proteases in the lysosomal
lumen, does not prevent apoptosis [34]. Thus, it is possible
that, by eliminating endogenous repressors of the apopto-
tic process, autophagy guarantees complete execution of
cell death.
Recent reports reconcile these opposing roles of auto-
phagy in disease and show that autophagy can act as both
protector and killer of the cell, depending on the stage of
the disease, the surrounding cellular environment or the
therapeutic interventions attempted [35]. The initial
activation of autophagy in response to cellular damage
probably aims to protect the cell by sequestering and,
when possible, degrading the altered macromolecules or
organelles. Once a certain level of intracellular damage is
reached, autophagy might instead become an effective way
of removing the injured cell from a tissue. Examples of this
dual role of autophagy in several pathologies and the
different outcomes of the activation or inactivation of
autophagy are shown in Table 2 and discussed below.
The following sections describe the implications of
autophagy in disease, most of which involve macroauto-
phagy (often referred to as autophagy). Pathological roles
of other autophagic pathways are also emerging, examples
of which are provided throughout the text.
Cancer
To understand the role of autophagy in the progress of
cancer, investigators have compared the rate of autophagy
in tumoral cells with that in their corresponding nontumor
cells; even for the same type of tumor, different labora-
tories found an increase, decrease or no net change in the
rate of autophagy [35]. In theory, both activation and
inactivation of autophagy could benefit cancer cells.
Cellular growth stops when cells switch from an anabolic
 Review TRENDS in Cell Biology
Table 2. Possible outcomes of the activation and inactivation of autophagy in different pathologiesa
Disease Activation of autophagy
Cancer
Early stages Blocks tumor growth
Late stages Favors survival of cells in low-vascularized tumors
Favors removal of damaged intracellular macromolecules
after anticancer treatments
Vacuolar myopathies Promotes elimination of the cytosolic autophagic vacuoles
If hyperactivated, could result in muscle waste
Neurodegeneration
Early stages Favors removal of cytosolic protein aggregates
Late stages Destroys irreversibly damaged neurons by autophagic cell
death
Axonal injury Favors removal of neurotransmitter vesicles and damaged
organelles
Provides energy and membranes for regeneration
Infectious disease Contributes to the elimination of bacterial and viral particles
a
Outcomes that favor progression of the disease are annotated in red; those that prevent it are annotated in blue. Data have been compiled from the literature cited throughout
the text.
(protein synthesis greater than protein degradation) to a
catabolic state after reaching confluence [10]. If cells
cannot activate autophagy, protein synthesis predomin-
ates over protein degradation and cellular growth con-
tinues (typical characteristic of tumoral cells). In addition,
these cells would be insensitive to agents that mediate
cellular death by autophagy because this program is
inactive. By contrast, autophagy could be activated in
more advanced stages of cancer to guarantee survival
of cancer cells under extreme conditions, such as the
restricted access of cells located in the inner areas of solid
tumors to nutrients. The activation of autophagy in some
types of tumoral cells in response to radiation and
chemotherapy is also beneficial for these cells because it
contributes to eliminate damaged organelles from their
cytosol, thereby preventing the activation of apoptosis that
would kill them [36].
These opposite functions of autophagy in cancer can be
reconciled considering oncogenesis as a dynamic process
(Figure 2). For example, in solid tumors, during the early
stages of development, blockage of autophagy maintains
continuous growth. As the tumor mass grows, although
cells in the periphery close to blood vessels can maintain
the anabolic state, internal cells will probably switch to a
catabolic state to guarantee their survival. In addition to
the stage of cancer, the level of cell differentiation, type of
tissue, surrounding conditions and genetic background
influence autophagic activity in cancer cells [35,37].
A definitive proof for the role of autophagy in different
stages of cancer development would be to show that the
blockage of autophagy-related genes affects sensitivity to
tumorigenesis. The only gene studied in this context is
beclin 1, the human homolog of ATG 6 in yeast, which is
required for autophagosome formation. One of the alleles
for the beclin 1 gene is deleted in several types of breast
cancer that are unable to activate autophagy [38]; the
shut down of autophagy is essential for maintaining the
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Vol.14 No.2 February 2004 73
Inactivation of autophagy
Favors tumor growth
Makes cells unable to enter autophagic cell death after
exposure to anticancer treatments
Prevents survival of cells in low-vascularized tumors
Increases efficiency of anticancer treatments because
damaged macromolecules cannot be eliminated
Results in the accumulation of autophagic vacuoles that
weaken skeletal and cardiac muscles
Increases accumulation of cytosolic protein aggregates
Prevents removal of damaged organelles and
neurotransmitter vesicles.
Cytosolic release of neurotransmitters induces apoptosis
Slows down regeneration
Offers a survival environment for the bacteria that are able
to inhibit autophagosome maturation
Facilitates viral infection
malignant phenotype of these cells. When beclin 1 was
overexpressed in these cancerous cells, autophagy was
restored, and malignancy was reverted [38]. In fact, some
cancer drugs, such as tamoxifen, seem to function by
inducing the expression of beclin 1. Finally, some cancer
cells that cannot undergo apoptosis because of specific
mutations in the apoptotic pathway, can still be removed
by autophagy [36].
The increasing evidence connecting cancer and auto-
phagy makes the manipulation of autophagy a very
attractive prospect for the treatment of cancer. However,
the immediate priority is to understand the role of
autophagy in specific stages of cancer development.
Muscular disorders
Reports of cytosolic vacuoles in the muscle cells of patients
with altered muscular function are numerous. However,
only recently have some of these pathologies been related
to alteration in autophagy [39,40]. The introduction of
new autophagic markers has been pivotal in proving the
autophagic nature of the vacuoles in muscle cells.
Direct evidence for impaired autophagy in a myopathy
was first obtained when the gene encoding a lysosomal
membrane protein (lamp 2) was knocked out in mice
[41,42]. The predominant phenotype of these mice is a
massive accumulation of autophagic vacuoles in their
liver, muscle and heart cells. Despite the increased
number of autophagic vesicles, the rate of lysosomal
protein degradation is reduced because autophagosome
clearance through lysosomal fusion is impaired. The
histological resemblance of the skeletal and heart muscles
of the lamp2 knockout mice to those from patients with
Danon disease led to the identification of mutations in
lamp2 as the primary defect in this lysosomal storage
disease the clinical characteristics of which are cardiomyo-
pathy, myopathy and variable mental retardation [43].
74 Review TRENDS in Cell Biology Vol.14 No.2 February 2004

(a) Initial stage (b) Advanced stage

Decreased autophagy Increased autophagy favours
favors tumor growth tumoral cells survival

Source of nutrients for hipoxic areas

Defense against therapeutic drugs
Defense against irradiation damage

Anticancer
Decreased
autophagy
treatments

autophagy
Increased
Synthesis > Degradation = Growth
Death by autography not possible

TRENDS in Cell Biology

Figure 2. Hypothetical model for the double role of macroautophagy in cancer. Depending on their maturation stage, a switch from the inhibition of macroautophagy to
maximum activation, could be beneficial for some types of cancer, especially those forming solid tumors. (a) In the early stages of the tumor development, a decrease in
protein degradation by autophagy would shift the balance between protein synthesis and degradation towards synthesis, increasing intracellular protein content and thus
favoring cellular growth. Also, the low rates of autophagy might render these cells resistant to death after some courses of treatment because autophagic programmed cell
death (PCD) could not be activated. (b) In advanced stages of cancer, activation of autophagy might allow the survival of the cells located in central areas of the tumor
(blue), which show low vascularization. To compensate for the low supply of nutrients coming to these cells from the blood stream, they could activate autophagy to
degrade dispensable intracellular macromolecules, thereby obtaining the building blocks required for the synthesis of the more essential components. Some of these
tumoral cells could also activate autophagy when exposed to different cancer treatments as a defensive mechanism. By eliminating intracellular damaged structures before
they accumulate inside, these cells prevent the activation of PCD.

Recently, a second myopathy, characterized by both
muscle weakness at birth and early death, has been linked
to a defect in myotubularin, a phosphatase that modulates
the levels of phosphatidylinositol (PtdIns); PtdIns has been
implicated in vesicular trafficking and autophagy [44].
The identification of these and other possible mutations in
autophagy-related genes are helping to redefine and classify
these muscular pathologies [43]. However, a pending
question is that, despite the ubiquitous distribution of
the mutated genes, why vacuoles accumulate in some
tissues but not in others.
Neurodegeneration
Alterations in the lysosomal compartment have been
linked to neuronal death in many neurodegenerative
disorders, as well as in transmissible neuronal pathologies
(prion diseases) [31,45,46]. The morphology of the lyso-
somal system changes dramatically in experimental
models for Alzheimer’s [45], Huntington’s [47] and
Parkinson’s diseases [48], and signaling cascades that
regulate autophagy are also altered [49]. Furthermore,
dopamine, a neurotransmitter with a known role in neuro-
degeneration, also triggers autophagy-mediated PCD
[50,51]. By contrast, a possible protective role for auto-
hagy in neurodegeneration had not been reported until
recently. Activation of autophagy might facilitate the
removal of intracellular protein aggregates – a hallmark
of neurodegenerative diseases [31,52].
Two features – the presence of intracellular protein
aggregates and alterations in the activity of the major
proteolytic systems – are commonly found in affected
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neurons in several neurodegenerative disorders. Although
the mutated protein is different in each of these disorders,
the sequence of events leading to protein aggregation is
apparently the same (Figure 3) and as follows: (i) the
abnormal conformation (misfolding) of the affected protein
exposes normally hidden hydrophobic residues; (ii) the cell
responds to these abnormal proteins by activating the
chaperone system (to promote refolding) and cytosolic
proteases (to promote removal); and (iii) in the initial
stages of the disorder, chaperones and proteases can
sometimes revert, or at least slow down, protein aggrega-
tion; however, as the levels of the altered protein increase,
the process becomes irreversible and these ‘helpers’
become trapped in the aggregates [53]. Although aggrega-
tion might also be a defensive mechanism against the
hydrophobic patches, it makes these proteins resistant to
attack by cytosolic proteases, leaving their removal by
macroautophagy the only viable possibility [53]. Recent
studies show that, at least in experimental systems, the
activation of macroautophagy facilitates the removal of
newly formed aggregates [28,54]. However, as the disease
progresses, the increasing number of aggregates, their
decreased susceptibility to degradation by lysosomal
enzymes and the maintained activation of autophagy
might lead to cell exhaustion and engagement in PCD type
II (Figure 3).
The main challenge in this field is, thus, to prevent or
slow down aggregation by facilitating the degradation of
the proteins still in soluble form. DiFiglia and colleagues
[55] have recently reported that, in Huntington’s disease,
the degradation of small fragments of the mutant protein
 Review TRENDS in Cell Biology
(a) Mutant
protein
Chaperones
Proteases
Aggregates
Activation of autophagy facilitates
Early stage
removal of cytosolic aggregates
(b)
Autophagy is used to completely
Late stage eliminate the damaged neuron
(autophagic cell death)
TRENDS in Cell Biology
Figure 3. Autophagy in the progression of neurodegenerative disorders. Cytosolic
accumulation of misfolded proteins as aggregates is common to several forms of
neurodegeneration. These mutant proteins expose hydrophobic regions (red),
which promote unwanted associations between their different molecules. Conse-
quently, other proteins are recruited – chaperones and proteases to assist the
refolding and degradation of mutant proteins, respectively – but they also become
trapped in the aggregates. (a) Activation of autophagy in the early stages of the
disease might degrade some of these aggregates, preventing, or at least slowing
down, their accumulation. (b) As the disease progresses, the presence of undi-
gested materials accumulating inside autophagic vacuoles, the sustained acti-
vation of macroautophagy to sequester the aggregates and the removal of crucial
cellular elements by autophagy along with the aggregates, could lead to a general-
ized cellular failure. In this case, the cell can use autophagy to undergo autophagic
cell death.
by macroautophagy prevents their aggregation; therefore,
the activation of autophagy in early stages of neuro-
degeneration might have potential therapeutic value.
A second case of the protective role of autophagy in
neurons was reported during axonal injury [56]. When
axons are disconnected from their neuronal body, auto-
phagy is activated [56], facilitating the removal of
damaged organelles and secretory vesicles that can no
longer reach the synaptic terminal. Autophagy also
contributes to axon regeneration by providing the injured
area with both energy sources (through the degradation of
intracellular macromolecules to their essential constitu-
ents) and membranes (by direct fusion of autophagic
vesicles enriched in membranous structures with the
plasma membrane) [56]. This process will probably receive
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Vol.14 No.2 February 2004 75
renewed attention in the light of recent findings on
autophagy, and questions such as the following will be
addressed: do autophagic vesicles originate in the body
or in the axon?; what is the activating signal?; what
determines the switch from regeneration to cell death?
Pathogen-to-host response
The activation of autophagy could be an effective way of
eliminating infectious agents that access the cytosol either
directly through the plasma membrane or after being
internalized in vesicles (phagosomes). In fact, autophagy is
activated in most cases of bacterial infection [26].
However, a group of microorganisms, including Brucella
abortus and Porphyromonas gingivalis, use the auto-
phagosomes as ‘shelter’ after escaping the endophagocytic
pathway [57]. In this case, phagosomes fuse with early
endosomes; however, instead of maturing to late endo-
somes, the presence of bacteria inside leads to the fusion of
these early endosomes with autophagosomes preventing
them from subsequent fusion with lysosomes [58]. Thus,
the autophagosome offers microorganisms protection from
the lytic compartment and provides the energy sources
required for their survival – the bacteria use their own
hydrolases to process the autophagosome contents. The
audacity of other bacteria, such as Legionella pneumo-
phila, goes even farther. Legionella reaches autophago-
lysosomes that already contain lytic enzymes and
replicates there [57,59,60]. The hydrolases of the host
are, in this case, the ones processing the sequestered
products to provide energy [59]. It is unclear how
Legionella protects itself from these hydrolases. An
interesting finding is that autophagy is directly activated
by a product secreted by the bacteria. If secretion in
bacteria is blocked, autophagy is no longer stimulated and
the bacteria are destroyed in phagolysosomes [60]. Once
the bacterial product that stimulates autophagy is
isolated, it could be used to enhance the impaired auto-
phagy detected in some pathologies.
Autophagy is also activated in response to viruses.
Autophagy-like vacuoles have been described in the cytosol
of cells infected with different types of virus [61]. Recently,
Levine and coworkers [27] demonstrated that cells infected
with herpes simplex virus respond to the infection by
increasing intracellular rates of autophagy, probably aiming
to eliminate the viral particles present in their cytosol. As in
the case of Legionella, here, a viral product modifies auto-
phagy antagonizing its activation, and thus allowing the
herpes virus to escape degradation [27].
The identification of bacterial and viral products that
modify the autophagic response could provide useful tools
to modulate autophagy for therapeutic use.
Autophagy and aging: helping to live longer
Morphological alterations in the lysosomal system and
changes in its enzymatic content are common in almost all
old tissues [62,63]. The efficiency of at least two forms of
autophagy – macroautophagy and chaperone-mediated –
decrease with age [64,65]. Considering the physiological
functions of autophagy, the cellular consequences of
this diminished activity are easily inferred and include
inefficient removal of damaged intracellular structures,
76 Review TRENDS in Cell Biology
alterations in cellular homeostasis, inability to adapt to
extracellular changes and poor defensive response against
damaging agents.
Current research focuses on an understanding of the
reasons behind age-dependent failure of autophagy at a
molecular level. Both the formation of autophagic vacuoles
and their removal by lysosomal fusion decrease with age
[66]. There might also be signaling problems, because
the ability to up- or downregulate macroautophagy in
response to changes in the blood levels of amino acids
and hormones is altered [65]. In chaperone-mediated
autophagy, the internalization of substrate proteins into
lysosomes diminishes, at least in part, because of an age-
related decrease in the levels of the lysosomal receptor that
mediates substrate uptake [64].
Proper functioning of autophagy has been related to
longevity. In old rodents subjected to caloric restriction
since early in life – an intervention that slows down aging
in mammals – the levels and regulation of macroauto-
phagy resemble those of young animals [67]. In addition,
the first genetic evidence linking autophagy and longevity
were presented recently in studies of Caenorhabditis
elegans [11], where specific mutations in genes related to
the insulin-like signaling pathway doubles the lifespan of
the worms. If macroautophagy is blocked in these mutant
worms, their lifespan returns to control values, suggesting
that the activation of macroautophagy is one of the down-
stream effectors that contribute to longevity.
Concluding remarks – future perspective
The connections between autophagy and human pathol-
ogies described here are only a small glimpse of the current
state of this research field. As new autophagy-related
genes are identified and the consequences of their
mutations analyzed, new links between autophagy and
disease are becoming evident. A whole new part of
research in autophagy focuses on the selective removal
of cytosolic components. Learning how damaged mito-
chondria are eliminated, whereas their neighboring
healthy counterparts are spared from degradation [6]
would be crucial for the future treatment of conditions
related to oxidative stress, in which mitochondrial mal-
function predominates. The fact that, at least in yeast,
specific nuclear regions can be eliminated by microauto-
phagy [8] opens new therapeutic ‘routes’ for protein
conformational disorders, many of which display protein
aggregates inside the nucleus. Selective removal of
damaged proteins by chaperone-mediated autophagy
occurs in a type of toxic-induced nephropathy [4]. To
find out whether degenerating disorders could benefit
from the selectivity of this pathway requires further
investigation.
There is increasing evidence for interaction among
autophagic pathways [68], but how this crosstalk is
affected in disease remains unknown. Questions such as
the following must be resolved: to what extent can
microautophagy compensate for the age-related decrease
in other forms of autophagy? in cancer cells with impaired
macroautophagy, how do the activities of chaperone-
mediated autophagy and microautophagy change?
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Vol.14 No.2 February 2004
In summary, the rapid advancement in our under-
standing of the mechanisms and regulation of autophagy
has placed this process in the center of current research in
major human disorders. The future challenge is to develop
easy methods to separately manipulate the activity of each
of the autophagic pathways. This would allow to further
understand their contribution to disease and possibly will
provide therapeutic tools.
Acknowledgements
I thank Ashish Massey and Fernando Macian for critically reading the
manuscript. Special thanks to my ‘forever-mentors’ Paulo Dice and Erwin
Knecht for sharing with me their particular insights on autophagy. Also
many thanks to all the participants of the First Gordon Research
Conference on Autophagy for the stimulating discussions during the
meeting. Work in my laboratory is supported by NIH/NIA (AG021904) and
an Ellison Medical Foundation Award. I apologize to colleagues whose
work has not been cited owing to space limitations.
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