REVIEW

CURRENT
OPINION Calcinosis: insights from other calcinoses
Sofia Serena Tsakali and Catherine M. Shanahan

Purpose of review
This review examines the current knowledge and recent developments in the field of vascular calcification
focusing on the emerging role of senescence and inflammation in driving this disorder and exploring the
overlap and relevance of these pathways to calcinosis in rheumatic disease.
Recent findings
Vascular calcification is an age-associated disorder. Recent studies have identified DNA damage, cellular
senescence and consequent inflammation as key drivers of vascular smooth muscle cell osteogenic change
and mineralization. Similar ageing and inflammatory factors are associated with calcinosis in rheumatic
disease and some are targets of experimental drugs currently undergoing clinical trials.
Downloaded from http://journals.lww.com/co-rheumatology by BhDMf5ePHKbH4TTImqenVLDYB5WEYn0wskXcqoz/SXyAF5R6ugCWjgQU64gm/qbGmgqSFjLEl7I= on 10/08/2020

Summary
Calcinosis in the vascular system and in rheumatic disease share similarities in terms of biomineralization
and cardiovascular outcomes. Although research into the role of senescence and inflammation has recently
been advanced in vascular calcification, little is known about the mechanistic role of inflammation in
calcinosis in rheumatic disease. This review explores whether lessons from one calcinosis can be
transferred and applied to the other to provide further insights and inform treatment strategies.
Keywords
calcinosis, inflammation, rheumatic disease, senescence, vascular calcification

INTRODUCTION (SSc), systemic lupus erythematosus (SLE) or rheu-

Calcinosis or dystrophic calcification is the abnor- matoid arthritis (RA) and other fibrosing syndromes,
mal deposition of insoluble calcium apatite in soft which are part of the CREST syndrome (calcinosis,
tissues. Vascular calcinosis is the most widespread Raynaud’s phenomenon, oesophageal dysmotility,
&

form of dystrophic calcification and is prevalent
in ageing and accelerated in diabetes and chronic
kidney disease (CKD) [1]. Calcification is an inde-
pendent risk factor for cardiovascular mortality and
directly causal in cardiovascular events [2]. Vascular
calcification can be divided into intimal or medial
calcification depending on its anatomical location
in the vessel wall. The mineral deposited varies in
shape and size and the type and location of mineral
impacts on the damage inflicted on the vessel. Inti-
mal calcification is associated with atherosclerosis
and characterized by lipid accumulation, inflamma-
tory macrophages and fibrosis and the extent of
calcification present in coronary arteries strongly
correlates with the risk of myocardial infarction
[3]. Medial calcification is associated with ageing,
diabetes and CKD and causes arterial stiffening,
which in turn leads to hypertension, poor cardiac
perfusion, eventually leading to cardiac remodelling
and heart failure [4].
Calcinosis of the vasculature is also regularly
observed in patients who suffer from rheumatic
autoimmune diseases, such as systemic sclerosis
sclerodactyly and telangiectasia) [5,6,7 ]. In these
rheumatic diseases, calcification occurs in conjunc-
tion with accelerated cardiovascular disease (CVD)
including atherosclerosis, pulmonary arterial hyper-
tension and elevated pulse wave velocity (PWV),
which can be a surrogate marker for vascular calcifi-
cation [8–11]. In these patients, calcinosis also man-
ifests on the surface of skin and facial areas as well as
in pressure sites including the elbows and knees [12].
These soft tissue mineral deposits vary in size and
shape and can form sheets that adhere to muscle,
British Heart Foundation Centre for Research Excellence, School of
Cardiovascular Medicine and Sciences, James Black Centre, King’s
College London, London, UK
Correspondence to Catherine M. Shanahan, British Heart Foundation
Centre of Research Excellence, School of Cardiovascular Medicine and
Sciences, James Black Centre, King’s College London, 125Coldharbour
Lane, London SE5 9 NU, UK. Tel: +44 2078485221;
e-mail: cathy.shanahan@kcl.ac.uk
Curr Opin Rheumatol 2020, 32:472–478
DOI:10.1097/BOR.0000000000000746

www.co-rheumatology.com Volume 32  Number 6  November 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Calcinosis: insights from other calcinoses Tsakali and Shanahan
KEY POINTS
 Calcinosis is prevalent in rheumatic diseases presenting
with risk factors common to vascular calcification
including ageing and inflammation, however, the cause
of its pathogenesis remains unknown.
 Cellular senescence and inflammation are emerging as
mediators of vascular calcification whereas interleukin-
6, in particular, is shown to be a common factor in
both vascular and rheumatic calcinosis.
 The treatment and management of calcinosis in
rheumatic diseases remains an urgent need with current
drugs targeting and inhibiting key inflammatory
mediators or cellular ageing pathways potential
new targets.
tendon and ligaments that result in significant pain
and limit motility [13,14].
Currently, the underlying mechanisms and
etiopathogenesis of soft tissue calcification in these
rheumatic diseases remain underexplored. However,
the presence of vascular calcification and elevated
cardiovascular risk means there may be mechanistic
similarities with vascular calcification.
Ageing is the strongest risk factor for vascular
calcification and calcification is accelerated in
patients with CKD leading to the suggestion that
these patients manifest with premature vascular
ageing [15]. Importantly, cellular senescence is
associated with the proinflammatory senescence-
associated secretory phenotype (SASP) whereas ath-
erosclerosis itself is a chronic inflammatory condition
[2,16]. Likewise, rheumatic conditions are inflamma-
tory autoimmune disorders that increase with preva-
lence with age and calcinosis in soft tissues is also
known to promote a strong local inflammatory
response. This has led to the suggestion that sterile
inflammation in association with tissue ageing may
also be a key pathway driving dystrophic calcification
&
in the CREST syndromes [7 ,17].
This review will present recent evidence from
vascular calcification that confirms these links sug-
gesting that the accrual of persistent DNA damage
and subsequent cellular senescence-induced inflam-
mation may be important for dystrophic calcifica-
tion in all contexts.
VASCULAR CALCIFICATION: PATHWAYS
TO PREMATURE AGEING
Vascular calcification is an active process mediated
by vascular smooth muscle cells (VSMCs). These
cells respond to environmental stressors and insti-
gate a number of processes, in response to cellular
1040-8711 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
damage and death, that together act to drive miner-
alization. This includes phenotypic modulation from
a contractile cell to a more proliferative, mesenchy-
mal-like cell, secretion of extracellular vesicles, loss of
protective mineralization inhibitors and differentia-
tion into an osteochondrogenic phenotype to
orchestrate mineralization of the extracellular matrix
[18]. Driving this VSMC osteochondrogenic conver-
sion is increased expression of transcription factors
that include the key bone and cartilage master reg-
ulators Runx2 and Sox9 resulting in the upregulation
of their downstream targets. These targets include
mineralization regulators, such as bone sialoprotein
and alkaline phosphatase as well as extracellular
matrix components, such as collagens and proteo-
glycans [2]. There is an array of environmental stress-
ors including mechanical and chemical stimuli
known to activate multiple signalling pathways
that upregulate these transcription factors and
impact calcification. Amongst the most potent are
oxidative stress driven by factors, such as hypergly-
caemia and elevated calcium and phosphate concen-
trations, which are prevalent in patients with CKD
on dialysis [15]. Recent studies have shown that these
stressors can drive DNA damage and that DNA dam-
age signalling can directly impact on pathways to
osteochondrogenic differentiation, inflammation
and calcification [19,20].
DNA damage, the senescence-associated
secretory phenotype and inflammation
The preservation of the human genome is of vital
importance for the healthy function of the human
body and the conservation of life. In living organ-
isms, the genome is constantly exposed to harmful
agents that induce DNA damage that, if left unre-
paired can lead to the accumulation of senescent
cells that impact health and instigate disease-
associated disorders [17]. In order to maintain
genomic integrity and stability, cells respond to
DNA damage by activating the DNA damage
response (DDR). This is a robust and highly efficient
system of complex signalling pathways that act to
repair the inflicted damage. In the case of failure
or inefficiency of any of these DDR pathways,
unrepairable or persistent DNA damage leads to
cellular ageing, apoptosis and/or senescence [21].
In response to strand breaks in the DNA, the first
protein to be recruited to the lesion site is the kinase
ataxia telangiectasia mutated (ATM), which is
responsible for the phosphorylation of gH2AX
histone [22]. This initial event acts to promote the
appropriate DNA repair factors and effectors
depending on the type of DNA lesion. A frequent
form of stressor-induced damage is oxidative DNA
www.co-rheumatology.com 473
Raynaud phenomenon, scleroderma, overlap syndromes and other fibrosing syndromes
damage that triggers recruitment of the repair effec-
tor proteins poly[ADP-ribose] polymerases (PARPs) 1
and 2, which conjugate the posttranslational modi-
fication poly[ADP-ribose] (PAR) to proteins in a
process known as the PARylation [23]. This modifies
the signalling responses of target proteins to deter-
mine cell fate and enable cellular growth arrest in
order to facilitate repair, induce senescence or as a
last resolve proceed with apoptosis/cell death [24].
Cells exit the cell cycle and enter senescence by
activating p53 and/or upregulating cyclin-depen-
dent kinases p21 (CDKN1A) and p16 (CDKN2A)
[25,26]. Senescent cells exhibit an inflammatory
phenotype and activate the SASP during which they
start to secrete a diverse selection of proteases and
pro-inflammatory factors, such as cytokines and
chemokines [27]. More importantly, the senescence
cascade and subsequent inflammation is a down-
stream event of DDR signalling and numerous stud-
ies have reported that VSMCs display DNA damage,
ageing and senescence markers at sites of calcifica-
&& &
tion (Fig. 1) [17,28 ,29 ,30].
The DNA damage response and vascular
smooth muscle cell osteogenic signalling
The first evidence that vascular calcification was
associated with cellular ageing came from studies
showing that the nuclear ageing biomarker prelamin
A, that is causal in the premature vascular ageing of
patients with progeria, accumulated in calcifying
VSMCs both in vitro and in vivo, and this accumula-
tion was independent of chronological age [31–33].
Mechanistic studies in vitro showed that prelamin A
acts to interfere with DNA damage repair driving
persistent DNA damage and premature senescence
[31,34]. Calcifying nodular VSMCs in vitro were also
found to accumulate prelamin A and to be positive
for the senescence markers senescence-associated
galactosidase (SabG) and p16. Correlating with prel-
amin A accumulation and senescence was increased
osteogenic marker expression [35,36]. These obser-
vations led to the hypothesis that DNA damage sig-
nalling may be a driver of VSMC osteochondrogenic
differentiation. Studies using inhibitors of ATM sig-
nalling showed that blocking the DDR could block
VSMC osteochondrogenic differentiation and calci-
fication. Co-culture studies with mesenchymal pre-
cursor cells showed that senescent VSMCs could drive
osteochondrogenic differentiation in a paracrine
manner [17]. Importantly, several of the SASP factors
released by the senescent VSMCs, including BMP2 as
well as pro-inflammatory factors interleukin-6 (IL-6)
and interleukin-8 (IL-8), had previously been impli-
cated in driving VSMC osteochondrogenic differen-
&&
tiation and calcification [28 ,31]. Inhibition of ATM
474 www.co-rheumatology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
reduced transcriptional and secreted levels of these
SASP factors and reduced osteochondrogenic differ-
entiation and mineralization strongly suggesting a
causal link between pro-inflammatory factors and
vascular calcification [31]. Interestingly, previous
studies had already identified NF-kB and Akt signal-
ling as promoters of VSMC osteochondrogenic dif-
ferentiation and calcification in response to oxidative
stress and both these pathways are also upstream of
SASP activation [37–40].
Inflammatory mediators, such as IL-6 and IL-8
increase in the circulation with age and are also
increased in patients with CKD and this has led to
the idea of ‘Inflammaging’ as causal in chronic age-
associated conditions, such as vascular calcification
[41]. However, studying ageing in elderly popula-
tions is complicated because of the multiplicity of
factors that can potentially drive the increases in
ageing indicators. Instead children with CKD on
dialysis who develop rapid vascular calcification
and show evidence of premature vascular ageing
make an ideal model to investigate how biological
ageing mechanisms may impact on disorder in vivo
[17,42]. Calcified vessels from children on dialysis
showed an accumulation of prelamin A, the DNA
damage marker 8-oxo-dG and upregulation of senes-
&&
cence factors p16 and p21 [28 ]. Moreover, cultured
VSMCs from these vessels showed increased DNA
damage and deficient DNA damage repair leading to
early senescence when compared with healthy con-
trol VSMCs. In addition to the upregulation of p16
and p21 markers, VSMCs from children on dialysis
also showed elevated levels of pro-inflammatory
SASP factors IL-6 and IL-8, as well as the osteogenic
&&
marker BMP2 [28 ,43]. Interestingly, ATM inhibi-
tion impeded calcification and showed loss of SASP
factor expression in response to calcifying media
supplemented with elevated levels of calcium and
&&
phosphate [44 ,45]. In clinical studies with paedi-
atric CKD patients, circulating levels of both BMP2
and IL-6 positively correlated with pulse wave veloc-
ity, which is indicative of vascular stiffening,
and with coronary artery calcification measured
&&
by computer tomography scanning [28 ,46]. Stud-
ies in adult patients with CKD and calcification also
indicated increased tissue indices of senescence
and increased circulating SASP factors, IL-6, IL-8
and BMP2, further suggesting that inflammation
may be one of the drivers of calcification in this
&&
population [28 ,47–49].
Further evidence for the role of DDR signalling
in vascular calcification has come from studies
examining PARP signalling, which is activated in
response to oxidative DNA damage. Studies focusing
on animal models and human vessels showed that
PAR was present at sites of calcification whereas
Volume 32  Number 6  November 2020
 Calcinosis: insights from other calcinoses Tsakali and Shanahan

FIGURE 1. Persistent DNA damage promotes the senescence-associated secretory phenotype response in VSMCs. Oxidative
stress induces DNA damage that if unrepaired leads to activation of the SASP in VSMCs leading to the secretion of cytokines
and chemokines that further promote senescence and reinforce vascular osteochondrogenic change and calcification. Similar
pathways may also apply in rheumatic diseases. SASP, senescence associated secretory phenotype; VSMCs, vascular smooth
muscle cells.

1040-8711 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-rheumatology.com 475

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Raynaud phenomenon, scleroderma, overlap syndromes and other fibrosing syndromes
PARP inhibitors impede calcification in both cellular
&&
and animal models [44 ,50]. PAR is a posttransla-
tion modification normally produced in the
nucleus. Chemically, it is a phosphate sugar struc-
turally similar to mineralization regulators. Studies
suggest that PAR, produced in response to oxidative
stress, is released into the extracellular matrix dur-
ing the cell death and vesicle release that accom-
&&
pany VSMC osteochondrogenic change [44 ,50].
Chemically PAR acts to gather and concentrate
calcium and can biomimetically mineralize both
collagen and elastin. Thus, a by-product of the
DDR plays a direct role in the nucleation of mineral
within the extracellular matrix providing an expla-
nation for why calcification might associate
strongly with ageing as DNA damage accrues.
MECHANISMS OF CALCINOSIS IN
RHEUMATIC DISORDER
Inflammation and senescence are also emerging as
key features in rheumatic diseases suggesting
senescent VSMCs, fibroblasts or other mesenchy-
mal-like cells, such as pericytes may account for at
least some of the calcinosis observed in soft tissues.
A number of studies have shown that all these cell
types can undergo Runx2-mediated osteogenic dif-
ferentiation in response to pathological damage
[51–54].
A role for inflammation and senescence in
calcinosis in rheumatic disease
Studies in vitro and in vivo have shown that cell
senescence is a feature of rheumatic diseases. Bone
marrow-derived mesenchymal stem cells (BM-
MSCs) from patients with SSc, were positive for
SabG, expressed high levels of p21 and p53 and
showed increased mRNA and protein levels of IL-6
when cultured in vitro [55]. Similarly, synovial tissue
and fibroblasts from old healthy donors or patients
with RA or osteoarthritis were positive for SabG
staining and also showed upregulation of p16, IL-
6 and IL-8 compared with healthy young donors.
Oxidative stress induced by H2O2 or TNFa enhanced
senescence in these fibroblasts as well as increased
IL-6, IL-8, monocyte recruitment chemokine CCL2
and matrix metallopeptidase 3 transcription and
protein expression [56]. Elevated circulating levels
of the procalcific inflammatory mediator IL-6 is also
a consistent feature in rheumatic diseases with SSc
patients also showing elevated levels in skin
although it remains unclear whether it is in associa-
tion with calcinosis sites [49,57]. Multiple cell types
including macrophages and fibroblasts secrete IL-6
that binds to the IL-6 receptor and activates the
476 www.co-rheumatology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Janus kinases and signal transducers and activators
of transcription (JAK/STAT) pathway that mediates
gene transcription modulating immune, differenti-
ation and growth [58,59]. IL-6-induced calcification
in mesenchymal stem cells derived from adipose
tissues has been shown to be STAT3-dependent
and can activate osteochondrogenic differentiation
via Runx2 modulation [60]. These studies showcase
that IL-6 may act as a potential link and driver of
calcinoses in cell types in close apposition to calci-
nosis in rheumatic diseases.
Targeting inflammation and senescence to
treat calcinosis
Currently, there are no treatments for vascular cal-
cification and despite the evidence for the role of
inflammation and senescence in calcification, there
have been few clinical studies examining how tar-
geting these pathways might impact on disease.
However, preclinical studies using PARP inhibitors
and senolytics are suggesting that these may be
effective targets for further therapy. Minocycline
is an antibiotic that is a potent PARP2 inhibitor.
This drug was shown to reduce calcification in rats
induced to calcify in response to CKD [36]. Interest-
ingly, this drug has also been used in patients with
cutaneous SSc and is potentially effective in the
control of calcinosis; however, further trials in larger
patient cohorts are now required to verify its effec-
&&
tiveness [44 ,61].
Senolytic approaches to remove senescent cells
have been examined in preclinical animal models
of atherosclerosis and have been shown to extend
lifespan and delay vascular calcification [62–64].
Senolytic drugs have also been used to combat
senescence and inflammation both in vitro and in
animal models mimicking systemic autoimmune
syndromes [65,66]. Fibroblast treatment with the
senolytic drug fenofibrate normalized the levels of
the SASP factors highlighting the link between pro-
inflammatory mediators and senescence in RA [56].
However, whether senolytic drugs had an effect on
calcinosis was not addressed making this a crucial
question for further study.
Targeting inflammatory factors in vascular cal-
cification has not yet been trialled. The Canakinu-
mab Antiinflammatory Thrombosis Outcome Study
(CANTOS) used an antibody, canakinumab, to
inhibit interleukin-1b to impede inflammation in
patients with previous myocardial infarction and
found reduced IL-6 levels after 12 months and
reduced cardiovascular events; however, the effects
on calcification were not examined [67]. The use of
specific inflammatory inhibitors has also been tri-
alled in patients with rheumatic diseases. A Swedish
Volume 32  Number 6  November 2020
 Calcinosis: insights from other calcinoses Tsakali and Shanahan
cohort of LSE patients treated with the monoclonal
antibody belimumab against the counterpart of
B-cell activating factor, showed reduced IL-6 serum
levels during early stages, which correlated with
favourable patient outcome including reduced
disease activity [68]. Tocilizumab (TCZ), an IL-6
inhibitor has been administrated to RA patients
for over a decade, exhibiting evidence of efficacy
in the management of inflammatory symptoms
[69]. Although the effect of drugs for RA treatment
on CVD risk remains unclear, a study comparing
TCZ with other RA drugs showed that there was
no increased risk of CVD in these patients [70].
Importantly, treatment with a combination or
monotherapy of conventional synthetic or biolog-
ical disease-modifying antirheumatic drugs, such
as the immunosuppressant methotrexate or an
antibody directed against B cells, rituximab, in
RA patients resulted in improved PWV and preven-
tion of arterial stiffening progression [71]. TCZ and
rituximab in combination was also found to reduce
PWV in RA patients [72]. However, there is no clear
data on whether any of these drugs impact on
calcinosis in either the vasculature or soft tissues,
so further trials are needed to address these specific
& 12. Valenzuela A, Chung L. Management of calcinosis associated with systemic
questions [7 ].
CONCLUSION
Vascular calcification and calcinosis in systemic
autoimmune diseases share features including pre-
mature cellular ageing, senescence and inflamma-
tion. Research in the field of vascular calcification is
showing promising advances in better understand-
ing the molecular mechanisms driving calcinosis,
including the role of DDR signalling, and therefore,
indicating novel targets for drug development. Even
though further investigation in calcinosis in rheu-
matic disorders is clearly required, it is worth noting
that common inflammatory mediators, such as IL-6
and IL-8 could in part be driving these disorders.
Further dissection of the key procalcific inflamma-
tory mediators may provide the groundwork for
the development of novel treatments for these
devastating disorders.
Acknowledgements
None.
Financial support and sponsorship
This work was supported by a British Heart Foundation
Project Grant (PG/17/37/33023).
Conflicts of interest
There are no conflicts of interest.
1040-8711 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Paloian NJ, Giachelli CM. A current understanding of vascular calcification in
CKD. Am J Physiol Ren Physiol 2014; 307:F891–F900.
2. Durham AL, Speer MY, Scatena M, et al. Role of smooth muscle cells in
vascular calcification: implications in atherosclerosis and arterial stiffness.
Cardiovasc Res 2018; 114:590–600.
3. Pohle K, Ropers D, Mäffert R, et al. Coronary calcifications in young patients
with first, unheralded myocardial infarction: a risk factor matched analysis by
electron beam tomography. Heart 2003; 89:625–628.
4. Proudfoot D, Shanahan CM. Biology of calcification in vascular cells: intima
versus media. Herz 2001; 26:245–251.
5. Harigane K, Mochida Y, Ishii K, et al. Dystrophic calcinosis in a patient with
rheumatoid arthritis. Mod Rheumatol 2011; 21:85–88.
6. Duzgun N. Cutaneous calcinosis in a patient with limited scleroderma:
CREST syndrome. Eur J Rheumatol 2017; 4:305–306.
7. Hsu V, Varga J, Schlesinger N. Calcinosis in scleroderma made crystal clear.
& Curr Opin Rheumatol 2019; 31:589–594.
This review summarized the current knowledge on the effects of rituximab on
calcinosis in patients with various rheumatic diseases.
8. Cannarile F, Valentini V, Mirabelli G, et al. Cardiovascular disease in systemic
sclerosis. Ann Transl Med 2015; 3:8.
9. Udachkina HV, Novikova DS, Popkova TV, et al. Calcification of coronary
arteries in early rheumatoid arthritis prior to antirheumatic therapy. Rheumatol
Int 2018; 38:211–217.
10. Gunter S, Robinson C, Norton GR, et al. Cardiovascular risk factors and
disease characteristics are consistently associated with arterial function in
rheumatoid arthritis. J Rheumatol 2017; 44:1125–1133.
11. Paccou J, Brazier M, Mentaverri R, et al. Vascular calcification in rheumatoid
arthritis: prevalence, pathophysiological aspects and potential targets. Ather-
osclerosis 2012; 224:283–290.
sclerosis. Curr Treat Options Rheumatol 2016; 2:85–96.
13. Freire V, Moser TP, Lepage-Saucier M. Radiological identification and ana-
lysis of soft tissue musculoskeletal calcifications. Insights Imaging 2018;
9:477–492.
14. Hwang ZA, Suh KJ, Chen D, et al. Imaging features of soft-tissue calcifications
and related diseases: a systematic approach. Korean J Radiol 2018;
19:1147–1160.
15. Shroff R, Long DA, Shanahan C. Mechanistic insights into vascular calcifica-
tion in CKD. J Am Soc Nephrol 2013; 24:179–189.
16. Gardner SE, Humphry M, Bennett MR, Clarke MCH. Senescent vascular
smooth muscle cells drive inflammation through an interleukin-1a-dependent
senescence-associated secretory phenotype. Arterioscler Thromb Vasc Biol
2015; 35:1963–1974.
17. Dai L, Schurgers LJ, Shiels PG, Stenvinkel P. Early vascular ageing in chronic
kidney disease: impact of inflammation, vitamin K, senescence and genomic
damage. Nephrol Dial Transplant 2020; 35(Suppl 2):ii31–ii37.
18. Shanahan CM. Mechanisms of vascular calcification in CKD—evidence for
premature ageing? Nat Rev Nephrol 2013; 9:661–670.
19. Pescatore LA, Gamarra LF, Liberman M. Multifaceted mechanisms of
vascular calcification in aging. Arterioscler Thromb Vasc Biol 2019;
39:1307–1316.
20. Chung HY, Kim DH, Lee EK, et al. Redefining chronic inflammation in aging
and age-related diseases: proposal of the senoinflammation concept. Aging
Dis 2019; 10:367–382.
21. Fumagalli M, d’Adda di Fagagna F. SASPense and DDRama in cancer and
ageing. Nat Cell Biol 2009; 11:921–923.
22. Turgeon MO, Perry NJS, Poulogiannis G. DNA damage, repair, and cancer
metabolism. Front Oncol 2018; 8:15.
23. Morales JC, Li L, Fattah FJ, et al. Review of poly (ADP-ribose) polymerase
(PARP) mechanisms of action and rationale for targeting in cancer and other
diseases. Crit Rev Eukaryot Gene Expr 2014; 24:15–28.
24. Schuhwerk H, Bruhn C, Siniuk K, et al. Kinetics of poly(ADP-ribosyl)ation, but
not PARP1 itself, determines the cell fate in response to DNA damage in vitro
and in vivo. Nucleic Acids Res 2017; 45:11174–11192.
25. Chen J, Huang X, Halicka D, et al. Contribution of p16INK4a and p21CIP1
pathways to induction of premature senescence of human endothelial cells:
permissive role of p53. Am J Physiol Hear Circ Physiol 2006;
290:H1575–H1586.
26. Miao SB, Xie XL, Yin YJ, et al. Accumulation of smooth muscle 22a protein
accelerates senescence of vascular smooth muscle cells via stabilization
of p53 in vitro and in vivo. Arterioscler Thromb Vasc Biol 2017;
37:1849–1859.
27. Burton DGA, Matsubara H, Ikeda K. Pathophysiology of vascular calcification:
pivotal role of cellular senescence in vascular smooth muscle cells. Exp
Gerontol 2010; 45:819–824.
www.co-rheumatology.com 477
Raynaud phenomenon, scleroderma, overlap syndromes and other fibrosing syndromes
28. Sanchis P, Ho CY, Liu Y, et al. Arterial ‘inflammaging’ drives vascular
&& calcification in children on dialysis. Kidney Int 2019; 95:958–972.
This article highlights the link bewteen DNA damage and the pro-inflammatory
SASP in vascular calcification providing direction for new strategies targeting DNA
damage signalling or senescence to prevent the disorder.
29. Bartoli-Leonard F, Wilkinson FL, Schiro A, et al. Loss of SIRT1 in diabetes
& accelerates DNA damage-induced vascular calcification. Cardiovasc Res
2020; 1:1–14.
This article provides evidence that DNA damage signalling is also prevalent in
calcification in diabetes and implicates SIRT1 signalling as a key switch in
regulating smooth muscle cells osteogenic differentiation.
30. Yamada S, Tatsumoto N, Tokumoto M, et al. Phosphate binders prevent
phosphate-induced cellular senescence of vascular smooth muscle cells and
vascular calcification in a modified, adenine-based uremic rat model. Calcif
Tissue Int 2015; 96:347–358.
31. Liu Y, Drozdov I, Shroff R, et al. Prelamin A accelerates vascular calcification
via activation of the DNA damage response and senescence-associated
secretory phenotype in vascular smooth muscle cells. Circ Res 2013;
112:e99–e109.
32. Hamczyk MR, del Campo L, Andrés V. Aging in the cardiovascular system:
lessons from hutchinson-gilford progeria syndrome. Annu Rev Physiol 2018;
80:27–48.
33. Casasola A, Scalzo D, Nandakumar V, et al. Prelamin A processing, accu-
mulation and distribution in normal cells and laminopathy disorders. Nucleus
2016; 7:84–102.
34. Cobb AM, Larrieu D, Warren DT, et al. Prelamin A impairs 53BP1 nuclear
entry by mislocalizing NUP153 and disrupting the Ran gradient. Aging Cell
2016; 15:1039–1050.
35. Ragnauth CD, Warren DT, Liu Y, et al. Prelamin A acts to accelerate smooth
muscle cell senescence and is a novel biomarker of human vascular aging.
Circulation 2010; 121:2200–2210.
36. Duer M, Cobb AM, Shanahan CM. Arteriosclerosis, thrombosis, and vascular
biology DNA damage response. ATVB 2020; 40:1–10.
37. Zhao G, Xu MJ, Zhao MM, et al. Activation of nuclear factor-kappa B
accelerates vascular calcification by inhibiting ankylosis protein homolog
expression. Kidney Int 2012; 82:34–44.
38. Bent EH, Gilbert LA, Hemann MT. A senescence secretory switch mediated
by PI3K/AKT/mTOR activation controls chemoprotective endothelial secre-
tory responses. Genes Dev 2016; 30:1811–1821.
39. Xie J, Lin J, Wei M, et al. Sustained Akt signaling in articular chondrocytes
causes osteoarthritis via oxidative stress-induced senescence in mice. Bone
Res 2019; 7:23.
40. Chien Y, Scuoppo C, Wang X, et al. Control of the senescence-associated
secretory phenotype by NF-kB promotes senescence and enhances che-
mosensitivity. Genes Dev 2011; 25:2125–2136.
41. Calder PC, Bosco N, Bourdet-Sicard R, et al. Health relevance of the
modification of low grade inflammation in ageing (inflammageing) and the
role of nutrition. Ageing Res Rev 2017; 40:95–119.
42. Dai L, Qureshi AR, Witasp A, et al. Early vascular ageing and cellular
senescence in chronic kidney disease. Comput Struct Biotechnol J 2019;
17:721–729.
43. Akchurin O, Patino E, Dalal V, et al. Interleukin-6 Contributes to the Devel-
opment of Anemia in Juvenile CKD. Kidney Int Rep 2019; 4:470–483.
44. M€ uller KH, Hayward R, Rajan R, et al. Poly(ADP-Ribose) links the DNA
&& damage response and biomineralization. Cell Rep 2019;
27:3124.e13–3138.e13.
This article shows the detailed evidence implicating PARP signalling in vascular
calcification demonstrating PAR can act to nucleate mineral and highlighting the
efficacy of the specific PARP2 inhibitor monocycline in inhibiting vascular calci-
fication in vitro and in vivo.
45. Paez-Ribes M, González-Gualda E, Doherty GJ, Muñoz-Espı́n D. Targeting
senescent cells in translational medicine. EMBO Mol Med 2019; 11:e10234.
46. Wang Y, Osborne MT, Tung B, et al. Imaging cardiovascular calcification. J
Am Heart Assoc 2018; 7:e008564.
47. Kamińska J, Stopiński M, Mucha K, et al. IL 6 but not TNF is linked to coronary
artery calcification in patients with chronic kidney disease. Cytokine 2019;
120:9–14.
48. Rysz J, Banach M, Cialkowska-Rysz A, et al. Blood serum levels of IL-2, IL-6,
IL-8, TNF-alpha and IL-1beta in patients on maintenance hemodialysis. Cell
Mol Immunol 2006; 3:151–154.
478 www.co-rheumatology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
49. Henaut L, Massy Z. New insights into the key role of interleukin 6 in vascular
calcification of chronic kidney disease. Nephrol Dial Transplant 2018;
33:543–548.
50. Wang C, Xu W, An J, et al. Poly(ADP-ribose) polymerase 1 accelerates
vascular calcification by upregulating Runx2. Nat Commun 2019; 10:1203.
51. Guauque-Olarte S, Messika-Zeitoun D, Droit A, et al. Calcium signaling
pathway genes RUNX2 and CACNA1C are associated with calcific aortic
valve disease. Circ Cardiovasc Genet 2015; 8:812–822.
52. Pillai ICL, Li S, Romay M, et al. Cardiac fibroblasts adopt osteogenic fates and
can be targeted to attenuate pathological heart calcification. Cell Stem Cell
2017; 20:218.e5 –232.e5.
53. Song R, Fullerton DA, Ao L, et al. Altered MicroRNA expression is responsible
for the pro-osteogenic phenotype of interstitial cells in calcified human aortic
valves. J Am Heart Assoc 2017; 6:e005364.
54. Yu C, Li L, Xie F, et al. LncRNA TUG1 sponges miR-204-5p to promote
osteoblast differentiation through upregulating Runx2 in aortic valve calcifica-
tion. Cardiovasc Res 2018; 114:168–179.
55. Cipriani P, Di Benedetto P, Liakouli V, et al. Mesenchymal stem cells (MSCs)
from scleroderma patients (SSc) preserve their immunomodulatory properties
although senescent and normally induce T regulatory cells (Tregs) with a
functional phenotype: implications for cellular-based therapy. Clin Exp Im-
munol 2013; 173:195–206.
56. Del Rey MJ, Valı́n Á, Usategui A, et al. Senescent synovial fibroblasts
accumulate prematurely in rheumatoid arthritis tissues and display an en-
hanced inflammatory phenotype. Immun Ageing 2019; 16:29.
57. Choy EH, De Benedetti F, Takeuchi T, et al. Translating IL-6 biology into
effective treatments. Nat Rev Rheumatol 2020; 16:335–345.
58. Daniel E Johnson, Rachel A, Grandis JR. Targeting the IL-6/JAK/STAT3
signalling axis in cancer. Nat Rev Clin Oncol 2018; 15:234–248.
59. Fragoulis GE, Mcinnes IB, Siebert S; JAK-inhibitors. New players in the field of
immune-mediated diseases, beyond rheumatoid arthritis. Rheumatology (Ox-
ford) 2019; 58:i43–i54.
60. Fukuyo S, Yamaoka K, Sonomoto K, et al. IL-6-accelerated calcification by
induction of ROR2 in human adipose tissue-derived mesenchymal stem cells
is STAT3 dependent. Rheumatology (Oxford) 2014; 53:1282–1290.
61. Robertson LP, Marshall RW, Hickling P. Treatment of cutaneous calcinosis in
limited systemic sclerosis with minocycline. Ann Rheum Dis 2003;
62:267–269.
62. Childs BG, Baker DJ, Wijshake T, et al. Senescent intimal foam cells are
deleterious at all stages of atherosclerosis. Science 2016; 354:472–477.
63. Baker DJ, Wijshake T, Tchkonia T, et al. Clearance of p16 Ink4a-positive
senescent cells delays ageing-associated disorders. Nature 2011;
479:232–236.
64. Stojanović SD, Fiedler J, Bauersachs J, et al. Senescence-induced inflamma-
tion: an important player and key therapeutic target in atherosclerosis. Eur
Heart J 2020; ehz919.
65. Gao L, Slack M, McDavid A, et al. Cell senescence in lupus. Curr Rheumatol
Rep 2019; 21:1.
66. Gorgoulis V, Adams PD, Alimonti A, et al. Cellular senescence: defining a path
forward. Cell 2019; 179:813–827.
67. Ridker PM, Everett BM, Thuren T, et al., CANTOS Trial Group. Antiinflamma-
tory therapy with canakinumab for atherosclerotic disease. N Engl J Med
2017; 377:1119–1131.
68. Parodis I, Åkerström E, Sjöwall C, et al. Autoantibody and cytokine profiles
during treatment with belimumab in patients with systemic lupus erythema-
tosus. Int J Mol Sci 2020; 21:3463.
69. Ogata A, Kato Y, Higa S, Yoshizaki K. IL-6 inhibitor for the treatment of
rheumatoid arthritis: a comprehensive review. Mod Rheumatol 2019;
29:258–267.
70. Xie F, Yun H, Levitan EB, et al. Tocilizumab and the risk of cardiovascular
disease: direct comparison among biologic disease-modifying antirheumatic
drugs for rheumatoid arthritis patients. Arthritis Care Res (Hoboken) 2019;
71:1004–1018.
71. Tam LH, Shang Q, Li EK, et al. Effect of treat-to-target strategies aiming at
remission of arterial stiffness in early rheumatoid arthritis: a randomized
controlled study. J Rheumatol 2018; 45:1229–1239.
72. Provan SA, Berg IJ, Hammer HB, et al. The impact of newer biological disease
modifying antirheumatic drugs on cardiovascular risk factors: a 12-month
longitudinal study in rheumatoid arthritis patients treated with rituximab,
abatacept and tociliziumab. PLoS One 2015; 10:e0130709.
Volume 32  Number 6  November 2020