Human Cathelicidin

Antimicrobial
Peptide LL-37
Birgitta Agerberth1 and Gudmundur H. Gudmundsson2,3,*
1
Department of Medical Biochemistry and Biophysics, Karolinska Institutet, S-171 77 Stockholm, Sweden
2
Microbiology and Tumorbiology Center, Karolinska Institutet, S-171 77 Stockholm, Sweden
3
Biology Institute, University of Iceland, 101 ReykjavõÂ k, Iceland
* corresponding author tel: ‡354 525 5276, fax: ‡354 525 4886, e-mail: ghrafn@hi.is
DOI: 10.1006/rwcy.2002.1209.

SUMMARY
The antimicrobial peptide LL-37 is a single cathe-
licidin defense peptide of human origin. Cathelicidins
are so far only found in mammals and contain a
conserved pro region of the cathelin type and a
C-terminal variant domain, which is liberated by
processing enzyme(s) as a mature antimicrobial
peptide. In humans the gene encoding LL-37 is
expressed in various tissues and cells but most
pronounced in polymorphonuclear granulocytes and
epithelial cells. Epithelial cells are constantly exposed
to bacteria and phagocytes are recruited to sites of
bacterial infections to terminate the bacterial spread
and eliminate the invader. Thus, LL-37 is an effector
in the armament of immediate and early host
defenses. In addition to bactericidal activity, LL-37
exhibits chemotactic activity for several types of
inflammatory and immune cells. Thus LL-37 exhibits
a dual adaptive roles, being involved in killing
bacteria and additionally in recruiting host effector
cells for enhancing early innate defenses and for
initiating the adaptive axis of immunity.
BACKGROUND
Discovery
The discovery of human cathelicidin was reported
independently by three different research groups. The
first report was based on a PCR strategy with primers
directed towards the conserved cathelin pro region
(Agerberth et al., 1995). By comparison of cDNA
sequences for antimicrobial peptides of bovine origin
it became clear that cathelin was a conserved pro
region, functioning as a carrier of antimicrobial
peptides. Based on this information and our
characterization of the gene for the porcine anti-
microbial peptide PR-39 (Gudmundsson et al., 1995)
primers were directed to conserved regions between
bovine and porcine sequences and used in PCR
amplification (Agerberth et al., 1995). The amplified
cDNA sequence was confirmed to encode cathelin
and then used as a probe to screen a human bone
marrow cDNA library. Several clones were isolated
and characterized, containing the complete coding

Cytokine Reference Copyright # 2002 Published by Elsevier Science Ltd

2 Birgitta Agerberth and Gudmundur H. Gudmundsson
sequence. By synthesizing the putative C-terminal
peptide based on a predicted processing site, the
antibacterial domain was recovered. Antibodies were
raised against the peptide and later used as an
important tool for isolation of the mature active
peptide, LL-37.
The second report on the identification of a cDNA
encoding the precursor for LL-37 (human CAP18 or
hCAP18) was based on a low stringency screen of a
cDNA library from human bone marrow (Larrick
et al., 1995). The cDNA probe used in the screen
encoded rabbit CAP18 (18 kDa cationic antimicrobial
protein). Earlier, the same research group had found
that the CAP18 protein from rabbit granulocytes
exhibited potent LPS-binding activity (Larrick et al.,
1991). For the human counterpart, the C-terminal
domain of hCAP18 was shown to be responsible for
the LPS-binding activity (Larrick et al., 1995), i.e. the
part that corresponds to the peptide LL-37.
The third approach was based on the characteriza-
tion of a unique protein derived from specific
granules of human neutrophils. Information from
partial amino acid sequence analysis of this
protein made it possible to design primers, which
were used to clone the corresponding cDNA from a
library of chronic myeloid leukemia cells (Cowland
et al., 1995).
Alternative names
Concerning the discovery of LL-37 and its terminol-
ogy it is important to emphasize the presence of the
pro region, cathelin. The name cathelicidin was
initially suggested by Zanetti's group (Zanetti et al.,
1995) based on this conserved pro region. Cathelin
was originally isolated and characterized as a
cathepsin L inhibitor, hence the name (Ritonja et al.,
1989). Later this activity was retracted (Lenarcic
et al., 1993). However, cathelicidin was then already
established as a name for this major family of
mammalian antimicrobial peptides.
LL-37 refers to the length of the mature peptide
with 37 amino acid residues, starting with two N-
terminal leucines (Gudmundsson et al., 1996).
Initially, the putative active peptide was thought to
be a 39 residue peptide and subsequently called
FALL-39 after the first four N-terminal residues and
the length. The rationale for selecting this peptide was
a potential dibasic processing site, and a synthetic
replica of this peptide exhibited antibacterial ac-
tivity and was dependent on salt for potent
activity (Agerberth et al., 1995). Antisera was raised
against this putative peptide and used for isolation
of the active mature peptide from degranulated
granulocytes (Gudmundsson et al., 1996). The
characterized peptide was two amino acid residues
shorter than the putative peptide or 37 residues and
was renamed LL-37.
The name hCAP18 (human cationic antimicrobial
protein) refers to the relation to the rabbit homolog
CAP18 (Larrick et al., 1995) that was originally
characterized as a LPS-binding protein of 18 kDa.
This name is now used for the complete precursor
protein. Since the peptide and the pro form go hand
in hand, some researchers have preferred to use the
mixed term hCAP18/LL-37, when the processing
stage is not known, as in immunohistochemistry and/
or by expression on the mRNA level. Today with the
emerging picture of variant peptides connected to the
cathelin carrier it seems logical to refer to the family
as cathelicidins, and to specify the product in question
based on the active peptide.
Structure
Initial studies using an Edmundsson wheel plot
revealed that the peptide could form an amphipathic
 helix (Agerberth et al., 1995). Amino acid residues
from position 11 (E) to 32 (V) were recognized to
form a perfect amphipathic helix. The -helical
conformation was later found to be critical for the
antibacterial activity, hence the helical fold is
connected to the activity (Johansson et al., 1998).
We demonstrated that pH, anion, and peptide
concentration are the main determinants for the
conformation and the activity of LL-37 (Johansson
et al., 1998). Thus, the conformation was found to
depend on the microenvironment and was not
induced upon contact with bacteria. Effects of the
microenvironment are of interest concerning the
activity of antimicrobial peptides. In the mucus of
cystic fibrosis patients it was found that antibacterial
activity was diminished and the decreased activity was
correlated to increased salt concentrations (Smith
et al., 1996). It is known that the activity of defensins
is decreased at high salt concentrations, but it has
not been established if improper folding is the reason
for their decreased activity. However, it must be
emphasized that intact epithelial cell surface defenses
are based on a complicated network with many active
components, which can also work in synergy or in an
additive manner (Agerberth et al., 1999; Travis et al.,
1999).
The observation that antimicrobial peptides are
clinically relevant has turned out to be of great
importance. It has opened up the field and focused
much deserved attention on both the peptides and
immediate host defenses.

Main activities and
pathophysiological roles
Most likely the peptides shield the epithelia from
invading microbes. It was suggested previously that
one function of peptide antibiotics could be to
counterbalance the commensal microflora (Boman,
1991) and several recent lines of evidence confirm
this view (Porter et al., 2002). In addition to cell
surface protection, LL-37 is involved in the destruc-
tion of bacterial invaders since it is included as
an active part of the neutrophil armament (Cowland
et al., 1995; Gudmundsson et al., 1996). LL-37 might
be an effector involved both in intracellular phago-
cytic killing as well as extracellularly, when phago-
cytes are recruited and degranulated at sites of
infection or inflammation (Frohm et al., 1996).
However, it has to be emphasized that the peptides
most likely act in synergy with other components
in vivo.
During our studies on the expression of LL-37 in
specific lymphocyte and monocyte populations we
observed chemotactic activity for polymorphonuclear
and CD4 T cells. This chemotaxis was also reported
by J. J. Oppenheim's group, who showed that LL-37
was able to induce Ca2+ mobilization in monocytes
(Yang et al., 2000a). The receptor mediating the
chemotactic response to LL-37 was characterized as
the formyl peptide receptor-like 1 (FPRL1) which is
present on neutrophils, monocytes, and T cells (Yang
et al., 2000b).
The function of cathelin is still not clear although
the protein is related to a family of thiol protease
inhibitors such as kininogenin, cystatin, and spp24.
Interestingly, the kininogenin precursor most similar
to cathelin is a carrier of the potent vasodilator
bradykinin, which is released when the precursor
protein is cleaved by kallikrein (Hu et al., 1995). The
only study on cathelin function indicates protease
inhibition and chemotactic activity (Verbanac et al.,
1993). However, detailed characterization has not yet
been carried out and in the mean time its function
remains uncertain.
LL-37 has also been found to induce histamine
release and affect intracellular Ca2+ mobilization in
rat mast cells (Niyonsaba et al., 2001), indicating that
mast cells are a target for LL-37. Furthermore, the
same research group has shown rat mast cells to be
chemotactic for LL-37, an effect mediated indepen-
dently of the FPRL1 receptor. Instead, the protein
phospholipase C signaling pathway is involved
(Niyonsaba et al., 2002). Due to sequence variation
between related peptides of different species it is of
importance to confirm these results in a homologous
Human Cathelicidin Antimicrobial Peptide LL-37 3
system and confirm that LL-37 has the same effect on
human mast cells.
Together, these observations demonstrate a dual
function of LL-37 in host defense by killing bacteria and
by recruiting inflammatory and immune effector cells.
GENE AND GENE REGULATION
Accession numbers
For retrieving the gene sequences or cDNA use LL-37
as a search word in the Entrez (NCBI) database.
cDNA: NM_004345
Gene: X96735
Chromosome location
3p21.3 is the chromosomal location for the CAMP
gene encoding LL-37. To our knowledge this chro-
mosomal region is not associated with sensitivity to
infections. However, it is likely that such a situation will
be demonstrable with reference to the mouse model.
Relevant linkages
There are no available data connecting human disease
and the location of the gene for LL-37.
Gene structure and evolution
The structure of the gene encoding LL-37 (named
CAMP for cathelicidin antimicrobial peptide) has
been determined and the gene mapped to chromo-
some 3 (3p21.3) (Gudmundsson et al., 1995, 1996;
Frohm et al., 1997). To our knowledge this region has
not been mapped in relation to sensitivity for
infections in humans. The gene consists of four
exons, where exon 1±3 encode the signal peptide for
export and the cathelin domain, and exon 4 encodes
the processing site and the mature peptide LL-37.
This organization is consistent with the general gene
structure of all characterized cathelicidin genes
(Gudmundsson et al., 1995; Zhao et al., 1995a,b;
Pestonjamasp et al., 2001).
Not only are the coding regions conserved between
the cathelicidin genes; identities in introns and
promoter regions are also pronounced, as in the
genes encoding PR-39 and LL-37 (Gudmundsson
et al., 1996). However, when comparing the noncod-
ing sequences between the mouse gene CRAMP and
4 Birgitta Agerberth and Gudmundur H. Gudmundsson
human CAMP, only promoter sequences are con-
served, indicating similar regulation (Gudmundsson
responses (Pestonjamasp et al., 2001). How-
et al., 1996; Pestonjamasp et al., 2001).
Regulatory sites and corresponding
transcription factors
Expression of antimicrobial peptides is sometimes
regulated through the presence of microbial products,
stimulating factor), NFB, IFN (interferon ), and
IFN
ever, the functional relevance of these binding
motives remains to be established. Since different
levels of expression seem to occur for the cathelicidin
genes one can assume that several different regulatory
pathways are involved. The complete picture certainly
includes several regulatory factors and/or different
combinations, depending on the cell type.
In cells like granulocytes and epithelial cells the
expression of the LL-37 gene is included in the
as has been shown for -defensin 2 (O'Neil et al.,
1999). Toll-like receptor 2 has been found as a
mediator in this response to bacterial lipoprotein,
through a signal pathway involving NFB, thereby
enhancing the potency of innate defenses (Birchler
et al., 2001). Microbial activation has not been shown
for LL-37. Since the expression of the gene encoding
LL-37 is increased in inflammation, several groups
have screened for direct cytokine induction. In skin,
IL-1 has been found to upregulate the transcription
of LL-37 in composite keratinocyte grafts (Erdag
and Morgan, 2002). Currently it is not known if
this induction reflects direct activation through the
IL-1 receptor or a secondary effect. In addition,
colocalization of IL-6 and LL-37 has also been
reported (Frohm Nilsson et al., 1999). Due to
differentiation program. The gene encoding LL-37 is
expressed in pro-granulocytic cells of the bone
marrow and in epithelial cell lines, where the
expression is induced with sodium butyrate a well-
known inducer of differentiation (Hase et al., 2002).
According to Hase et al., the expression of the
gene encoding LL-37 is intrinsic in cellular epithelial
differentiation (Hase et al., 2002). However, parallel
induction is possible and we have indications
that differentiation can be separated from LL-37
expression.
With respect to gene regulation, detailed informa-
tion is lacking for genes of antimicrobial defenses.
However, it is clear that the regulation of genes
encoding antimicrobial peptides follows different
routes. -Defensins are mainly found in phagocytic
regulatory elements in the promoter of the gene for cells, while -defensins are expressed in epithelia,
LL-37, IL-6 has been considered a regulator of LL-37
(Gudmundsson et al., 1996). However, it is unclear if
IL-6 is induced parallel to LL-37 or involved in the
regulation of the LL-37-encoding gene.
During our characterization of the gene encoding
LL-37 (the CAMP gene) we identified several
promoter elements that could be of interest for the
regulation of the gene. The binding sites of potential
interest were for the transcriptional factors NF-IL6
(nuclear factor for IL-6 expression) and APRF (acute
phase response factor), now known as STAT3.
NF-IL6 is a member of the C/EBP family of tran-
scription factors with a basic-leucine zipper domain
involved in DNA binding and dimerization. The
C/EBP transcription factors are engaged in several
cellular responses including growth, differentiation,
immune, and inflammatory processes with relation to
various diseases (Ramji and Foka, 2002). According
to current terminology NF-IL6 is equivalent to
where -defensin 1 (HBD-1) is constitutively
expressed, while HBD-2 is inducible, with activation
through NFB (O'Neil et al., 1999). LL-37 is
constitutively expressed by both phagocytes and
epithelial cells. The variant antimicrobial peptides
are likely an adaptation to different microbial
challenges, making it harder for the microbe offender
to escape. By using different regulatory pathways the
system is not as vulnerable as it would be if one main
switch were used. The upregulation of innate effectors
such as antimicrobial peptides is a process that could
be harnessed in preventive medicine to hinder
bacterial invasion at epithelial surfaces. In the gut
butyrate is a possible inducer that can be utilized for
this purpose (Hase et al., 2002).
Cells and tissues that express
C/EBP. Interestingly, in a mouse deficient in the
related C/EBP", expression of the mouse cathelicidin
was virtually absent in bone marrow and a binding site
for C/EBP" was identified in both the human and
mouse promoters (Verbeek et al., 1999).
Other potential binding sites for regulatory factors
were found in the promoter of the mouse cathelicidin
gene related to GM-CSF (granulocyte-monocyte
the gene
The main sites of expression for the gene encoding
LL-37 are epithelial cells and phagocytes, but the
highest concentrations are found in granulocytic
neutrophils (Frohm et al., 1997; Sorensen et al.,
1997). Both epithelial cells and phagocytes are located
at strategic sites for host defenses, i.e. occurring

immediately on the epithelial surfaces and soon
thereafter by recruited leukocytes. In lungs the peptide
and the pro form have been detected in epithelial cells
(Bals et al., 1998; Agerberth et al., 1999) and epithelial
expression has also been observed in the gastro-
intestinal tract (Bals et al., 1998; Frohm Nilsson et al.,
1999; Islam et al., 2001; Hase et al., 2002).
Borregaard's group detected the unprocessed pro
form of LL-37 (hCAP18) in plasma and after
developing an enzyme-linked immunosorbent assay
(ELISA) estimated its concentration to be 1.12 mg/mL
plasma (Sorensen et al., 1997). Interestingly, the pro
form of LL-37 is present at several fold higher
concentration in plasma than other proteins derived
from the specific granules of neutrophils. Later we
demonstrated that not only blood neutrophils produce
LL-37, but also B cells, NK cells,
 T cells, and However, it is unclear if cathelin has a function in
monocytes (Agerberth et al., 2000). It is therefore
conceivable that some of the pro-LL-37 is derived from
these mononuclear cells. The presence of the pro form
of LL-37 in plasma provides the capacity of a rapid
activation process that must be an advantageous
response to infection. Only one proteolytic cleavage
would be needed for releasing a bactericidal defense
molecule or an LPS scavenger. However, it must be
emphasized that the details of this activation process
are far from clear since the signal for the processing
enzyme and the role of apolipoprotein AI as a binding
protein to LL-37 in plasma are unknown (Wang et al.,
1998; Sorensen et al., 1999).
In our original report on the characterization of the
LL-37 cDNA we detected expression in testis by using
commercially available northern blots (Agerberth
et al., 1995). A detailed study showed expression of
the gene to be mainly localized to the epithelia of
the epididymis (Malm et al., 2000). In addition, high
levels of the pro form for LL-37 (hCAP18) was
detected in seminal plasma and was associated with
spermatozoa (Malm et al., 2000).
PROTEIN
Accession numbers
For retrieving the protein sequence use LL-37 as a
search word in the Entrez (NCBI) database.
Protein: P49913
Description of protein
Concerning the human cathelin pro region there are
no available data on the protein. The active peptide
Human Cathelicidin Antimicrobial Peptide LL-37 5
LL-37 is a 37 residue peptide with two leucines at
the N-terminus and forms an -helical amphipathic
structure that is dependent on the microenvironment
for folding and activity (Johansson et al., 1998).
Discussion of crystal structure
There are no available data on the crystal structure.
Important homologies
The cathelin pro region is related to the cystatin
family of thiol protease inhibitors that includes:
kininogenin, cystatin, and spp24 (Hu et al., 1995).
protease inhibition as the related proteins.
Variant peptides are connected to the cathelin
region and LL-37 is related to the amphipathic
-helical peptides that are linked to the cathelin
region in other mammalian species.
Posttranslational modifications
One can assume that the signal peptide is cleaved off
from the precursor of LL-37 during the process of
cotranslational delivery to the lumen of the rough
endoplasmic reticulum. Originally when cathelin was
isolated and characterized from porcine leukocytes,
the N-terminus was found to be blocked (Ritonja
et al., 1989). The N-terminal glutamine had been
converted, yielding pyrroglutamate. This glutamine is
conserved in all the known cathelicidins so it suggests
a similar modification in all cathelicidins.
To liberate the active peptide LL-37, proteinase 3
was identified as the processing enzyme by
Borregaard's group. This processing is connected to
exocytosis, and no detectable cleavage was observed
after phagocytosis, indicating an extracellular func-
tion for LL-37 (Sorensen et al., 2001). In contrast the
bovine and porcine cathelicidins are processed by
elastase (Panyutich et al., 1997; Scocchi et al., 1992).
CELLULAR SOURCES AND
TISSUE EXPRESSION
Cellular sources that produce
The main cell types where the peptide LL-37 is
located are epithelial cells and neutrophilic granulo-
cytes. In addition to the epithelia of lung and colon
6 Birgitta Agerberth and Gudmundur H. Gudmundsson
the peptide has been found to be expressed in the
epithelia of mouth, tongue, esophagus, vagina, cervix,
and epididymid (Frohm Nilsson et al., 1999; Malm
et al., 2000). In blood the peptide has also been
located in B cells, NK cells,
 T cells and monocytes
(Agerberth et al., 2000).
Eliciting and inhibitory stimuli,
including exogenous and
endogenous modulators
Expression of LL-37 is found upregulated in
connection to inflammation most clearly in the skin
(Frohm et al., 1997) at both mRNA and protein level.
The elicitors for this increased expression during
inflammation are unknown.
The downregulation of LL-37 expression in
Shigella infections has been noted, and in vitro
Shigella plasmid DNA can mediate this effect (Islam
et al., 2001).
RECEPTOR UTILIZATION
The receptor mediating the chemotactic response to
LL-37 was characterized as the formyl peptide
receptor-like 1 (FPRL1) which is present on
neutrophils, monocytes, and T cells (Yang et al.,
2000b). Several other antimicrobial peptides have
been shown to exhibit chemotactic activity. However,
different human peptides have distinct host cell
affinity (Yang et al., 2000a).
IN VITRO ACTIVITIES
In vitro findings
The main activity characterized so far for LL-37 is
killing of bacteria. LL-37 has broad-spectrum activity
against gram-positive and gram-negative bacteria,
while the antifungal activity is limited. The most
detailed study concerning bactericidal activities has
been performed by Lehrer's group (Turner et al.,
1998). For the protection of the skin it is notable that
the most common skin pathogen, Streptococcus
group A, is very sensitive to LL-37 (Dorschner et al.,
2001). Furthermore, activity has also been detected
against herpes simplex virus types 1 and 2. However,
the antiviral activity is limited against this type of
virus (Yasin et al., 2000).
IN VIVO BIOLOGICAL
ACTIVITIES OF LIGANDS IN
ANIMAL MODELS
Normal physiological roles
Studies by our group showed LL-37 to be induced in
skin epithelia during inflammation (Frohm et al.,
1997). In psoriatic lesions and in contact dermatitis
this upregulation most likely has adaptive value to
prevent infections in the ruptured skin. Notably,
bacterial infections are surprisingly uncommon in
psoriatic lesions. Expression of LL-37 has also been
demonstrated at wound edges at sites of sterile
incisions (Dorschner et al., 2001), however the
peptide is also delivered to the wound fluid by
incoming granulocytes (Frohm et al., 1996).
Consequently, high concentrations of LL-37 are
found in the wound crust (Dorschner et al., 2001).
Furthermore, the peptide is very active against group
A Streptococcus, one of the commonest and most
invasive skin pathogens (Dorschner et al., 2001).
Thus, LL-37 seems to be a key element in cutaneous
innate immunity.
In this context it is of interest that vernix caseosum,
a white creamy substance rich in lipids and present on
the skin surface of newborn infants, contains several
antimicrobial polypeptides, including LL-37
(Marchini et al., 2002; Yoshio et al., 2002) . It is
tempting to conclude that LL-37 contributes to
strengthening of the skin barrier and thereby prevents
microbial colonization of the infant skin.
In the colon, as in lungs, a complex defense system
operates where LL-37 is expressed in epithelial cells
(Bals et al., 1998; Islam et al., 2001). However, the
situation in the colon is totally different from that in
lungs. In the lung a bacteria-free microenvironment is
the aim, while colon epithelia provide an important
surface for communications with the commensal
microflora. The bacterial load in the colon is
overwhelming and as already mentioned peptides
like LL-37 could be involved in the regulation of this
microflora.
We have also observed an important relation
between surface defenses and pathogens of the
gastrointestinal tract. During Shigella or Vibrio
infections expression of the antimicrobial peptides
LL-37 and the defensin HBD-1 was downregulated
(Islam et al., 2001). This downregulation might
represent an immune escape strategy used by
pathogens in order to overcome surface defenses. As
part of a successful invasion pathogenic bacteria not
only affect the expression of antimicrobial peptides,

they have also evolved resistance to these peptides by
utilizing efflux pumps (Neisseria) (Shafer et al., 1998)
or by modifying lipid A by acylation (Salmonella)
(Guo et al., 1998). Preventing downregulation or
enhancing antimicrobial peptide expression could
thus provide an alternative treatment in protect-
ing human and animal stocks against bacterial
intruders. Notably, using sodium butyrate treatments,
symptoms of shigellosis were reduced in a rabbit
experimental model (Rabbani et al., 1999). Butyrate,
a well-known inducer of differentiation in colon
epithelial cells, has indeed been shown to enhance the
expression of LL-37 (Hase et al., 2002).
Species differences
An interesting evolutionary pattern emerges when the
known mammalian cathelicidin sequences are com-
pared. As usually for related genes, changes due to
point mutations are observed in homologous
domains. These changes are seen in the cathelin
encoding exons, and in sequences encoding peptides
that have common origin such as the amphipathic
linear peptides, including LL-37. In some species
rapid divergence has occurred through gene duplica-
tions and shuffling of exon 4, connecting totally
unrelated peptides to cathelin and thus enhancing
the variation profoundly. This predicted evolutionary
pattern has occurred in the porcine genome, where
more than 10 cathelicidins with various different
peptides are found (Lehrer and Ganz, 2002). Through
analyses of different cathelicidins this divergence
seems lineage- and species-specific which indicates
events parallel to mammalian evolution. One may
predict that the evolutionary radiation reflects an
adaptation to variant microbial challenges. Fur-
thermore, in species that only have one cathelicidin
gene, like mouse, rat, and human, the peptide
domain is of the linear -helical amphipathic
type. This suggests that the original peptide version
was amphipathic and -helical or that there are
evolutionary constraints on this peptide structure
due to other functions, where receptor binding is
included.
Knockout mouse phenotype
Interestingly, gene-deficient knockout mice lacking
the cathelicidin CRAMP, a structural and functional
homolog to LL-37, are much more sensitive to group
A Streptococcus infections in the skin, resulting in
necrotic skin lesions and lower efficiency of bacterial
clearance (Gallo et al., 1997; Nizet et al., 2001). This
Human Cathelicidin Antimicrobial Peptide LL-37 7
knockout mouse model will certainly be an important
tool to determine the general contributions of
cathelicidins in resistance to infections and inflam-
matory responses.
The importance of other antimicrobial peptides in
the gastrointestinal tract came from the matrilysin
knockout mouse. The matrilysin protease is necessary
for cleavage and generation of defensins in the gut
(the cryptdins). The matrilysin-deficient mouse
exhibited increased sensitivity to orally administered
bacteria (Wilson et al., 1999). Together these knock-
out mice models indicate the importance of anti-
microbial peptides in immunity.
Endogenous inhibitors and
enhancers
In plasma LL-37 is bound to ApoA-1 with a Kd in the
range of 0.6±2.4 mM and thus work as a scavenger for
the cytotoxic effect of LL-37 (Wang et al., 1998;
Sorensen et al., 1999).
PATHOPHYSIOLOGICAL ROLES
IN NORMAL HUMANS AND
DISEASE STATES AND
DIAGNOSTIC UTILITY
Normal levels and effects
There is very limited information on the exact
concentration of the peptide in normal and diseased
tissues. The concentration of the pro form in normal
plasma was found to be 1.12 mg/mL (Sorensen et al.,
1997).
Role in experiments of nature and
disease states
The association between antimicrobial peptides and a
human disease was originally observed based on
studies of cystic fibrosis. This indicated the impor-
tance of antimicrobial peptides in immunity (Smith
et al., 1996). This finding was first reported by the
group of M. Welsh and is now considered a milestone
in research on antimicrobial peptides. In cystic
fibrosis (CF), the CFTR (cystic fibrosis transmem-
brane-conductance regulator) protein, a chloride
channel, is mutated leading to abnormal airway
surface fluid and a failure of CF epithelia to kill
8 Birgitta Agerberth and Gudmundur H. Gudmundsson
bacteria (Smith et al., 1996). Which mechanisms are
involved is still under debate, but it is now accepted
that antimicrobial peptides, including LL-37, are of
importance for lung surface defenses. Increased salt
concentrations have been suggested as an important
denaturating factor; indeed salt affects individual
antimicrobial peptides/proteins in addition to dimin-
ishing their synergistic and/or additive action (Singh
et al., 2000). LL-37 is expressed in lung epithelial cells
and alveolar macrophages (Agerberth et al., 1999).
Increased concentrations are found in aspirates of
newborn infants during lung infection(s) (Schaller-
Bals et al., 2002). Furthermore, it is of interest that in
a xenograft model antimicrobial activity could be
restored after exposure of CF xenografts to an
adenovirus expressing the gene encoding LL-37 (Bals
et al., 1999).
IN THERAPY
Toxicity
LL-37 like most antimicrobial peptides has effect
on eukaryotic cells but at concentrations that
are higher than the effective antimicrobial concen-
trations (Johansson et al., 1997). Whether this
cytotoxic effect becomes problematic during the
phase of upregulation in inflammation has not been
documented.
ACKNOWLEDGEMENT
The authors would like to thank Eirikur
Steingrimsson for critical reading of the manuscript.
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