Molecular Aspects of Medicine xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Molecular Aspects of Medicine

journal homepage: www.elsevier.com/locate/mam

Organ and tissue fibrosis: Molecular signals, cellular mechanisms and

translational implications
Ralf Weiskirchena, Sabine Weiskirchena, Frank Tackeb,∗
a
Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry, RWTH University Hospital Aachen, Germany
b
Dept. of Medicine III, University Hospital Aachen, Germany

A R T I C LE I N FO A B S T R A C T

Keywords: Fibrosis denotes excessive scarring, which exceeds the normal wound healing response to injury in many tissues.
Organ fibrosis Although the extracellular matrix deposition appears unstructured disrupting the normal tissue architecture and
Matrix subsequently impairing proper organ function, fibrogenesis is a highly orchestrated process determined by de-
Regression fined sequences of molecular signals and cellular response mechanisms. Persistent injury and parenchymal cell
Biomarkers
death provokes tissue inflammation, macrophage activation and immune cell infiltration. The release of biolo-
Imaging
gically highly active soluble mediators (alarmins, cytokines, chemokines) lead to the local activation of collagen
Fibroblasts
Exosome producing mesenchymal cells such as pericytes, myofibroblasts or Gli1 positive mesenchymal stem cell-like cells,
Macrophage to a transition of various cell types into myofibroblasts as well as to the recruitment of fibroblast precursors.
Therapy Clinical observations and experimental models highlighted that fibrosis is not a one-way road. Specific me-
chanistic principles of fibrosis regression involve the resolution of chronic tissue injury, the shift of inflammatory
processes towards recovery, deactivation of myofibroblasts and finally fibrolysis of excess matrix scaffold. The
thorough understanding of common principles of fibrogenic molecular signals and cellular mechanisms in
various organs - such as liver, kidney, lung, heart or skin - is the basis for developing improved diagnostics
including biomarkers or imaging techniques and novel antifibrotic therapeutics.

1. Introduction: principles of physiological wound healing vs.
pathological fibrosis
Fibrosis is a reparative or reactive process that is majorly char-
acterised by the formation and deposition of excess fibrous connective
tissue resulting in progressive architectural remodeling in nearly all
tissues and organs (Fig. 1). This scarring process is a leading cause of
morbidity and mortality and may account for up to 45% of all causes of
death in the United States (Wynn, 2004). Mechanistically, fibrogenic
responses encompass the same fundamental mechanisms that are part
of the normal wound healing response. However, upon scarring the
respective mechanisms become exacerbated due to tissue injury. Con-
sequently, chronic fibrogenesis provokes a shift from a supportive
(“good”) fibrotic tissue to a microenvironment, in which extracellular
matrix (ECM) producing cells increase in number or become excessively
active, thereby forming way too much ECM resulting in substantial
(“bad”) scar formation and destruction of normal organ architecture
(Pakshir and Hinz, 2018).
In most cases, fibrosis is initiated by parenchymal cell destruction,
in which cell death (necrosis, apoptosis, necroptosis, pyroptosis,
ferroptosis and others) is driven by various injurious agents and me-
chanisms. The resulting tissue damage is associated with an in-
flammatory response, in which local immune cells (mainly tissue
macrophages) become activated and diverse sets of blood cells enter the
affected sites of injury. The local and invading immune cells produce a
large variety of biologically highly active soluble mediators (cytokines
and chemokines) that lead to a local activation of mesenchymal cells,
which have the capacity to produce ECM and to further increase pro-
duction of pro-inflammatory cytokines, chemokines, and angiogenic
factors. A hallmark of these cells is their transition from a resting to an
activated phenotype, by which they become strongly positive for α-
smooth muscle actin (α-SMA) expression and synthesize ECM compo-
nents. Moreover, the fraction of cells contributing to the formation of
fibrillar collagens and non-structural proteins with regulatory roles in
ECM is significantly increased by other cell populations that can transit
into myofibroblasts or matrix producing cells. Such potential progeni-
tors for myofibroblasts were identified during the last decades. In
particular, tissue-resident fibroblasts, circulating bone marrow-derived
fibrocytes, different epithelial and endothelial cell subsets that acquire
a myofibroblast phenotype in a process termed epithelial-to-

∗
Corresponding author. Department of Medicine III, University Hospital Aachen; Pauwelsstrasse 30, 52074, Aachen, Germany.
E-mail address: frank.tacke@gmx.net (F. Tacke).

https://doi.org/10.1016/j.mam.2018.06.003
Received 22 March 2018; Accepted 25 June 2018
0098-2997/ © 2018 Elsevier Ltd. All rights reserved.

Please cite this article as: Weiskirchen, R., Molecular Aspects of Medicine (2018), https://doi.org/10.1016/j.mam.2018.06.003
R. Weiskirchen et al.
Fig. 1. Common characteristics of organ fibrosis. Injurious events lead to
organ damage, inflammation, and fibrosis in liver, kidney, lung, heart and skin.
Hallmarks of fibrotic processes shared by all of these tissues include the ex-
cessive production of cytokines, chemokines, growth factors, extracellular
matrix (ECM) proteins as well as loss of normal organ architecture and function.
mesenchymal transition (EMT) as well as other mesenchymal cells such
as pericytes and resident mesenchymal stem/progenitor cells are po-
tential precursors for myofibroblasts (Di Carlo and Peduto, 2018). Be-
side their influence on ECM production, these cells have also essential
immunomodulatory and regenerative roles during wound healing
(Weiskirchen and Tacke, 2014). Although reparative during normal
wound healing, the resulting matrix involving the above mentioned
cells and a plenitude of different soluble factors (chemokines, cyto-
kines) loses its reparative capacity and can acquire a different archi-
tectural structure with elevation of characteristic matrix proteins (col-
lagen, elastin), structural (basement) glycoproteins, proteoglycans and
carbohydrates such as hyaluronan (Gressner and Weiskirchen, 2006).
This abundant fibrous stroma with increased ECM and growth factor
production forms a microenvironment that allows the development of
tumor-associated desmoplasia facilitating tumor initiation.
2. Organ-independent mechanisms of fibrosis
In the different organs, a wide range of noxious compounds and
triggers can lead to initiation and progression of fibrosis (Fig. 2). Tissue
damage initiates an orchestrated repair process aiming to preserve
organ function and tries to eliminate or insulate the initial cause of
injury or underlying harmful stimuli. This inflammatory response in-
volves the local vascular system, components of the immune systems,
2
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
and even a coordinated systemic mobilization of endocrine and neu-
rological mediators. In the affected organ the process is characterised
by typical cardinal signs of inflammation that include pain, heat, red-
ness, swelling and impairment or loss of function. Most important in the
initiation of this inflammatory response are resident immune cells al-
ready present in the (damaged) organ including macrophages, dendritic
cells, and mast cells. Commonly, these cells of the reticuloendothelial
system possess specialized surface receptors known as pattern re-
cognition receptors playing crucial roles in detecting pathogen-asso-
ciated molecular patterns (PAMPs) such as bacterial toxins and damage-
associated molecular patterns (DAMPs) released by injured cells
(Heymann and Tacke, 2016). After recognition of PAMPs and DAMPs,
respective cells release different inflammatory mediators that in turn
provoke increased blood flow, permeability of blood vessels, over-
heating of the tissue, increase the sensitivity to pain, and exudation of
plasma proteins and fluid into the tissue. These alterations manifest in
the mentioned cardinal signs of inflammation. In addition to the release
of inflammatory mediators, the complement system becomes activated.
This system consists of a number of small blood proteins that after
proteolytic activation attract phagocytes and stimulate them to clear
harmful or damaged material (Danobeitia et al., 2014). Likewise, the
coagulation cascade with capacity to physically trap invading microbes
in blood clots and the fibrinolysis system that reorganise and resorb
blood clots are stimulated. When all these responses are sufficient to
defend against injury, the soluble mediators are degraded and tissue
homeostasis is restored.
However, if this first line of defense is insufficient to remove nox-
ious compounds, the cause of inflammation persists and various im-
mune cells (e.g., macrophages, T-lymphocytes) are triggered to produce
cytokines and enzymes that cause more lasting damage. These pro-
cesses stimulate parenchymal cell death, resulting in loss of cell mem-
brane integrity and uncontrolled release of products of cell death and
pro-fibrogenic mediators into the extracellular space that stimulate
activity of pro-fibrogenic cell populations.
One prototypical factor in this scenario is transforming growth
factor-β (TGF-β). The three members of the TGF-β family (i.e. TGF-β1,
TGF-β2, and TGF-β3) are active as secreted peptides and share similar
biological activities in vitro, while eliciting more specific biological re-
sponses in vivo (Gressner and Weiskirchen, 2006). During inflammation
and fibrosis, TGF-β1 is the most important member in physiological
repair and collagen accumulation. On one side, it strongly promotes
collagen and fibronectin production in both epithelial and mesench-
ymal cells leading to the net accumulation of ECM tissue during wound
repair and fibrosis. On the other site, the targeted disruption of the
Tgfb1 gene in mice results in tissue necrosis in specific organs, over-
whelming inflammatory cell infiltration into numerous organs and
systemic infiltration suggesting that TGF-β is a general suppressor of
excessive inflammation (Shull et al., 1992). Therefore, TGF-β is con-
sidered as one of the common master switches for the induction of the
fibrotic program during chronic phases of inflammatory diseases in
many organs and tissue. Other important soluble pro-fibrogenic med-
iators include connective tissue growth factor (CTGF) and members of
the platelet-derived growth factor (PDGF) family of growth factors.
While CTGF is considered to bind to TGF-β and enhance its binding to
membrane-bound receptors (Abreu et al., 2002), members of the PDGF
family are potent mitogens and chemoattractants for fibrogenic cells in
most organs driving the recruitment and proliferation of these cells at
sites of tissue injury (Kazlauskas, 2017; Borkham-Kamphorst and
Weiskirchen, 2016). These common mediators promote activity and
increase total number of myofibroblasts, thereby up-regulating the rate
of matrix production and promoting a multitude of disease that affect a
variety of organs including skin, lung, liver, kidney, pancreas, heart,
and others.
R. Weiskirchen et al.
Fig. 2. Major causes of organ fibrosis. In the different organs, a wide range of noxious compounds and triggers can lead to initiation and progression of fibrosis. In
the affected organs, different changes and alterations are provoked that may lead to organ dysfunction or failure.
3. Cellular sources of extracellular matrix and fibrogenic signaling
As outlined above, there is a large variety of cellular subsets and
mechanisms contributing to the formation of extracellular matrix
during fibrogenesis (Fig. 3). Potential cellular sources of ECM produ-
cing cells promoting fibrosis in liver, kidney, lung, heart and skin are
manifold (Table 1). Most strikingly, the resident pro-fibrogenic cells
within the different tissues, their respective progenitors that invade the
inflamed tissue or cell fractions that become activated and obtain a
matrix-synthesizing phenotype are common in the different organs.
However, in regards to their biological origin, profibrogenic features,
overall contribution to fibrogenesis, and relevance in different types of
fibrogenesis each cell type has its peculiarities.
3.1. Fibroblasts
Fibroblasts are derived from the embryonic mesoderm tissue re-
presenting the most common cell type of the connective tissue with the
ability to form morphologically heterogeneous states with diverse ap-
pearances. Active fibroblasts have a branched cytoplasm with abundant
rough endoplasmic reticulum, while in an inactive state they are
smaller, more spindle-shaped with lower content of rough endoplasmic
reticulum. They produce a large variety of ECM structural proteins,
3
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
adhesive proteins, ground substance, and play fundamental roles in
ECM maintenance and reabsorption. Fibroblasts are dispersed
throughout the body and seem to be the least specialized cells in the
connective tissue that may differ across sites of the same organ. They
are chemotactic and can migrate within tissue. This important feature
permits to take over pivotal roles in wound healing, inflammation, and
fibrogenesis. Based on their contractile phenotype, they can contract
the matrix to seal an open wound. They further express proteins playing
a role in blood clotting, produce and are responsive to many in-
flammatory cytokines, and play critical biological roles in angiogenesis.
During fibrogenesis, they (or subsets of these cells) can transform into
myofibroblasts that are hypersensitive to chemical signals such as cy-
tokines, chemokines and growth factors, thereby provoking ex-
aggerated ECM production (Kendall and Feghali-Bostwick, 2014). In
most organs (e.g. skin, lung), resident fibroblast stromal cells that ex-
pand and become activated appear to be the most significant source of
myofibroblasts, while in distinct organs other cell types (e.g. hepatic
stellate cells and portal myofibroblasts in liver) are the most significant
contributing source of myofibroblasts.
3.2. Mesothelial cells
These cells are specialized cells forming monolayers (i.e. the
R. Weiskirchen et al.
mesothelia) covering the pleural, peritoneal and pericardial serosal
cavities. They derive from the embryonic mesoderm cell layer dis-
playing a phenotype resembling epithelial cells. Originally, it was
thought that the mesothelium is mostly relevant to protect the internal
organs of the body and to produce a lubricating fluid that is helpful in
protecting the body against infection. There is evidence that these cells
upon appropriate stimulus can be genetically reprogrammed. This
transition process, termed “mesothelial-to-mesenchymal transition”
(MMT) is associated with morphological and functional changes and
lead to cells producing extracellular matrix compounds. In vitro, TGF-β1
was shown to induce this reformation in differentiated human me-
sothelial cells and become positive for α-SMA, highlighting the fact that
these cells can act as progentiors for myofibroblasts (Yang et al., 2003).
Using mouse models and conditional cell lineages analysis, it was de-
monstrated that MMT give rise to hepatic stellate cells and myofibro-
blasts during liver fibrogenesis and that this process can be effectively
blocked in vitro and in vivo by antagonising TGF-β (Li et al., 2013).
3.3. Fibrocytes
This spindle-like shaped cell type is of mesenchymal origin and
possesses an inactive phenotype with limited amount of rough en-
doplasmic reticulum. It was first described in 1994 as a new leukocyte
subpopulation that appeared concurrently with circulating in-
flammatory cells accounting for approximately 10% of the cells that
infiltrate subcutaneously implanted wound chambers and found in re-
gions of scar formation (Bucala et al., 1994). Typically, these cells ex-
press fibroblasts components including vimentin, collagen, fibronectin
and display the leukocyte common antigen CD45 (Bucala et al., 1994).
Fibrocytes can be induced by TGF-β to express α-SMA, have funda-
mental roles in adaptive immunity and further have capacity to support
angiogenesis (Quan et al., 2004). A large variety of studies using bone
marrow (BM) transplantation in mice have demonstrated that BM is the
source of circulating fibrocytes that transmigrate with the blood stream
specifically into the side of injury.
3.4. Epithelial cells
This group of cells are located in surfaces of the body such as skin,
blood vessels, urinary tract, or organs. Their cell polarity allows them to
4
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
Fig. 3. Origin and mechanisms leading to myofi-
broblast formation. During fibrogenesis, myofibro-
blasts are key players in extracellular matrix synth-
esis. This cell population can be derived from
resident fibroblast, mesothelial cells, circulating fi-
brocytes, epithelial cells, endothelial cell, pericytes,
vascular smooth muscle cells, Gli1+ perivascular
mesenchymal stem cell-like cells, and other specia-
lized cell types. Different mechanisms including cel-
lular activation, transformation, proliferation, in-
filtration, expansion, epthelial-to-mesenchymal
transition (EMT), mesothelial-to-mesechymal transi-
tion (MMT), and endothelial-to-mesenchymal-tran-
sition (EndoMT) are relevant in increasing the net
pool of myofibroblasts.
convey diverse functions in secretion, absorption, protection, and sen-
sing. In general, epithelial cells are bound by a basal membrane and are
closely connected to each other by specialized intercellular connections
(i.e. gap junctions, tight junctions, adherent junctions). Most strikingly,
epithelial cells are most often multipotent having capacity to differ-
entiate into a variety of other cell types. In a process termed epithelial-
to-mesenchymal transition (EMT), epithelial cells can undergo multiple
biochemical changes in which they lose their polarity and acquire a
mesenchymal phenotype having enhanced migratory capacity, inva-
siveness, and massively increased production of ECM components
(Kalluri and Weinberg, 2009). As a further characteristic, these trans-
ited cells become positive for the fibroblast-specific protein (FSP1, also
known as S100A4). During the last decade, EMT and the cellular
plasticity of epithelial cells allowing them to acquire features of me-
senchymal cells was claimed to be another significant source of myo-
fibroblasts in injured tissues. Although this concept is still valid in many
organs, cell tracing experiments in other organs have questioned the
role of EMT in organ fibrosis (Österreicher et al., 2011). In particular,
there are many controversial reports on EMT in hepatic fibrogenesis.
While a large number of independent studies confirm that hepatocytes
or biliary epithelial cells (cholangiocytes) undergo EMT upon TGF-β
treatment in culture, in vivo experimentation which are based on ge-
netic fate mapping analysis suggested that EMT is not relevant for he-
patic fibrogenesis in vivo (Munker et al., 2017).
3.5. Endothelial cells
This cell population forms a one-cell thick walled layer (i.e. the
endothelium) that lines the entire interior surface of all blood vessels
such as arteries, arterioles, venules, veins and capillaries. These cells
contribute to the maintenance of barrier functions, blood flow and are
active cellular participants in inflammatory responses. In 1992, it was
demonstrated that the bovine aortic endothelial cells express α-SMA
when exposed to TGF-β1 suggesting that endothelial cells have capacity
to transit into a smooth-muscle-like phenotype (Arciniegas et al., 1992).
This phenotypic transition of endothelial cells into mesenchymal cells
was later termed “endothelial-to-mesenchymal-transition" (EndoMT).
There are evidence that the process of EndoMT can contribute to car-
diac fibrosis, kidney fibrosis, and pulmonary fibrosis (Piera-Velazquez
et al., 2016).
R. Weiskirchen et al. Molecular Aspects of Medicine xxx (xxxx) xxx–xxx

Table 1 In the liver, the sinusoidal pericytes are commonly named hepatic
Potential cellular sources of extracellular matrix producing cells in fibrosis of stellate cells (HSC). These cells are located in the space between par-
liver, kidney, lung, heart and skin. enchymal cells and sinusoidal endothelial cells (i.e. the space of Disse)
Organ Cell type References of the hepatic sinusoid and have several specialized functions. In par-
ticular, these cells are the major vitamin A storage site of the body and
Liver Hepatic stellate cells (lipocytes) Friedman et al., 1985 have hemodynamic and immunoregulatory functions (Tsuchida and
Portal myofibroblasts Tang et al., 1994;
Friedman, 2017). During fibrogenesis, HSC transdifferentiate into
Tuchweber et al., 1996
Resident fibroblast Guyot et al., 2006 myofibroblasts giving rise to 82–96% of the hepatic myofibroblast pool
Vascular smooth muscle cells Guyot et al., 2006 in experimental models of toxic, cholestatic, and fatty liver disease, as
BM-derived myofibroblast precursors Forbes et al., 2004 estimated in fate tracing experiments using a construct in which Cre
(fibrocytes, circulating mesenchymal cells)
expression was driven by a lecithin-retinol acyltransferase (Lrat) gene
Hepatocytes undergoing EMT Zeisberg et al., 2007
Biliary epithelial cells (cholangiocytes) Rygiel et al., 2008
promoter (Mederacke et al., 2013). Interestingly, activation of HSC into
undergoing EMT matrix-producing myofibroblasts in the liver is not unidirectional; ex-
Sinusoidal endothelial cells Bardadin and Desmet, perimental evidence unravelled the deactivation of myofibroblasts into
1985 a “quiescent-like" HSC phenotype during the resolution from injury
Mesothelial cells (MMT or EndoMT) Li et al., 2013
(Troeger et al., 2012; Kisseleva et al., 2012).
Gli1+ perivascular MSC Kramann et al., 2015
Kidney (Tubular) epithelial cells Grgic et al., 2012
Endothelial cells/monocytes Phua et al., 2013 3.7. Vascular smooth muscle cells
Circulating fibrocytes and mesenchymal LeBleu et al., 2013
stem cells of BM origin
These contractile cells are a specialized smooth muscle cell type
Resident fibroblasts LeBleu et al., 2013
Pericytes Lin et al., 2008;
within the normal blood vessel wall meditating contraction and re-
Humphreys et al., 2010 laxation. They typically express α-SMA, transgelin (SM22α), vimentin
Perivasuclar fibroblasts Lin et al., 2008 and desmin. In response to injury, they become activated, proliferate,
Podocytes undergoing EMT Ying and Wu, 2017 migrate and express different extracellular matrix proteins.
Gli1+ perivascular MSC Kramann et al., 2015
Mechanistically, it was demonstrated that bradykinin induces collagen
Lung Resident fibroblasts Low et al., 1984
BM-derived mesenchymal progenitor cells Hashimoto et al., 2004; type I production in vascular smooth muscle cells via autocrine acti-
(fibrocytes) Xu et al., 2009 vation of TGF-β1 and implication of mitogen-activated protein kinase
Pericytes Hung et al., 2013; Rock pathways (Douillet et al., 2000).
et al., 2011
Alveolar epithelial cells undergoing EMT Willis et al., 2005
Endothelial cells (EndoMT) Hashimoto et al., 2010
3.8. Gli1 positive perivascular mesenchymal stem-like cells
Gli1+ perivascular MSC Kramann et al., 2015
Heart Cardiac fibroblasts Kawaguchi et al., 2011 Mesenchymal stem cells (MSC) are multipotent connective tissue
Cardiomyocytes Kawaguchi et al., 2011 cells that reside in the perivascular niche of many organs. Genetic
BM-derived circulating fibrocytes Keeley et al., 2012
lineage tracing analysis demonstrated that tissue-resident, but not cir-
Endothial and vascular smooth muscle cells Douillet et al., 2000; Wu
et al., 2016 culating, glioma-associated oncogene homolog Gli1 positive (Gli1+)
Gli1+ perivascular MSC-like cells Kramann et al., 2015 cells that express typical MSC markers, expand and become myofibro-
Skin Resident fibroblasts (of different lineages) Rinkevich et al., 2015 blasts, thereby contributing to the formation of renal, hepatic, pul-
Pericytes Sundberg et al., 1996; Liu monary and cardiac fibrosis (Kramann et al., 2015). In line with this
et al., 2010
Fibrocytes Iqbal et al., 2012
assumption, the ablation of Gli1+ cells with an inducible diphtheria
Stromal cells Dulauroy et al., 2012 toxin receptor allele resulted in significant amelioration of experi-
mental kidney and heart fibrosis (Kramann et al., 2015).
Abbreviations usedare: BM, bone marrow; EndoMT, Endothelial-mesenchymal
transition; EMT, epithelial-to-mesenchymal transition; Gli1, glioma-associated 3.9. Specialized cells
oncogene family member 1; MSC, mesenchymal stem cell; MMT, mesothelial-
to-mesenchymal transition.
In some organs, specialized resident cells are present that contribute
to the excess of matrix during fibrogenesis. These have several features
3.6. Pericytes in common with the cells discussed above, but are located in defined
areas of a tissue or have somewhat different expression profiles than
Pericytes are multipotent, mesenchym-derived, and heterogeneous other myofibroblasts. For example, beside the above mentioned hepatic
cells with a variety of origins, functions, morphologies and surface
stellate cells, the liver contains so called portal myofibroblasts. These
markers. They contain contractile elements and are wrapped around the perivascular mesenchymal cells have been defined as liver myofibro-
endothelial cells that line the capillaries and venules or are embedded
blasts derived from cells that are distinct from HSC and located in the
in basement membranes in proximity to endothelial cells. They are portal tract (Lemoinne et al., 2013). It is well accepted that these cells
involved in regulation of capillary blood flow, phagocytic clearance of
become activated and obtain a myofibroblastic phenotype in cholestatic
cell debris, and support endothelial cells in forming the blood-brain liver fibrosis and can be distinguished from HSC on the basis of mor-
barrier. Importantly, although pericytes endogenously express α-SMA, phological criteria and growth behaviour (El Mourabit et al., 2016). In
they are not terminally differentiated and can transit into fibroblasts, the kidney, the podocytes found in the lining of the Bowman's capsules
osteoblasts, and smooth muscle cells (Kendall and Feghali-Bostwick, in the nephrons possess a well-developed endoplasmic reticulum and a
2014). The precise contribution of this cell population to the formation large Golgi apparatus. They are derived from the mesenchyme of the
of fibrogenesis in different organs is still controversially discussed. mesoderm and can undergo EMT in pathological states. During podo-
Particularly, conflicting data were reported for pericytes in the patho-
cyte transition, the expression of nephrin, podcin, P-cadherin and ZO-1
genesis of lung fibrosis. While one report excluded pericytes that ex- is downregulated, while the expression of α-SMA and N-cadherin are
press α-SMA, PDGFRβ and NG2 as an origin of myofibroblasts in the
increased in a process that is majorly dependent on TGF-β (Ying and
lung, another report suggested that Foxd1 progenitor-derived pericytes Wu, 2017). Similarly, a historical landmark paper that has provided
significantly contribute to the formation of lung fibrosis (Rock et al.,
first evidence for EMT in kidney demonstrated that tubular epithelial
2011; Hung et al., 2013). cells might also acquire migratory properties and transit into a

5
R. Weiskirchen et al.
myofibroblast-like phenotype characterised by de novo expression of
collagen, vimentin and FSP1 (Strutz et al., 1995).
4. Key mediators of inflammation and fibrogenesis
There are numerous pro-inflammatory and pro-fibrogenic mediators
that can act in a hierarchical manner. During the last decades, the
emerging role of chemokine production as a critical factor regulating
immune cell entry into the inflamed tissue at the onset and during
progression became evident. Similarly, several cytokines (TGF-β, PDGF,
IL-1β, IL-6, IL-13, IL-33, and TNF-α) hold important functions in the
inflammatory process and in the progression to fibrosis. Work from
recent years have shown that also some non-peptidic mediators (e.g.
reactive oxygen species, ROS; lipid mediators, acetaldehyde) induce
expression or activity of mediators relevant in fibrogenesis. In the fol-
lowing, we will briefly highlight the biological activities and impact of
these molecules on inflammation and fibrogenesis.
4.1. Chemokines
As stated above, the concerted recruitment of immune cells from the
circulation into persistently injured tissue is a key mechanism during
fibrogenesis in liver (Heymann and Tacke, 2016), kidney (Tecklenborg
et al., 2018), lung (Kolahian et al., 2016), heart (Frantz et al., 2018) or
other tissues affected by fibrosis. It has long been appreciated that
chemokines, chemoattractant cytokines that bind to specific chemokine
receptors on leukocytes, orchestrate the recruitment and partially also
the activation of immune cells in inflammation (Charo and Ransohoff,
2006). Altogether, the chemokine system includes about 50 different
chemokine ligands and 20 cognate chemokine receptors, of which many
have been linked to the progression or regression of organ fibrosis
(Zlontnik and Yoshie, 2000). The exact functions of chemokines in
organ injury and fibrosis have been reviewed elsewhere in detail for the
liver (Marra and Tacke, 2014), the kidney (Kurts et al., 2013), the lung
(Tomankova et al., 2015) and the heart (Jones et al., 2017; Swirski and
Nahrendorf, 2013).
One prime example for an organ-independent chemokine signal in
fibrosis is the C-C motif chemokine 2 (CCL2) or monocyte chemoat-
tractant protein-1 (MCP-1), which is released by parenchymal cells,
activated tissue macrophages and fibroblasts in organ injury. In human
disease as well as in experimental animal models of fibrosis, CCL2
provokes the accumulation of inflammatory, monocyte-derived mac-
rophages in injured tissue, which provoke activation of fibroblasts. This
principle has been recapitulated in liver (Karlmark et al., 2009), kidney
(Kitagawa et al., 2004), cardiac (Frangogiannis et al., 2007) and pul-
monary fibrosis (Okuma et al., 2004). Moreover, in several animal
models of fibrosis, the CCR2-CCL2 axis was an excellent target for
pharmacological interventions (Tacke, 2017; Baeck et al., 2012;
Krenkel and Tacke, 2017; Ninichuk et al., 2008). In an exploratory early
phase clinical trial, inhibition of CCL2 by the pegylated aptamer NOX-
E36 improved disease biomarkers in patients with diabetic nephropathy
(Menne et al., 2017). In a multicenter, randomized, placebo-controlled
phase 2 clinical trial involving 289 patients with non-alcoholic steato-
hepatitis and liver fibrosis, treatment with the dual CCR2/CCR5 in-
hibitor cenicriviroc demonstrated a higher rate of patients with histo-
logical improvement of hepatic fibrosis after 1 year of therapy
(Friedman et al., 2018). This led to the implementation of a large phase
3 clinical trial on this substance with the primary end-point to treat
liver fibrosis (Tacke, 2018). As there is a high redundancy within the
chemokine system as well as the involvement of multiple chemokines
and chemokine receptors during fibrogenesis, it can be anticipated that
targeting other (or even multiple) chemokine pathways will offer
therapeutic potential for organ fibrosis as well (Lee et al., 2015;
Cavalera and Frangogiannis., 2014; Tomankova et al., 2015; Marra and
Tacke, 2014).
6
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
4.2. Cytokines
Cytokines are small proteins produced by a broad range of cells that
can bind on specific cell-surface exposed receptors. They can act in an
autocrine (i.e. binding to receptors on to the cell that produces it) or
paracrine (i.e. released from one cell and binding to receptors on a
nearby cell) manner. After binding, cytokines initiate specific in-
tracellular signaling pathways impacting protein activity and mod-
ulating downstream gene expression. Some of these cytokines that are
critically involved in the pathogenesis of fibrosis are briefly discussed in
the following.
4.2.1. TGF-β
The three different TGF-βs belong to a large family of at least 35
structurally related members forming the TGF-β superfamily. The in-
dividual members of this family are encoded by genes dispersed
throughout the genome (Weiskirchen and Meurer, 2013). Typically,
they form similar, symmetric homodimers secreted as biologically in-
active mediators that are transformed into their biologically active form
by proteolytic processing. Once activated, they bind to two kinds of
membrane receptors with serine/threonine kinase activity, which
mediate their signals through Smad-dependent and Smad-independent
pathways (Weiskirchen and Meurer, 2013). There is strong evidence
that the blockade of TGF-β alone is sufficient to completely block ex-
perimental fibrogenesis in liver, kidney, lung, heart and skin (Gressner
et al., 2002; Weiskirchen, 2016; Natase et al., 2017; Aschner and
Downey, 2016; Thanigaimani et al., 2017; Andrews et al., 2016). In all
organs, TGF-β is a key cytokine driving collagen gene expression. This
was most obviously demonstrated in experimental liver fibrosis. The
suppression of TGF-β synthesis (Arias et al., 2003) or the expression of a
soluble TGF-β receptor sequestering biological active TGF-β resulted in
attenuation of experimentally induced hepatic fibrosis. Similar results
were obtained when BMP-7 acting as a physiological opposing factor of
TGF-β was overexpressed in a model of hepatic fibrogenesis (Kinoshita
et al., 2007). Most importantly, also antioxidants that interfere with
distinct molecular steps in TGF-β singaling were shown to mediate
beneficial effects on experimental liver fibrosis (Meurer et al., 2005;
Weiskirchen, 2016). As discussed above, TGF-β not only induces ex-
tracellular matrix formation in pro-fibrogenic cells, it also increases the
pool of myofibroblasts by promoting or triggering the processes of EMT,
MMT, and EndoMT.
4.2.2. PDGF
The PDGF family is comprised of five members (PDGF-AA, PDGF-
AB, PDGF-BB, PDGF-CC, and PDGF-DD). They mediate their biological
effects via the receptor tyrosine kinases PDGFRα and PDGFRβ that can
form pure or mixed dimers. Typically, PDGFs are potent mitogens
driving cell proliferation and differentiation. With regards to in-
flammatory liver insult, the expression of the different PDGF ligand and
receptors is differentially regulated (Borkham-Kamphorst et al., 2008;
Martin et al., 2013). In diverse models of hepatic fibrogenesis is was
suggested that the targeting of PDGF-B, PDGF-D, and PDGFRβ should
be therapeutically more effective than targeting ligands that act via the
PDGFRα receptor branch that seem to be more relevant in the patho-
genesis of tumor formation (Weiskirchen, 2016). Similarly, PDGF-DD
and PDGFRβ were markedly upregulated in both human and murine
kidneys on activated mesenchymal cells demonstrating their im-
portance for kidney disease (Buhl et al., 2016). Besides these simila-
rities there are also marked differences between hepatic and renal fi-
brosis. While PDGF-C deficiency or antagonism failed to protect from
liver fibrosis, the lack of PDGF-C prevented kidney fibrogenesis in the
unilateral ureteral obstruction model (Martin et al., 2013). With regards
to heart, lung, and skin, there is also clear evidence that PDGF sig-
nificantly contributes to the formation of cardiac and pulmonary fi-
brosis by stimulating the proliferation and migration of collagen-se-
creting fibroblasts as well as activating mesenchymal stem and/or
R. Weiskirchen et al.
progenitor cells contributing to the formation of novel myofibroblasts
during disease progression (Kong et al., 2014; Nishioka et al., 2013;
Iwayama and Olson, 2013).
4.2.3. Interleukins
IL-1β, IL-6, IL-13, and IL-33 belong to the interleukin family of
cytokines that contain over 40 different members. Most interleukins
possess pleiotropic activities in the innate and adaptive immune re-
sponse and in nearly all types of inflammatory responses. IL-1β and IL-6
are critical proinflammatory contributors to the pathogenesis of hepatic
inflammation, steatosis, and fibrosis (Del Campo et al., 2018). How-
ever, IL-6 can also exert tissue-protective and pro-regenerative func-
tions in the liver, thereby attenuating liver fibrosis (Kovalovich et al.,
2000; Hammerich and Tacke, 2014). IL-6 is also fundamentally in-
volved in renal fibrosis. It is produced by renal resident cells, including
podocytes, mesengial cells, endothelial cells and tubular epithelial cells
that are highly responsive towards IL-6 via classic signaling or via trans-
signaling pathways that are induced by binding of a ligand-bound so-
luble IL-6 receptor to gp130 on cells that do not express endogenous IL-
6 receptors (Su et., 2017).
Recently, it was demonstrated that IL-33 can promote the process of
pulmonary fibrosis by inducing the imbalance between MMP-9 and
TIMP-1 (Wu et al., 2018). On the other side, IL-33 signaling has been
found to have protective effects in cardiovascular disease and to at-
tenuate cardiac fibrosis by modulating fibroblast function and gene
expression (Zhu and Carver, 2012). However, it this study it was de-
monstrated that the major effects of IL-33 were induced by modulation
of cell migration and activation of cytokine/chemokine expression,
rather than modulating expression of extracellular matrix components
or impacting proliferation. Moreover, in liver fibrosis, IL-33 was de-
scribed to activate fibrosis-promoting innate lymphoid cells type 2 as
well as collagen-producing stellate cells (McHedlidze et al., 2013;
Weiskirchen and Tacke, 2017). These examples show that the effect of
individual interleukins might vary between organs and in different
disease settings. In addition, there is a wealth of information showing
that individual members of the interleukin family have overlapping but
also distinct biological activities and may evolve pro- or anti-in-
flammatory activities (as well as both activities). Therefore, it is most
likely that strategies aiming to antagonize a specific interleukin could
have serious side effects and might be beneficial only in selected disease
conditions. A good example for a potential therapeutic interleukin
target is Schistosomiasis, in which IL-13 appears to be the dominant
pro-fibrotic cytokine associated with liver fibrogenesis by directly in-
ducing expression of fibrosis-associated genes including collagens and
CTGF in profibrogenic hepatic stellate cells (Liu et al., 2012).
4.2.4. TNF-α
Tumor necrosis factor-α (TNF-α) belongs to the TNF family con-
sisting of 19 different proteins. It is mainly secreted by macrophage
subsets and binds to two different receptor types (TNF-R1 and TNF-R2)
that initiate a plenitude of signaling cascades leading to activation of
NF-κB and triggering cellular activation, differentiation, cytokine pro-
duction and cell apoptosis (Weiskirchen, 2016). As such it is an im-
portant inflammatory signaling molecule during fibrogenesis of liver,
kidney, heart, lung, and skin (Borkham-Kamphorst et al., 2013; Del
Campo et al., 2018; Lv et al., 2018; Sun et al., 2007; Murdaca et al.,
2016).
4.3. Non-peptide mediators
Excessive ROS generation, accelerated lipid accumulation, and for-
mation of acetaldehyde were identified as crucial factors in the pa-
thogenesis of fibrosis. Some of their biological activities are directly
associated with the induction of TGF-β gene expression or activity,
while others seemed to be mediated in a TGF-β-independent manner.
The biological significance of ROS, lipids, and acetaldehyde as
7
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
prototypes of these non-peptidic mediators will be briefly discussed.
4.3.1. ROS
Reactive oxygen species (ROS) formation is a critical driver of in-
flammation and fibrosis. Under healthy conditions, NADPH oxidase
(NOX)-derived ROS are essential modulators of signal transductions
pathways controlling cell growth, proliferation, migration, differentia-
tion and apoptosis (Manea et al., 2015). However, uncontrolled ROS
generation and oxidative stress induce cell damage. In liver damage,
elevated ROS concentrations play an important role in promoting liver
damage and initiating fibrosis by disrupting integrity of lipids, proteins,
DNA, inducing parenchymal cell necrosis and apoptosis, and stimu-
lating the production and release of profibrogenic mediators from
Kupffer cells and circulating inflammatory cells that subsequently ac-
tivate hepatic stellate cells (Sánchez-Valle et al., 2012).
Mechanistically, it is also now well accepted that ROS and TGF-β
are interlinked (Richter und Kietzmann, 2016). On one side, ROS for-
mation has been shown to be enhanced in response to TGF-β1, most
likely by suppressed expression of several antioxidant enzymes. On the
other hand, increased production of ROS leads to proteolytic activation
and elevated expression of TGF-β1 in different organs (De Bleser et al.,
1999; Barnes and Gorin, 2011). During the last year it was recognized
that one of the key enzymes linking ROS to TGF-β activity are the
different NOXs. Different NOX subtypes critically contribute to pro-
duction of intracellular ROS (Manea et al., 2015). In line with this as-
sumption, NOX1-or NOX-4 deficient mice are protected against liver
inflammation and fibrosis (Lan et al., 2015). Similar results were found
in the kidney, in which the depletion of the regulatory p47phox subunit
of NOX1 and NOX2 required for NOX-mediated ROS production re-
sulted in amelioration of renal fibrosis following injury (Wang et al.,
2015). In human gingival and dermal fibroblasts, the inhibition of
NOX1/4 by selective inhibitors resulted in an impairment of the ability
of TGF-β to induce profibrotic gene expression, further underpinning
the notion that ROS and TGF-β are connected in the pathogenesis of
fibrosis (Murphy-Marshman et al., 2017).
4.3.2. Lipid mediators and extracellular vesicles
Another mechanism contributing to the production of enhanced
TGF-β within a tissue was recently identified in lung fibrosis (Romero
et al., 2015). In the respective study, it was demonstrated that lipid-
laden macrophages (i.e. foam cells) that are regularly observed in fi-
brotic lung tissue release oxidized phosphatidylcholine, which induces
the production of TGF-β1 and promotes M2 polarization of macro-
phages. This finding provides first evidence of a paracrine lipid sig-
naling axis linking epithelial injury to macrophage activation, accu-
mulation of oxidized lipids, expression of TGF-β, and initiation of
fibrotic cascades. Moreover, stressed parenchymal cells can release
extracellular vesicles, termed exosomes, that can transmit stress signals
to neighbouring immune cells, mainly macrophages; this mechanism
has been well described in many fibrotic disease settings including
heart, kidney, lung and liver (Hirsova and Gores, 2015; Zhang et al.,
2016; Szabo and Momen-Heravi, 2017; Vanhaverbeke et al., 2017;
Kubo, 2018).
4.3.3. Acetaldehyde
In the liver, acetaldehyde induces expression of both type I collagen
genes via acetaldehyde-responsive elements binding different tran-
scriptions factors and by a mechanism dependent on the generation of
H2O2 (Greenwel et al., 2000; Svegliati-Baroni et al., 2005). Although
acetaldehyde and TGF-β1 both stimulate the phosphorylation and ex-
pression of the intracellular mediators Smad3 and Smad4 and their
binding to the collagen gene promoter, only TGF-β can enhance phos-
phorylation of Smad2 in hepatic stellate cells (Reyes-Gordillo et al.,
2014). In respective cells, neither acetaldehyde nor TGF-β1 alone had
significant stimulatory effect on a collagen reporter construct, while
cells treated with the combination of both showed a highly significant
R. Weiskirchen et al.
increase in reporter activity (Reyes-Gordillo et al., 2014). This finding
suggests that the fibrogenic signaling pathway triggered by acet-
aldehyde and TGF-β are additive and distinctly different. Since myo-
cardial fibrosis is regularly seen in patients with chronic alcohol in-
gestion (Ren and Wold, 2008), it might be possible that the activity of
acetaldehyde in promoting fibrogenesis is not restricted to the liver.
5. Mechanisms of fibrosis regression and resolution
Organ fibrosis with an excessive accumulation of extracellular ma-
trix in response to chronic tissue injury may disintegrate the regular
architecture of the organ and subsequently promote organ failure. This
is well known in chronic liver diseases, where cirrhosis is the end-stage
with impaired liver function and portal hypertension, chronic kidney
diseases with a destroyed glomerular filtration function in case of se-
vere glomerulosclerosis as well as in pulmonary diseases, in which fi-
brosis reduces the vital capacity of the lung (Rosenbloom et al., 2017).
While fibrosis development has long been viewed as a unidirectional
process consisting of non-reversible sequela from chronic injury to fi-
brosis to tissue destruction, there is clear evidence that fibrogenesis is to
a large extent reversible, even at later stages (Jun and Lau et al., 2018).
Already two decades ago, Fioretto and colleagues reported that patients
with type 1 diabetes (n = 8), who underwent pancreas transplantation,
reverted fibrotic lesions in their kidneys by histological analysis five
and ten years after pancreas transplantation, demonstrating that (early)
kidney fibrosis is in principle reversible (Fioretto et al., 1998). Around
the same time, Hammel and colleagues noted that patients with severe
liver fibrosis due to chronic obstruction of the common bile duct
(n = 11) regressed with their hepatic fibrosis by histological analysis
2.5 years after biliary drainage (Hammel et al., 2001). In a prospective
clinical trial on the use of tenofovir for chronic hepatitis B virus in-
fection, 75% of patients with cirrhosis at baseline were able to regress
to a non-cirrhotic stage in a follow-up liver biopsy five years after in-
itiation of an effective antiviral therapy (Marcellin et al., 2013). Given
the exceptional clinical relevance of fibrosis for predicting morbidity
and mortality in patients with liver diseases (Dulai et al., 2017), trials in
the area of non-alcoholic steatohepatitis commonly use “histological
improvement of fibrosis” as an end-point, and some of the compounds
under investigation yielded positive signals in early clinical trials
(Loomba et al., 2018; Friedman et al., 2018; Neuschwander-Tetri et al.,
2015). For cardiac or pulmonary fibrosis, there are less histological data
available from human patients that would support structural fibrosis
regression in these organs. Nonetheless, functional recovery of the
organ, e.g., improved left ventricular ejection function or improved
forced vital capacity in idiopathic pulmonary fibrosis, has been clearly
documented with presumably anti-fibrotic interventions (Murtha et al.,
2017; Karimi-Shah and Chowdhury, 2015).
The clinical findings on reversibility of fibrosis prompted extensive
studies using animal models to understand the mechanisms of fibrosis
regression and fibrosis resolution. In principle, fibrosis regression could
be recapitulated in experimental fibrosis models of the liver (Duffield
et al., 2005), kidney (Aldigier et al., 2005), lung (Reddy et al., 2014)
and heart (Jeong et al., 2016). In case that the underlying chronic in-
jury can be removed, the degree of full recovery seems to depend on the
capacity of the tissue to regenerate, likely explaining a higher chance
for fibrosis resolution in the liver as compared to lung, kidney or heart
(Cordero-Espinoza and Huch et al., 2018; Murtha et al., 2017).
From these various experimental animal models of organ fibrosis
and recovery, general principles of fibrosis regression have been iden-
tified (Tacke and Trautwein, 2015):
(1) cessation of chronic tissue injury: the removal or termination of the
underlying cause of tissue damage promotes regenerative pathways
in parenchymal cells and avoids further activation of myofibro-
blasts (Cordero-Espinoza and Huch et al., 2018)
(2) deactivation of inflammatory pathways and establishment of an anti-
8
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
inflammatory microenvironment: this implies major phenotypic ad-
justments of the immune cells, especially the induction of a “re-
storative phenotype” in macrophages and modulation of type 2
immunity (Krenkel et al., 2018; Pakshir and Hinz, 2018; Gieseck
et al., 2018)
(3) deactivation and elimination of myofibroblasts: activated fibrogenic
myofibroblasts can undergo apoptosis, become senescent (irrever-
sible cell cycle arrest) or revert to an inactive/quiescent phenotype
(Jun and Lau et al., 2018)
(4) degradation of extracellular matrix: this includes the activation of
matrix metalloproteinases (MMPs) that digest collagen and other
ECM proteins, the contribution of macrophages that phagocytize
matrix fragments as well as the reduction of MMP-inhibitory pro-
teins (e.g., tissue inhibitors of MMPs) (Karsdal et al., 2017; Jun and
Lau et al., 2018).
6. Diagnosis and staging of fibrosis
The presence and extent of organ fibrosis determines disease pro-
gression and outcome, as evidenced for chronic kidney diseases
(Berchtold et al., 2017), non-alcoholic fatty liver (Dulai et al., 2017)
and pulmonary fibrosis (Kaur et al., 2017). Thus, it is important to di-
agnose fibrosis – ideally at early stages – and to accurately assess the
stage of fibrosis. The gold standard for diagnosis and staging of fibrosis
is histology, which is usually performed on fine-needle biopsies or
surgically obtained samples. Different histological scores exist for the
various organs that usually also take into account the different pattern
of fibrosis dependent on the disease etiology. Nonetheless, histological
assessment of fibrosis has serious limitations: obtaining histology, such
as by percutaneous biopsy of the liver or the kidney, has procedure-
associated risks including bleeding (Kumar et al., 2018); the biopsy
represents only a fraction of the organ that might not be representative
for the distribution of fibrosis (Patel et al., 2015); and the interpretation
of the results shows a remarkable intra- and interobserver variability
regarding the exact fibrosis stage (Mäkelä et al., 2018; Manning and
Afdahl, 2008). Therefore, many additional methods have been pro-
posed and partially already implemented in clinical algorithms to non-
invasively assess the stage of fibrosis. These techniques include imaging
methods, mechanical and functional tests, serum biomarkers and ge-
netic risk factors for fibrosis (Table 2).
Imaging techniques are widely used in patients with chronic dis-
eases, in which fibrosis is suspected. However, ultrasound, for instance,
can only show indirect signs of fibrosis, such as small organ size with
impaired parenchyma in fibrotic kidneys or coarsened echotexture,
blunting of liver edges and signs of portal hypertension in fibrotic/
cirrhotic livers (Berchtold et al., 2017; Baues et al., 2017). Magnetic
resonance imaging (MRI) might be more suitable in these organs, as T1/
T2 mapping, specific contrast agents and diffusion-weighted imaging
emerge as tools for fibrosis evaluation (Berchtold et al., 2017; Baues
et al., 2017). In the liver, the MRI-derived proton density fat fraction
(MRI-PDFF) is already broadly applied to quantify hepatic fat content,
which has been used as an endpoint in early clinical trials with anti-
fibrotic agents in non-alcoholic steatohepatitis (Caussy et al., 2018).
Cardiac MRI is firmly implemented in clinical algorithms, because it
allows the assessment of cardiac wall thickness, myocardial mass, late
gadolinium enhancement and myocardial extracellular volume frac-
tion, which is related to myocardial fibrosis (Amano et al., 2018). Re-
garding pulmonary fibrosis, high-resolution chest computed tomo-
graphy (CT) provides diagnostic and prognostic information in patients
with lung fibrosis, and different radiological parameters are established
to stage disease severity so that lung biopsy is only seldom needed
(Ohkubo et al., 2018; Martinez et al., 2017). The particular advantages
and disadvantages of imaging modalities for organ fibrosis are reviewed
elsewhere (Baues et al., 2017).
Progressive fibrosis changes the “mechanical properties” of an
organ. This has been successfully translated into elastography
R. Weiskirchen et al. Molecular Aspects of Medicine xxx (xxxx) xxx–xxx

Table 2
Current methods for diagnosis and staging of fibrosis in selected organs.
Liver Kidney Lung Heart

Gold standard histology (biopsy)

Imaging ultrasound, CT scan, MRI ultrasound, MRI high-resolution chest CT echocardiography, cardiac MRI (e.g.,
extracellular volume)
Mechanical or elastography elastography (?) body plethysmography echocardiography, cardiac MRI
functional test
Serum biomarkers Composite scores (e.g., FIB-4, ELF, Not validated yet; TGF-β, Not validated yet; IL-8, CCL18, MMP- Not validated yet; NT-proBNP (?)
(examples) Fibrotest, NFS), hyaluronic acid, MCP-1, MMP-2, urinary 1, MMP-7, IGBPs
PIIINP, pro-C3 PIIINP
Genetic markers PNPLA3, TM6SF2, MBOAT7, GCKR, ACE, TGFβ1, PARN (?) MUC5B, TOLLIP, TERT, TERC, MYH7, MYBPC3
(examples) A1AT, HFE FAM13A, DSP, OBFC1, ATP11A, DPP9

Abbreviations usedare: A1AT, α1-Antitrypsin; ACE, angiotensin I-converting enzyme; ATP11A, ATPase phospholipid transporting 11A; CCL18, (C-C motif) ligand 18;
CT, computed tomography; DPP9, dipeptidyl peptidase IX; DSP, desmoplakin; ELF, enhanced liver fibrosis; FAM13A, family with sequence similarity 13 member A;
FIB-4, fibrosis-4; GCKR, glucokinase regulatory protein; HFE, hereditary hemochromatosis; IGBPs, immunoglobulin G binding proteins; IL-8, interleukin 8; MBOAT7,
membrane bound O-acyltransferase domain containing 7; MCP-1, monocyte chemoattractant protein-1; MMP-1/2/7, matrix metalloproteinase-1/2/7; MRI, magnetic
resonance imaging; MUC5B, mucin 5 subtype B; MYBPC3, myosin-binding protein C cardiac; MYH7, myosin heavy chain 7; NFS, nonalcoholic fatty liver disease
(NAFLD) fibrosis score; NT-proBNP, N-terminal pro-brain natriuretic peptide; OBFC1, oligonucleotide/oligosaccharide binding fold-containing protein 1; PIIINP, N-
terminal propeptide of type III collagen; PARN, polyadenylate-specific ribonuclease; PNPLA3, Patatin-like phospholipase domain-containing protein 3; pro-C3, N-
terminal type III collagen propeptide; TERC, telomerase RNA component; TERT, telomerase reverse transcriptase; TGF-β, transforming growth factor-β; TM6SF2,
transmembrane 6 superfamily 2; TOLLIP, toll interacting protein.

techniques for assessing fibrosis of the liver. These methods comprise
ultrasound-based transient elastography (TE, also termed fibroscan),
acoustic radiation force impulse imaging (ARFI) and shear wave elas-
tography (SWE) as well as MRI-based elastography (MRE). The under-
lying principle is that the propagation of a shear wave or ultrasound
pulse is followed by ultrasound or MRI and directly reflects the liver
stiffness as a surrogate for liver fibrosis (Friedrich-Rust et al., 2016).
This methodology has been widely evaluated in patients with different
chronic liver diseases, so that newer guidelines recommend in-
corporated this technique in the diagnosis of hepatic fibrosis (European
Association for Study of Liver, 2015). Similar ultrasound and MR
elastography approaches are currently adapted for renal fibrosis
(Berchtold et al., 2017; Morrell et al., 2017). On the contrary, lung and
heart fibrosis are oftentimes diagnostically evaluated by functional tests
(e.g., vital capacity of the lung or left ventricular ejection fraction of the
heart), using traditional methods like body plethysmography, echo-
cardiography or cardiac MRI (Table 2).
In contrast to histology, imaging or mechanical assessment, circu-
lating biomarkers of fibrosis are simple, reproducible and inexpensive.
Their biggest disadvantage, however, is their general lack of specificity
for fibrosis, the large overlap between fibrosis stages (which hampers
accurate staging) and the many confounding factors for single markers.
In pulmonary fibrosis, many mediators involved in alveolar epithelial
cell injury, inflammation, and matrix remodeling have been proposed
like chemokines (IL-8, CCL18), proteases (MMP-1, MMP-7) or growth
factors, but their utility in clinical routine is not yet established
(Drakopanagiotakis et al., 2018; Guiot et al., 2017). For kidney fibrosis,
biomarkers are routinely used to monitor glomerular filtration rate
(e.g., creatinine or cystatin C) or tubular damage (e.g., KIM-1, IL-18,
urinary NGAL), while biomarkers detecting renal fibrosis are not widely
accepted. Promising potential biomarkers for renal fibrosis include
TGF-β, monocyte chemoattractant protein-1 (MCP-1) and MMP-2 or the
urinary excretion of collagen III and its associated protein like N-
terminal propeptide of type III collagen (Mansour et al., 2017; Ghoul
et al., 2010). In the setting of suspected liver fibrosis, manifold bio-
markers have been proposed and are to some extent routinely used
(e.g., hyaluronic acid or N-terminal propeptide of type III collagen,
PIIINP). Best diagnostic and prognostic accuracy is achieved, when the
biomarkers are implemented in predictive models that account distinct
risk factors and integrate information from multiple biomarkers (Vilar-
Gomez and Chalasani, 2018). Such composite scores are the NAFLD
fibrosis scores, FIB-4 index, APRI score or the commercially available
ELF or FibroTest, and they overall provide valid diagnostic and prog-
nostic information in hepatic fibrosis (European Association for Study
of Liver et al., 2015; Boursier et al., 2016).
As many gene loci have been identified as risk factors for fibrosis
progression by genome-wide association studies, it can be expected that
the analysis of gene polymorphisms might be useful in the diagnosis of
fibrosis and/or risk stratification. For instance, a variant (rs35705950)
in the MUC5B gene promoter region, alongside other genetic risk loci,
has a strong association with idiopathic pulmonary fibrosis (IPF) and
familial interstitial pneumonia across multiple different cohorts
(Mathai et al., 2016). In cardiology, many genetic risk factors have been
identified for different disease entities, of which some are likely related
to fibrosis. For instance, sarcomere-associated genetic variations in the
β-myosin heavy chain (MYH7) and myosin-binding protein C
(MYBPC3) are linked to hypertrophic cardiomyopathy and interstitial
fibrosis (Marian and Braunwald et al., 2017). Genetic risk factors for
kidney fibrosis appear less well defined, but polymorphisms in the
angiotensin converting enzyme or transforming growth factor (TGF)-β1
have been associated with increased renal scarring after urinary tract
infections (Zaffanello et al., 2011). Large whole-exome sequencing
studies are ongoing that are expected to identify new risk factors for
renal fibrosis (Lata et al., 2018). Regarding liver fibrosis, genetic sus-
ceptibility has long been recognized (Zimmer and Lammert, 2011). A
particular focus of current research are genetic risk factors for fibrosis
progression in non-alcoholic fatty liver disease. The I148M variant of
Patatin-like phospholipase domain-containing protein 3 (PNPLA3,
“adiponutrin”) is a major risk genetic risk factor for disease progression,
and significant contributions have been also found for other genes such
as TM6SF2, MBOAT7 and GCKR (Eslam et al., 2018).
Novel targets in fibrosis biomarker research include circulating
micro-RNA (miRNA), long non-coding RNA, epigenetic changes, mi-
tochondrial DNA or microbiome signatures in the stool
(Drakopnagiotakis et al., 2018; Tan et al., 2014; Hardy et al., 2017;
Loomba et al., 2017; Chen et al., 2017). It appears biologically plausible
to search for biomarkers that directly reflect pathogenic processes of
fibrogenesis or fibrolysis. The different collagens and collagen frag-
ments that are being released into the circulating might therefore have
exceptional potential as biomarkers (Karsdal et al., 2017). The cleaved
N-terminal propeptide of type III collagen (Pro-C3) might represent
such a biomarker that mirrors collagen deposition (Nielsen et al.,
2015). In a similar direction, novel imaging methods combine visuali-
zation with molecular targeting. For instance, collagen- or elastin-

9
R. Weiskirchen et al.
specific probes yielded promising results in molecular MRI of animal
models of liver, renal, cardiac and pulmonary fibrosis (Baues et al.,
2017).
7. Perspective: general and organ-specific targets of antifibrotic therapies
The identification of the manifold mediators and pathways acti-
vated in tissue fibrogenesis offers a multitude of potential targets for
antifibrotic drugs. However, up to now, only two antifibrotic drugs
have been approved for idiopathic pulmonary fibrosis, while no specific
antifibrotic pharmacological therapy exists for liver, kidney or heart
fibrosis. And even in the case of pulmonary fibrosis, the two inhibitors
of profibrotic signaling, pirfenidone and nintedanib, improved forced
vital capacity and survival, but did not show histological resolution of
pulmonary fibrosis (Martinez et al., 2017). Building on these experi-
ences, early clinical data indicate that the monoclonal antibody FG-
3019 that interferes with connective tissue growth factor (CTGF) sig-
naling might convey antifibrotic activity in pulmonary fibrosis patients
(Raghu et al., 2016).
Despite the paucity of anti-fibrotic drugs approved to date, the
tremendous progress in deciphering the mechanisms of organ fibrosis
fueled enthusiasm in the field, giving rise to the expectation that anti-
fibrotic therapies will become a reality in the near future (Lee et al.,
2015; Lee et al., 2015; Klinkhammer et al., 2017; Murtha et al., 2017).
A particular interest are so-called “core mechanisms of fibrosis” that are
preserved between different organs; the expectation is that targeting
such pathways would provide compounds with anti-fibrotic activities
across different types of diseases and organs (Mehal et al., 2011). Such
pathways could be inflammation-linked mechanisms (e.g., in-
flammatory macrophage accumulation), receptor-ligand interactions
with subsequent fibrogenic intracellular signaling, myofibroblast acti-
vation, or matrix synthesis, deposition and stabilization (Weiskirchen
and Tacke, 2016). One of these core mechanisms is the stabilization of
extracellular matrix mediated by crosslinking activity via the enzyme
lysyl oxidase (LOX) and its homologs, LOX-like enzymes 1–4
(LOXL1–LOXL4). Inhibition of LOXL2 by a neutralizing antibody de-
monstrated potent antifibrotic efficacy in animal models of heart, lung
and liver fibrosis (Barry-Hamilton et al., 2010; Yang et al., 2016;
Ikenaga et al., 2017). Unfortunately, the humanized monoclonal anti-
LOXL2 antibody simtuzumab failed to show antifibrotic activity in
patients with pulmonary or hepatic fibrosis (Raghu et al., 2017;
Loomba et al., 2018). Other universal profibrogenic signaling cascades
and cytokines, such as TGF-β, may be more difficult to neutralize in
fibrotic tissue (Rosenbloom et al., 2017).
Therefore, there is currently a trend towards organ-specific anti-fi-
brotic drug development. This strategy carries the advantages of pre-
clinical testing in multiple, translationally relevant experimental
models, reducing systemic side effects by an organ-specific targeting
and a more tailored patient selection considering the proposed mode of
action (Lee et al., 2015; Klinkhammer et al., 2017; Murtha et al., 2017).
Many clinical studies are currently ongoing in the different fields of
organ fibrosis. For liver fibrosis, different compounds under investiga-
tion target the underlying disease etiology, mostly non-alcoholic stea-
tohepatitis, by reducing hepatic fat accumulation, alteration of meta-
bolic pathways or resultant hepatocyte cell death. Examples for these
compounds include farnesoid X receptor (FXR) agonists (obeticholic
acid or non-steroidal FXR agonists), peroxisome proliferator-activator
receptor agonists (e.g., elafibranor, lanifibranor, saroglitazar), acetyl-
CoA carboxylase inhibitors (e.g., GS-0976), caspase inhibitors (e.g.,
emricasan) and fibroblast growth factor (FGF)-21 or FGF-19 analogues
(Rotman and Sanyal, 2017). More direct anti-fibrotic compounds under
clinical investigation are selonsertib, an inhibitor of apoptosis signal-
regulating kinase 1 (ASK1) that is activated in myofibroblasts and
macrophages during fibrogenesis (Loomba et al., 2018), and cen-
icriviroc (CVC), an inhibitor of the chemokine receptors CCR2 and
CCR5 that mediate inflammatory monocyte recruitment upon liver
10
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
injury (Tacke, 2018). The landscape is similarly complex with many
compounds under clinical investigation for renal fibrosis (Klinkhammer
et al., 2017) and pulmonary fibrosis (Raghu, 2017).
Surprisingly, not many of the currently proposed pharmacological
therapies target the myofibroblast directly, but rather modulate their
activating signals or intracellular cascades (Schon et al., 2016). Many
new research directions therefore aim at improving strategies for drug
targeting to myofibroblasts in the liver, kidney or lung (Yazdani et al.,
2017). Potential targeting systems include modified albumin-, hy-
drogel-, peptide-, nanoparticle-, aptamer- or antibody-based systems,
which demonstrated promising myofibroblast targeting in preclinical
models (Yazdani et al., 2017; Bartneck et al., 2014; Nastase et al.,
2017). In addition, cell-based strategies are being tested, in which al-
logeneic or autologous mesenchymal stem cells or bone marrow-de-
rived cells are systemically infused to induce restorative processes in
fibrotic organs like heart, lung, kidney or liver (Lim et al., 2017; Pandey
et al., 2017). The better understanding of the processes and mechan-
isms that contribute to organ fibrosis should open new avenues for
therapeutic interventions, ultimately helping to decrease the enormous
morbidity and mortality linked to fibrotic diseases.
Grant support
This work was supported by the German Research Foundation (DFG;
SFB/TRR57, TA434/3-1) and grants from the Interdisciplinary Centre
for Clinical Research within the Faculty of Medicine at the RWTH
Aachen University.
Conflicts of interest
Work in the laboratory of Frank Tacke has been supported by
funding from Tobira Therapeutics and Galapagos. Ralf Weiskirchen
cooperates with Silence Therapeutics.
Acknowledgements
We cordially thank all members of our labs and collaborating sci-
entists for helpful discussions.
References
Abreu, J.G., Ketpura, N.I., Reversade, B., De Robertis, E.M., 2002. Connective-tissue
growth factor (CTGF) modulates cell signalling by BMP and TGF-β. Nat. Cell Biol. 4,
599–604. http://dx.doi.org/10.1038/ncb826.
Aldigier, J.C., Kanjanbuch, T., Ma, L.J., Brown, N.J., Fogo, A.B., 2005. Regression of
existing glomerulosclerosis by inhibition of aldosterone. J. Am. Soc. Nephrol. 16,
3306–3314. http://dx.doi.org/10.1681/ASN.2004090804.
Amano, Y., Kitamura, M., Takano, H., Yanagisawa, F., Tachi, M., Suzuki, Y., Kumita, S.,
Takayama, M., 2018 Jan 18. Cardiac MR imaging of hypertrophic cardiomyopathy:
techniques, findings, and clinical relevance. Magn. Reson. Med. Sci. http://dx.doi.
org/10.2463/mrms.rev.2017-0145.
Andrews, J.P., Marttala, J., Macarak, E., Rosenbloom, J., Uitto, J., 2016. Keloids: the
paradigm of skin fibrosis - pathomechanisms and treatment. Matrix Biol. 51, 37–46.
http://dx.doi.org/10.1016/j.matbio.2016.01.013.
Arciniegas, E., Sutton, A.B., Allen, T.D., Schor, A.M., 1992. Transforming growth factor
beta 1 promotes the differentiation of endothelial cells into smooth muscle-like cells
in vitro. J. Cell Sci. 103, 521–529.
Arias, M., Sauer-Lehnen, S., Treptau, J., Janoschek, N., Theuerkauf, I., Buettner, R.,
Gressner, A.M., Weiskirchen, R., 2003. Adenoviral expression of a transforming
growth factor-β1 antisense mRNA is effective in preventing liver fibrosis in bile-duct
ligated rats. BMC Gastroenterol. 3, 29. http://dx.doi.org/10.1186/1471-230X-3-29.
Aschner, Y., Downey, G.P., 2016. Transforming growth factor-β: master regulator of the
respiratory system in health and disease. Am. J. Respir. Cell Mol. Biol. 54, 647–655.
http://dx.doi.org/10.1165/rcmb.2015-0391TR.
Baeck, C., Wehr, A., Karlmark, K.R., Heymann, F., Vucur, M., Gassler, N., Huss, S.,
Klussmann, S., Eulberg, D., Luedde, T., Trautwein, C., Tacke, F., 2012.
Pharmacological inhibition of the chemokine CCL2 (MCP-1) diminishes liver mac-
rophage infiltration and steatohepatitis in chronic hepatic injury. Gut 61, 416–426.
http://dx.doi.org/10.1136/gutjnl-2011-300304.
Bardadin, K.A., Desmet, V.J., 1985. Ultrastructural observations on sinusoidal endothelial
cells in chronic active hepatitis. Histopathology 9, 171–181. http://dx.doi.org/10.
1111/j.1365-2559.1985.tb02433.x.
Barnes, J.L., Gorin, Y., 2011. Myofibroblast differentiation during fibrosis: role of NAD(P)
R. Weiskirchen et al.
H oxidases. Kidney Int. 79, 944–956. http://dx.doi.org/10.1038/ki.2010.516.
Barry-Hamilton, V., Spangler, R., Marshall, D., McCauley, S., Rodriguez, H.M., Oyasu, M.,
Mikels, A., Vaysberg, M., Ghermazien, H., Wai, C., Garcia, C.A., Velayo, A.C.,
Jorgensen, B., Biermann, D., Tsai, D., Green, J., Zaffryar-Eilot, S., Holzer, A., Ogg, S.,
Thai, D., Neufeld, G., Van Vlasselaer, P., Smith, V., 2010. Allosteric inhibition of lysyl
oxidase-like-2 impedes the development of a pathologic microenvironment. Nat.
Med. 16, 1009–1017. http://dx.doi.org/10.1038/nm.2208.
Bartneck, M., Warzecha, K.T., Tacke, F., 2014. Therapeutic targeting of liver inflamma-
tion and fibrosis by nanomedicine. Hepatobiliary Surg. Nutr. 3, 364–376. http://dx.
doi.org/10.3978/j.issn.2304-3881.2014.11.02.
Baues, M., Dasgupta, A., Ehling, J., Prakash, J., Boor, P., Tacke, F., Kiessling, F., Lammers,
T., 2017. Fibrosis imaging: current concepts and future directions. Adv. Drug Deliv.
Rev. 121, 9–26. http://dx.doi.org/10.1016/j.addr.2017.10.013.
Berchtold, L., Friedli, I., Vallée, J.P., Moll, S., Martin, P.Y., de Seigneux, S., 2017.
Diagnosis and assessment of renal fibrosis: the state of the art. Swiss Med. Wkly.
147http://dx.doi.org/10.4414/smw.2017.14442. w14442.
Borkham-Kamphorst, E., Kovalenko, E., van Roeyen, C.R., Gassler, N., Bomble, M.,
Ostendorf, T., Floege, J., Gressner, A.M., Weiskirchen, R., 2008. Platelet-derived
growth factor isoform expression in carbon tetrachloride-induced chronic liver in-
jury. Lab. Invest. 88, 1090–1100. http://dx.doi.org/10.1038/labinvest.2008.71.
Borkham-Kamphorst, E., van de Leur, E., Zimmermann, H.W., Karlmark, K.R., Tihaa, L.,
Haas, U., Tacke, F., Berger, T., Mak, T.W., Weiskirchen, R., 2013. Protective effects of
lipocalin-2 (LCN2) in acute liver injury suggest a novel function in liver homeostasis.
Biochim. Biophys. Acta 1832, 660–673. http://dx.doi.org/10.1016/j.bbadis.2013.01.
014.
Borkham-Kamphorst, E., Weiskirchen, R., 2016. The PDGF system and its antagonists in
liver fibrosis. Cytokine Growth Factor Rev. 28, 53–61. http://dx.doi.org/10.1016/j.
cytogfr.2015.10.002.
Boursier, J., Vergniol, J., Guillet, A., Hiriart, J.B., Lannes, A., Le Bail, B., Michalak, S.,
Chermak, F., Bertrais, S., Foucher, J., Oberti, F., Charbonnier, M., Fouchard-Hubert,
I., Rousselet, M.C., Calès, P., de Lédinghen, V., 2016. Diagnostic accuracy and
prognostic significance of blood fibrosis tests and liver stiffness measurement by
FibroScan in non-alcoholic fatty liver disease. J. Hepatol. 65, 570–578. http://dx.doi.
org/10.1016/j.jhep.2016.04.023.
Bucala, R., Spiegel, L.A., Chesney, J., Hogan, M., Cerami, A., 1994. Circulating fibrocytes
define a new leukocyte subpopulation that mediates tissue repair. Mol. Med. (Camb.)
1, 71–81.
Buhl, E.M., Djudjaj, S., Babickova, J., Klinkhammer, B.M., Folestad, E., Borkham-
Kamphorst, E., Weiskirchen, R., Hudkins, K., Alpers, C.E., Eriksson, U., Floege, J.,
Boor, P., 2016. The role of PDGF-D in healthy and fibrotic kidneys. Kidney Int. 89,
848–861. http://dx.doi.org/10.1016/j.kint.2015.12.037.
Caussy, C., Reeder, S.B., Sirlin, C.B., Loomba, R., 2018. Non-invasive, quantitative as-
sessment of liver fat by MRI-PDFF as an endpoint in NASH trials. Hepatology. http://
dx.doi.org/10.1002/hep.29797. Jan 21.
Cavalera, M., Frangogiannis, N.G., 2014. Targeting the chemokines in cardiac repair.
Curr. Pharmaceut. Des. 20, 1971–1979. http://dx.doi.org/10.2174/
13816128113199990449.
Charo, I.F., Ransohoff, R.M., 2006. The many roles of chemokines and chemokine re-
ceptors in inflammation. N. Engl. J. Med. 354, 610–621. http://dx.doi.org/10.1056/
NEJMra052723.
Chen, Z., Li, C., Lin, K., Cai, H., Ruan, W., Han, J., Rao, L., 2017. Non-coding RNAs in
cardiac fibrosis: emerging biomarkers and therapeutic targets. Cardiol. J. http://dx.
doi.org/10.5603/CJ.a2017.0153. Dec 14.
Cordero-Espinoza, L., Huch, M., 2018. The balancing act of the liver: tissue regeneration
versus fibrosis. J. Clin. Invest. 128, 85–96. http://dx.doi.org/10.1172/JCI93562.
Danobeitia, J.S., Djamali, A., Fernandez, L.A., 2014. The role of complement in the pa-
thogenesis of renal ischemia-reperfusion injury and fibrosis. Fibrogenesis Tissue
Repair 7, 16. http://dx.doi.org/10.1186/1755-1536-7-16.
De Bleser, P.J., Xu, G., Rombouts, K., Rogiers, V., Geerts, A., 1999. Glutathione levels
discriminate between oxidative stress and transforming growth factor-β signaling in
activated rat hepatic stellate cells. J. Biol. Chem. 274, 33881–33887. http://dx.doi.
org/10.1074/jbc.274.48.33881.
Del Campo, J.A., Gallego, P., Grande, L., 2018. Role of inflammatory response in liver
diseases: therapeutic strategies. World J. Hepatol. 10, 1–7. http://dx.doi.org/10.
4254/wjh.v10.i1.1.
Di Carlo, S.E., Peduto, L., 2018. The perivascular origin of pathological fibroblasts. J.
Clin. Invest. 128, 54–63. http://dx.doi.org/10.1172/JCI93558.
Douillet, C.D., Velarde, V., Christopher, J.T., Mayfield, R.K., Trojanowska, M.E., Jaffa,
A.A., 2000. Mechanisms by which bradykinin promotes fibrosis in vascular smooth
muscle cells: role of TGF-beta and MAPK. Am. J. Physiol. Heart Circ. Physiol. 279,
H2829–H2837. http://dx.doi.org/10.1152/ajpheart.2000.279.6.H2829.
Drakopanagiotakis, F., Wujak, L., Wygrecka, M., Markart, P., 2018. Biomarkers in idio-
pathic pulmonary fibrosis. Matrix Biol. http://dx.doi.org/10.1016/j.matbio.2018.01.
023. Jan 30.
Duffield, J.S., Forbes, S.J., Constandinou, C.M., Clay, S., Partolina, M., Vuthoori, S., Wu,
S., Lang, R., Iredale, J.P., 2005. Selective depletion of macrophages reveals distinct,
opposing roles during liver injury and repair. J. Clin. Invest. 115, 56–65. http://dx.
doi.org/10.1172/JCI200522675.
Dulai, P.S., Singh, S., Patel, J., Soni, M., Prokop, L.J., Younossi, Z., Sebastiani, G., Ekstedt,
M., Hagstrom, H., Nasr, P., Stal, P., Wong, V.W., Kechagias, S., Hultcrantz, R.,
Loomba, R., 2017. Increased risk of mortality by fibrosis stage in nonalcoholic fatty
liver disease: systematic review and meta-analysis. Hepatology 65, 1557–1565.
http://dx.doi.org/10.1002/hep.29085.
Dulauroy, S., Di Carlo, S.E., Langa, F., Eberl, G., Peduto, L., 2012. Lineage tracing and
genetic ablation of ADAM12+ perivascular cells identify a major source of profibrotic
cells during acute tissue injury. Nat. Med. 18, 1262–1270. http://dx.doi.org/10.
11
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
1038/nm.2848.
El Mourabit, H., Loeuillard, E., Lemoinne, S., Cadoret, A., Housset, C., 2016. Culture
model of rat portal myofibroblasts. Front. Physiol. 7, 120. http://dx.doi.org/10.
3389/fphys.2016.00120.
Eslam, M., Valenti, L., Romeo, S., 2018. Genetics and epigenetics of NAFLD and NASH:
clinical impact. J. Hepatol. 68, 268–279. http://dx.doi.org/10.1016/j.jhep.2017.09.
003.
European Association for Study of Liver, 2015. Asociacion Latinoamericana para el
Estudio del Higado. EASL-ALEH Clinical Practice Guidelines: non-invasive tests for
evaluation of liver disease severity and prognosis. J. Hepatol. 63, 237–264. http://dx.
doi.org/10.1016/j.jhep.2015.04.006.
Fioretto, P., Steffes, M.W., Sutherland, D.E., Goetz, F.C., Mauer, M., 1998. Reversal of
lesions of diabetic nephropathy after pancreas transplantation. N. Engl. J. Med. 339,
69–75. http://dx.doi.org/10.1056/NEJM199807093390202.
Forbes, S.J., Russo, F.P., Rey, V., Burra, P., Rugge, M., Wright, N.A., Alison, M.R., 2004. A
significant proportion of myofibroblasts are of bone marrow origin in human liver
fibrosis. Gastroenterology 126, 955–963. http://dx.doi.org/10.1053/j.gastro.2004.
02.025.
Frangogiannis, N.G., Dewald, O., Xia, Y., Ren, G., Haudek, S., Leucker, T., Kraemer, D.,
Taffet, G., Rollins, B.J., Entman, M.L., 2007. Critical role of monocyte chemoat-
tractant protein-1/CC chemokine ligand 2 in the pathogenesis of ischemic cardio-
myopathy. Circulation 115, 584–592. http://dx.doi.org/10.1161/
CIRCULATIONAHA.106.646091.
Frantz, S., Falcao-Pires, I., Balligand, J.L., Bauersachs, J., Brutsaert, D., Ciccarelli, M.,
Dawson, D., de Windt, L.J., Giacca, M., Hamdani, N., Hilfiker-Kleiner, D., Hirsch, E.,
Leite-Moreira, A., Mayr, M., Thum, T., Tocchetti, C.G., van der Velden, J., Varricchi,
G., Heymans, S., 2018. The innate immune system in chronic cardiomyopathy: a
European Society of Cardiology (ESC) scientific statement from the Working Group
on Myocardial Function of the ESC. Eur. J. Heart Fail. http://dx.doi.org/10.1002/
ejhf.1138. Jan 15.
Friedman, S.L., Roll, F.J., Boyles, J., Bissell, D.M., 1985. Hepatic lipocytes: the principal
collagen-producing cells of normal rat liver. Proc. Natl. Acad. Sci. U. S. A. 82,
8681–8685. http://dx.doi.org/10.1073/pnas.82.24.8681.
Friedman, S.L., Ratziu, V., Harrison, S.A., Abdelmalek, M.F., Aithal, G.P., Caballeria, J.,
Francque, S., Farrell, G., Kowdley, K.V., Craxi, A., Simon, K., Fischer, L., Melchor-
Khan, L., Vest, J., Wiens, B.L., Vig, P., Seyedkazemi, S., Goodman, Z., Wong, V.W.,
Loomba, R., Tacke, F., Sanyal, A., Lefebvre, E., 2018. A randomized, placebo-con-
trolled trial of cenicriviroc for treatment of nonalcoholic steatohepatitis with fibrosis.
Hepatology 67, 1754–1767. https://doi.org/10.1002/hep.29477.
Friedrich-Rust, M., Poynard, T., Castera, L., 2016. Critical comparison of elastography
methods to assess chronic liver disease. Nat. Rev. Gastroenterol. Hepatol. 13,
402–411. http://dx.doi.org/10.1038/nrgastro.2016.86.
Ghoul, B.E., Squalli, T., Servais, A., Elie, C., Meas-Yedid, V., Trivint, C., Vanmassenhove,
J., Grünfeld, J.P., Olivo-Marin, J.C., Thervet, E., Noël, L.H., Prié, D., Fakhouri, F.,
2010. Urinary procollagen III aminoterminal propeptide (PIIINP): a fibrotest for the
nephrologist. Clin. J. Am. Soc. Nephrol. 5, 205–210. http://dx.doi.org/10.2215/CJN.
06610909.
Gieseck 3rd, R.L., Wilson, M.S., Wynn, T.A., 2018. Type 2 immunity in tissue repair and
fibrosis. Nat. Rev. Immunol. 18, 62–76. http://dx.doi.org/10.1038/nri.2017.90.
Greenwel, P., Domínguez-Rosales, J.A., Mavi, G., Rivas-Estilla, A.M., Rojkind, M., 2000.
Hydrogen peroxide: a link between acetaldehyde-elicited alpha1(I) collagen gene up-
regulation and oxidative stress in mouse hepatic stellate cells. Hepatology 31,
109–116. http://dx.doi.org/10.1002/hep.510310118.
Gressner, A.M., Weiskirchen, R., Breitkopf, K., Dooley, S., 2002. Roles of TGF-β in hepatic
fibrosis. Front. Biosci. 7, d793–807. http://dx.doi.org/10.2741/A812.
Gressner, A.M., Weiskirchen, R., 2006. Modern pathogenetic concepts of liver fibrosis
suggest stellate cells and TGF-β as major players and therapeutic targets. J. Cell Mol.
Med. 10, 76–99. http://dx.doi.org/10.1111/j.1582-4934.2006.tb00292.x.
Grgic, I., Campanholle, G., Bijol, V., Wang, C., Sabbisetti, V.S., Ichimura, T., Humphreys,
B.D., Bonventre, J.V., 2012. Targeted proximal tubule injury triggers interstitial fi-
brosis and glomerulosclerosis. Kidney Int. 82, 172–183. http://dx.doi.org/10.1038/
ki.2012.20.
Guiot, J., Moermans, C., Henket, M., Corhay, J.L., Louis, R., 2017. Blood biomarkers in
idiopathic pulmonary fibrosis. Lung 195, 273–280. http://dx.doi.org/10.1007/
s00408-017-9993-5.
Guyot, C., Lepreux, S., Combe, C., Doudnikoff, E., Bioulac-Sage, P., Balabaud, C.,
Desmoulière, A., 2006. Hepatic fibrosis and cirrhosis: the (myo)fibroblastic cell
subpopulations involved. Int. J. Biochem. Cell Biol. 38, 135–151.
Hammel, P., Couvelard, A., O'Toole, D., Ratouis, A., Sauvanet, A., Fléjou, J.F., Degott, C.,
Belghiti, J., Bernades, P., Valla, D., Ruszniewski, P., Lévy, P., 2001. Regression of
liver fibrosis after biliary drainage in patients with chronic pancreatitis and stenosis
of the common bile duct. N. Engl. J. Med. 344, 418–423. http://dx.doi.org/10.1056/
NEJM200102083440604.
Hammerich, L., Tacke, F., 2014. Interleukins in chronic liver disease: lessons learned from
experimental mouse models. Clin. Exp. Gastroenterol. 7, 297–306. http://dx.doi.org/
10.2147/CEG.S43737.
Hardy, T., Zeybel, M., Day, C.P., Dipper, C., Masson, S., McPherson, S., Henderson, E.,
Tiniakos, D., White, S., French, J., Mann, D.A., Anstee, Q.M., Mann, J., 2017. Plasma
DNA methylation: a potential biomarker for stratification of liver fibrosis in non-
alcoholic fatty liver disease. Gut 66, 1321–1328. http://dx.doi.org/10.1136/gutjnl-
2016-311526.
Hashimoto, N., Jin, H., Liu, T., Chensue, S.W., Phan, S.H., 2004. Bone marrow-derived
progenitor cells in pulmonary fibrosis. J. Clin. Invest. 113, 243–252. http://dx.doi.
org/10.1172/JCI200418847.
Hashimoto, N., Phan, S.H., Imaizumi, K., Matsuo, M., Nakashima, H., Kawabe, T.,
Shimokata, K., Hasegawa, Y., 2010. Endothelial-mesenchymal transition in
R. Weiskirchen et al.
bleomycin-induced pulmonary fibrosis. Am. J. Respir. Cell Mol. Biol. 43, 161–172.
http://dx.doi.org/10.1165/rcmb.2009-0031OC.
Heymann, F., Tacke, F., 2016. Immunology in the liver–from homeostasis to disease. Nat.
Rev. Gastroenterol. Hepatol. 13, 88–110. http://dx.doi.org/10.1038/nrgastro.2015.
200.
Hirsova, P., Gores, G.J., 2015. Death receptor-mediated cell death and proinflammatory
signaling in nonalcoholic steatohepatitis. Cell Mol Gastroenterol Hepatol 1, 17–27.
http://dx.doi.org/10.1016/j.jcmgh.2014.11.005.
Humphreys, B.D., Lin, S.L., Kobayashi, A., Hudson, T.E., Nowlin, B.T., Bonventre, J.V.,
Valerius, M.T., McMahon, A.P., Duffield, J.S., 2010. Fate tracing reveals the pericyte
and not epithelial origin of myofibroblasts in kidney fibrosis. Am. J. Pathol. 176,
85–97. http://dx.doi.org/10.2353/ajpath.2010.090517.
Hung, C., Linn, G., Chow, Y.H., Kobayashi, A., Mittelsteadt, K., Altemeier, W.A., Gharib,
S.A., Schnapp, L.M., Duffield, J.S., 2013. Role of lung pericytes and resident fibro-
blasts in the pathogenesis of pulmonary fibrosis. Am. J. Respir. Crit. Care Med. 188,
820–830. http://dx.doi.org/10.1164/rccm.201212-2297OC.
Ikenaga, N., Peng, Z.W., Vaid, K.A., Liu, S.B., Yoshida, S., Sverdlov, D.Y., Mikels-Vigdal,
A., Smith, V., Schuppan, D., Popov, Y.V., 2017. Selective targeting of lysyl oxidase-
like 2 (LOXL2) suppresses hepatic fibrosis progression and accelerates its reversal.
Gut 66, 1697–1708. http://dx.doi.org/10.1136/gutjnl-2016-312473.
Iqbal, S.A., Sidgwick, G.P., Bayat, A., 2012. Identification of fibrocytes from mesenchymal
stem cells in keloid tissue: a potential source of abnormal fibroblasts in keloid scar-
ring. Arch. Dermatol. Res. 304, 665–671. http://dx.doi.org/10.1007/s00403-012-
1225-5.
Iwayama, T., Olson, L.E., 2013. Involvement of PDGF in fibrosis and scleroderma: recent
insights from animal models and potential therapeutic opportunities. Curr.
Rheumatol. Rep. 15, 304. http://dx.doi.org/10.1007/s11926-012-0304-0.
Jeong, D., Lee, M.A., Li, Y., Yang, D.K., Kho, C., Oh, J.G., Hong, G., Lee, A., Song, M.H.,
LaRocca, T.J., Chen, J., Liang, L., Mitsuyama, S., D'Escamard, V., Kovacic, J.C., Kwak,
T.H., Hajjar, R.J., Park, W.J., 2016. Matricellular protein CCN5 reverses established
cardiac fibrosis. J. Am. Coll. Cardiol. 67, 1556–1568. http://dx.doi.org/10.1016/j.
jacc.2016.01.030.
Jones, D.P., True, H.D., Patel, J., 2017. Leukocyte trafficking in cardiovascular disease:
insights from experimental models. Mediat. Inflamm. 2017, 9746169. http://dx.doi.
org/10.1155/2017/9746169.
Jun, J.I., Lau, L.F., 2018. Resolution of organ fibrosis. J. Clin. Invest. 128, 97–107. http://
dx.doi.org/10.1172/JCI93563.
Kalluri, R., Weinberg, R.A., 2009. The basics of epithelial-mesenchymal transition. J. Clin.
Invest. 119, 1420–1428. http://dx.doi.org/10.1172/JCI39104.
Karimi-Shah, B.A., Chowdhury, B.A., 2015. Forced vital capacity in idiopathic pulmonary
fibrosis–FDA review of pirfenidone and nintedanib. N. Engl. J. Med. 372, 1189–1191.
http://dx.doi.org/10.1056/NEJMp1500526.
Karlmark, K.R., Weiskirchen, R., Zimmermann, H.W., Gassler, N., Ginhoux, F., Weber, C.,
Merad, M., Luedde, T., Trautwein, C., Tacke, F., 2009. Hepatic recruitment of the
inflammatory Gr1+ monocyte subset upon liver injury promotes hepatic fibrosis.
Hepatology 50, 261–274. http://dx.doi.org/10.1002/hep.22950.
Karsdal, M.A., Nielsen, S.H., Leeming, D.J., Langholm, L.L., Nielsen, M.J., Manon-Jensen,
T., Siebuhr, A., Gudmann, N.S., Rønnow, S., Sand, J.M., Daniels, S.J., Mortensen,
J.H., Schuppan, D., 2017. The good and the bad collagens of fibrosis - their role in
signaling and organ function. Adv. Drug Deliv. Rev. 121, 43–56. http://dx.doi.org/
10.1016/j.addr.2017.07.014.
Kaur, A., Mathai, S.K., Schwartz, D.A., 2017. Genetics in idiopathic pulmonary fibrosis
pathogenesis, prognosis, and treatment. Front. Med. 4, 154. http://dx.doi.org/10.
3389/fmed.2017.00154.
Kawaguchi, M., Takahashi, M., Hata, T., Kashima, Y., Usui, F., Morimoto, H., Izawa, A.,
Takahashi, Y., Masumoto, J., Koyama, J., Hongo, M., Noda, T., Nakayama, J., Sagara,
J., Taniguchi, S., Ikeda, U., 2011. Inflammasome activation of cardiac fibroblasts is
essential for myocardial ischemia/reperfusion injury. Circulation 123, 594–604.
http://dx.doi.org/10.1161/CIRCULATIONAHA.110.982777.
Kazlauskas, A., 2017. PDGFs and their receptors. Gene 614, 1–7. http://dx.doi.org/10.
1016/j.gene.2017.03.003.
Keeley, E.C., Mehrad, B., Janardhanan, R., Salerno, M., Hunter, J.R., Burdick, M.M., Field,
J.J., Strieter, R.M., Kramer, C.M., 2012. Elevated circulating fibrocyte levels in pa-
tients with hypertensive heart disease. J. Hypertens. 30, 1856–1861. http://dx.doi.
org/10.1097/HJH.0b013e32835639bb.
Kendall, R.T., Feghali-Bostwick, C.A., 2014. Fibroblasts in fibrosis: novel roles and
mediators. Front. Pharmacol. 5, 123. http://dx.doi.org/10.3389/fphar.2014.00123.
Kisseleva, T., Cong, M., Paik, Y., Scholten, D., Jiang, C., Benner, C., Iwaisako, K., Moore-
Morris, T., Scott, B., Tsukamoto, H., Evans, S.M., Dillmann, W., Glass, C.K., Brenner,
D.A., 2012. Myofibroblasts revert to an inactive phenotype during regression of liver
fibrosis. Proc. Natl. Acad. Sci. U. S. A. 109, 9448–9453. http://dx.doi.org/10.1073/
pnas.1201840109.
Kinoshita, K., Iimuro, Y., Otogawa, K., Saika, S., Inagaki, Y., Nakajima, Y., Kawada, N.,
Fujimoto, J., Friedman, S.L., Ikeda, K., 2007. Adenovirus-mediated expression of
BMP-7 suppresses the development of liver fibrosis in rats. Gut 56, 706–714. http://
dx.doi.org/10.1136/gut.2006.092460.
Kitagawa, K., Wada, T., Furuichi, K., Hashimoto, H., Ishiwata, Y., Asano, M., Takeya, M.,
Kuziel, W.A., Matsushima, K., Mukaida, N., Yokoyama, H., 2004. Blockade of CCR2
ameliorates progressive fibrosis in kidney. Am. J. Pathol. 165, 237–246. http://dx.
doi.org/10.1016/S0002-9440(10)63292-0.
Klinkhammer, B.M., Goldschmeding, R., Floege, J., Boor, P., 2017. Treatment of renal
fibrosis-turning challenges into opportunities. Adv. Chron. Kidney Dis. 24, 117–129.
http://dx.doi.org/10.1053/j.ackd.2016.11.002.
Kolahian, S., Fernandez, I.E., Eickelberg, O., Hartl, D., 2016. Immune mechanisms in
pulmonary fibrosis. Am. J. Respir. Cell Mol. Biol. 55, 309–322. http://dx.doi.org/10.
1165/rcmb.2016-0121TR.
12
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
Kong, P., Christia, P., Frangogiannis, N.G., 2014. The pathogenesis of cardiac fibrosis.
Cell. Mol. Life Sci. 71, 549–574. http://dx.doi.org/10.1007/s00018-013-1349-6.
Kovalovich, K., DeAngelis, R.A., Li, W., Furth, E.E., Ciliberto, G., Taub, R., 2000.
Increased toxin-induced liver injury and fibrosis in interleukin-6-deficient mice.
Hepatology 31, 149–159. http://dx.doi.org/10.1002/hep.510310123.
Kramann, R., Schneider, R.K., DiRocco, D.P., Machado, F., Fleig, S., Bondzie, P.A.,
Henderson, J.M., Ebert, B.L., Humphreys, B.D., 2015. Perivascular Gli1+ progenitors
are key contributors to injury-induced organ fibrosis. Cell Stem Cell. 16, 51–66.
http://dx.doi.org/10.1016/j.stem.2014.11.004.
Krenkel, O., Tacke, F., 2017. Liver macrophages in tissue homeostasis and disease. Nat.
Rev. Immunol. 17, 306–321. http://dx.doi.org/10.1038/nri.2017.11.
Krenkel, O., Puengel, T., Govaere, O., Abdallah, A.T., Mossanen, J.C., Kohlhepp, M.,
Liepelt, A., Lefebvre, E., Luedde, T., Hellerbrand, C., Weiskirchen, R., Longerich, T.,
Costa, I.G., Anstee, Q.M., Trautwein, C., Tacke, F., 2018. Therapeutic inhibition of
inflammatory monocyte recruitment reduces steatohepatitis and liver fibrosis.
Hepatology 67, 1270–1283. http://dx.doi.org/10.1002/hep.29544.
Kubo, H., 2018. Extracellular vesicles in lung disease. Chest 153, 210–216. http://dx.doi.
org/10.1016/j.chest.2017.06.026.
Kumar, V., Mitchell, M.D., Umscheid, C.A., Berns, J.S., Hogan, J.J., 2018. Risk of com-
plications with use of aspirin during renal biopsy: a systematic review. Clin. Nephrol.
89, 67–76. http://dx.doi.org/10.5414/CN109274.
Kurts, C., Panzer, U., Anders, H.J., Rees, A.J., 2013. The immune system and kidney
disease: basic concepts and clinical implications. Nat. Rev. Immunol. 13, 738–753.
http://dx.doi.org/10.1038/nri3523.
Lan, T., Kisseleva, T., Brenner, D.A., 2015. Deficiency of NOX1 or NOX4 prevents liver
inflammation and fibrosis in mice through inhibition of hepatic stellate cell activa-
tion. PLoS One (7), 10. http://dx.doi.org/10.1371/journal.pone.0129743. e0129743.
Lata, S., Marasa, M., Li, Y., Fasel, D.A., Groopman, E., Jobanputra, V., Rasouly, H.,
Mitrotti, A., Westland, R., Verbitsky, M., Nestor, J., Slater, L.M., D'Agati, V., Zaniew,
M., Materna-Kiryluk, A., Lugani, F., Caridi, G., Rampoldi, L., Mattoo, A., Newton,
C.A., Rao, M.K., Radhakrishnan, J., Ahn, W., Canetta, P.A., Bomback, A.S., Appel,
G.B., Antignac, C., Markowitz, G.S., Garcia, C.K., Kiryluk, K., Sanna-Cherchi, S.,
Gharavi, A.G., 2018. Whole-exome sequencing in adults with chronic kidney disease:
a pilot study. Ann. Intern. Med. 168, 100–109. http://dx.doi.org/10.7326/M17-
1319.
LeBleu, V.S., Taduri, G., O'Connell, J., Teng, Y., Cooke, V.G., Woda, C., Sugimoto, H.,
Kalluri, R., 2013. Origin and function of myofibroblasts in kidney fibrosis. Nat. Med.
19, 1047–1053. http://dx.doi.org/10.1038/nm.3218.
Lee, S.Y., Kim, S.I., Choi, M.E., 2015. Therapeutic targets for treating fibrotic kidney
diseases. Transl. Res. 165, 512–530. http://dx.doi.org/10.1016/j.trsl.2014.07.010.
Lee, Y.A., Wallace, M.C., Friedman, S.L., 2015. Pathobiology of liver fibrosis: a transla-
tional success story. Gut 64, 830–841. http://dx.doi.org/10.1136/gutjnl-2014-
306842. Erratum in: Gut 2015;64:1337.
Lemoinne, S., Cadoret, A., El Mourabit, H., Thabut, D., Housset, C., 2013. Origins and
functions of liver myofibroblasts. Biochim. Biophys. Acta 1832, 948–954. http://dx.
doi.org/10.1016/j.bbadis.2013.02.019.
Li, Y., Wang, J., Asahina, K., 2013. Mesothelial cells give rise to hepatic stellate cells and
myofibroblasts via mesothelial-mesenchymal transition in liver injury. Proc. Natl.
Acad. Sci. U. S. A. 110, 2324–2329. http://dx.doi.org/10.1073/pnas.1214136110.
Lim, R., Ricardo, S.D., Sievert, W., 2017. Cell-based therapies for tissue fibrosis. Front.
Pharmacol. 8, 633. http://dx.doi.org/10.3389/fphar.2017.00633.
Lin, S.L., Kisseleva, T., Brenner, D.A., Duffield, J.S., 2008. Pericytes and perivascular fi-
broblasts are the primary source of collagen-producing cells in obstructive fibrosis of
the kidney. Am. J. Pathol. 173, 1617–1627. http://dx.doi.org/10.2353/ajpath.2008.
080433.
Liu, S., Taghavi, R., Leask, A., 2010. Connective tissue growth factor is induced in
bleomycin-induced skin scleroderma. J Cell Commun Signal 4, 25–30. http://dx.doi.
org/10.1007/s12079-009-0081-3.
Liu, Y., Munker, S., Müllenbach, R., Weng, H.L., 2012. IL-13 signaling in liver fibrogen-
esis. Front. Immunol. 3, 116. http://dx.doi.org/10.3389/fimmu.2012.00116.
Loomba, R., Seguritan, V., Li, W., Long, T., Klitgord, N., Bhatt, A., Dulai, P.S., Caussy, C.,
Bettencourt, R., Highlander, S.K., Jones, M.B., Sirlin, C.B., Schnabl, B., Brinkac, L.,
Schork, N., Chen, C.H., Brenner, D.A., Biggs, W., Yooseph, S., Venter, J.C., Nelson,
K.E., 2017. Gut microbiome-based metagenomic signature for non-invasive detection
of advanced fibrosis in human nonalcoholic fatty liver disease. Cell Metabol. 25,
1054–1062. http://dx.doi.org/10.1016/j.cmet.2017.04.001. e5.
Loomba, R., Lawitz, E., Mantry, P.S., Jayakumar, S., Caldwell, S.H., Arnold, H., Diehl,
A.M., Djedjos, C.S., Han, L., Myers, R.P., Subramanian, G.M., McHutchison, J.G.,
Goodman, Z.D., Afdhal, N.H., Charlton, M.R., 2018. GS-US-384-1497 Investigators.
The ASK1 inhibitor selonsertib in patients with nonalcoholic steatohepatitis: a ran-
domized, phase 2 trial. Hepatology 67, 549–559. http://dx.doi.org/10.1002/hep.
29514.
Low, R.B., Woodcock-Mitchell, J., Evans, J.N., Adler, K.B., 1984. Actin content of normal
and of bleomycin-fibrotic rat lung. Am. Rev. Respir. Dis. 129, 311–316.
Lv, W., Booz, G.W., Wang, Y., Fan, F., Roman, R.J., 2018. Inflammation and renal fibrosis:
recent developments on key signaling molecules as potential therapeutic targets. Eur.
J. Pharmacol. 820, 65–76. http://dx.doi.org/10.1016/j.ejphar.2017.12.016.
Mäkelä, K., Hodgson, U., Piilonen, A., Kelloniemi, K., Bloigu, R., Sutinen, E., Salmenkivi,
K., Rönty, M., Lappi-Blanco, E., Myllärniemi, M., Kaarteenaho, R., 2018. Analysis of
the histologic features associated with interobserver variation in idiopathic pul-
monary fibrosis. Am. J. Surg. Pathol. http://dx.doi.org/10.1097/PAS.
0000000000001031. Feb 12.
Manea, S.A., Constantin, A., Manda, G., Sasson, S., Manea, A., 2015. Regulation of Nox
enzymes expression in vascular pathophysiology: focusing on transcription factors
and epigenetic mechanisms. Redox Biol. 5, 358–366. http://dx.doi.org/10.1016/j.
redox.2015.06.012.
R. Weiskirchen et al.
Manning, D.S., Afdhal, N.H., 2008. Diagnosis and quantitation of fibrosis.
Gastroenterology 134, 1670–1681. http://dx.doi.org/10.1053/j.gastro.2008.03.001.
Mansour, S.G., Puthumana, J., Coca, S.G., Gentry, M., Parikh, C.R., 2017. Biomarkers for
the detection of renal fibrosis and prediction of renal outcomes: a systematic review.
BMC Nephrol. 18 (1), 72. http://dx.doi.org/10.1186/s12882-017-0490-0.
Marcellin, P., Gane, E., Buti, M., Afdhal, N., Sievert, W., Jacobson, I.M., Washington,
M.K., Germanidis, G., Flaherty, J.F., Aguilar Schall, R., Bornstein, J.D., Kitrinos, K.M.,
Subramanian, G.M., McHutchison, J.G., Heathcote, E.J., 2013. Regression of cirrhosis
during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5-year
open-label follow-up study. Lancet 381, 468–475. http://dx.doi.org/10.1016/S0140-
6736(12)61425-1.
Marian, A.J., Braunwald, E., 2017. Hypertrophic cardiomyopathy: genetics, pathogenesis,
clinical manifestations, diagnosis, and therapy. Circ. Res. 121, 749–770. http://dx.
doi.org/10.1161/CIRCRESAHA.117.311059.
Marra, F., Tacke, F., 2014. Roles for chemokines in liver disease. Gastroenterology 147,
577–594. http://dx.doi.org/10.1053/j.gastro.2014.06.043. e1.
Martin, I.V., Borkham-Kamphorst, E., Zok, S., van Roeyen, C.R., Eriksson, U., Boor, P.,
Hittatiya, K., Fischer, H.P., Wasmuth, H.E., Weiskirchen, R., Eitner, F., Floege, J.,
Ostendorf, T., 2013. Platelet-derived growth factor (PDGF)-C neutralization reveals
differential roles of PDGF receptors in liver and kidney fibrosis. Am. J. Pathol. 182,
107–117. http://dx.doi.org/10.1016/j.ajpath.2012.09.006.
Martinez, F.J., Collard, H.R., Pardo, A., Raghu, G., Richeldi, L., Selman, M., Swigris, J.J.,
Taniguchi, H., Wells, A.U., 2017. Idiopathic pulmonary fibrosis. Nat Rev Dis Primers
3, 17074. http://dx.doi.org/10.1038/nrdp.2017.74.
Mathai, S.K., Newton, C.A., Schwartz, D.A., Garcia, C.K., 2016. Pulmonary fibrosis in the
era of stratified medicine. Thorax 71, 1154–1160. http://dx.doi.org/10.1136/
thoraxjnl-2016-209172.
McHedlidze, T., Waldner, M., Zopf, S., Walker, J., Rankin, A.L., Schuchmann, M.,
Voehringer, D., McKenzie, A.N., Neurath, M.F., Pflanz, S., Wirtz, S., 2013.
Interleukin-33-dependent innate lymphoid cells mediate hepatic fibrosis. Immunity
39, 357–371. http://dx.doi.org/10.1016/j.immuni.2013.07.018.
Mederacke, I., Hsu, C.C., Troeger, J.S., Huebener, P., Mu, X., Dapito, D.H., Pradere, J.P.,
Schwabe, R.F., 2013. Fate tracing reveals hepatic stellate cells as dominant con-
tributors to liver fibrosis independent of its aetiology. Nat. Commun. 4, 2823. http://
dx.doi.org/10.1038/ncomms3823.
Mehal, W.Z., Iredale, J., Friedman, S.L., 2011. Scraping fibrosis: expressway to the core of
fibrosis. Nat. Med. 17, 552–553. http://dx.doi.org/10.1038/nm0511-552.
Menne, J., Eulberg, D., Beyer, D., Baumann, M., Saudek, F., Valkusz, Z., Więcek, A.,
Haller, H., 2017. Emapticap Study Group. C-C motif-ligand 2 inhibition with emap-
ticap pegol (NOX-E36) in type 2 diabetic patients with albuminuria. Nephrol. Dial.
Transplant. 32, 307–315. http://dx.doi.org/10.1093/ndt/gfv459.
Meurer, S.K., Lahme, B., Tihaa, L., Weiskirchen, R., Gressner, A.M., 2005. N-acetyl-L-
cysteine suppresses TGF-β signaling at distinct molecular steps: the biochemical and
biological efficacy of a multifunctional, antifibrotic drug. Biochem. Pharmacol. 70,
1026–1034. http://dx.doi.org/10.1016/j.bcp.2005.07.001.
Morrell, G.R., Zhang, J.L., Lee, V.S., 2017. Magnetic resonance imaging of the fibrotic
kidney. J. Am. Soc. Nephrol. 28, 2564–2570. http://dx.doi.org/10.1681/ASN.
2016101089.
Munker, S., Wu, Y.L., Ding, H.G., Liebe, R., Weng, H.L., 2017. Can a fibrotic liver afford
epithelial-mesenchymal transition? World J. Gastroenterol. 23, 4661–4668. http://
dx.doi.org/10.3748/wjg.v23.i26.4661. v23.i26.4661" > .
Murdaca, G., Contatore, M., Gulli, R., Mandich, P., Puppo, F., 2016. Genetic factors and
systemic sclerosis. Autoimmun. Rev. 15, 427–432. http://dx.doi.org/10.1016/j.
autrev.2016.01.016.
Murtha, L.A., Schuliga, M.J., Mabotuwana, N.S., Hardy, S.A., Waters, D.W., Burgess, J.K.,
Knight, D.A., Boyle, A.J., 2017. The processes and mechanisms of cardiac and pul-
monary fibrosis. Front. Physiol. 8, 777. http://dx.doi.org/10.3389/fphys.2017.
00777.
Murphy-Marshman, H., Quensel, K., Shi-Wen, X., Barnfield, R., Kelly, J., Peidl, A.,
Stratton, R.J., Leask, A., 2017. Antioxidants and NOX1/NOX4 inhibition blocks
TGFβ1-induced CCN2 and α-SMA expression in dermal and gingival fibroblasts. PLoS
One (10), 12. http://dx.doi.org/10.1371/journal.pone.0186740. e0186740.
Nastase, M.V., Zeng-Brouwers, J., Wygrecka, M., Schaefer, L., 2017. Targeting renal fi-
brosis: mechanisms and drug delivery systems. Adv. Drug Deliv. Rev. http://dx.doi.
org/10.1016/j.addr.2017.12.019. Dec 27.
Neuschwander-Tetri, B.A., Loomba, R., Sanyal, A.J., Lavine, J.E., Van Natta, M.L.,
Abdelmalek, M.F., Chalasani, N., Dasarathy, S., Diehl, A.M., Hameed, B., Kowdley,
K.V., McCullough, A., Terrault, N., Clark, J.M., Tonascia, J., Brunt, E.M., Kleiner,
D.E., Doo, E., 2015. NASH Clinical Research Network. Farnesoid X nuclear receptor
ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (FLINT): a
multicentre, randomised, placebo-controlled trial. Lancet 385, 956–965. http://dx.
doi.org/10.1016/S0140-6736(14)61933-4. Erratum in: Lancet 2015;385:946. Lancet
2016;387:1618.
Nielsen, M.J., Veidal, S.S., Karsdal, M.A., Ørsnes-Leeming, D.J., Vainer, B., Gardner, S.D.,
Hamatake, R., Goodman, Z.D., Schuppan, D., Patel, K., 2015. Plasma Pro-C3 (N-
terminal type III collagen propeptide) predicts fibrosis progression in patients with
chronic hepatitis C. Liver Int. 35, 429–437. http://dx.doi.org/10.1111/liv.12700.
Ninichuk, V., Clauss, S., Kulkarni, O., Schmid, H., Segerer, S., Radomska, E., Eulberg, D.,
Buchner, K., Selve, N., Klussmann, S., Anders, H.J., 2008. Late onset of Ccl2 blockade
with the Spiegelmer mNOX-E36-3'PEG prevents glomerulosclerosis and improves
glomerular filtration rate in db/db mice. Am. J. Pathol. 172, 628–637. http://dx.doi.
org/10.2353/ajpath.2008.070601.
Nishioka, Y., Azuma, M., Kishi, M., Aono, Y., 2013. Targeting platelet-derived growth
factor as a therapeutic approach in pulmonary fibrosis. J. Med. Invest. 60, 175–183.
http://dx.doi.org/10.2152/jmi.60.175.
Ohkubo, H., Nakagawa, H., Niimi, A., 2018. Computer-based quantitative computed
13
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
tomography image analysis in idiopathic pulmonary fibrosis: a mini review. Respir
Investig 56, 5–13. http://dx.doi.org/10.1016/j.resinv.2017.10.003.
Okuma, T., Terasaki, Y., Kaikita, K., Kobayashi, H., Kuziel, W.A., Kawasuji, M., Takeya,
M., 2004. C-C chemokine receptor 2 (CCR2) deficiency improves bleomycin-induced
pulmonary fibrosis by attenuation of both macrophage infiltration and production of
macrophage-derived matrix metalloproteinases. J. Pathol. 204, 594–604. http://dx.
doi.org/10.1002/path.1667.
Österreicher, C.H., Penz-Österreicher, M., Grivennikov, S.I., Guma, M., Koltsova, E.K.,
Datz, C., Sasik, R., Hardiman, G., Karin, M., Brenner, D.A., 2011. Fibroblast-specific
protein 1 identifies an inflammatory subpopulation of macrophages in the liver. Proc.
Natl. Acad. Sci. U. S. A. 108, 308–313. http://dx.doi.org/10.1073/pnas.1017547108.
Pakshir, P., Hinz, B., 2018. The big five in fibrosis: macrophages, myofibroblasts, matrix,
mechanics, and miscommunication. Matrix Biol. http://dx.doi.org/10.1016/j.
matbio.2018.01.019. Jan 30. pii: S0945–053X(18)30034-9.
Pandey, A.C., Lancaster, J.J., Harris, D.T., Goldman, S., Juneman, E., 2017. Cellular
therapeutics for heart failure: focus on mesenchymal stem cells. Stem Cell. Int. 2017,
9640108. http://dx.doi.org/10.1155/2017/9640108.
Patel, K., Bedossa, P., Castera, L., 2015. Diagnosis of liver fibrosis: present and future.
Semin. Liver Dis. 35, 166–183. http://dx.doi.org/10.1055/s-0035-1550059.
Phua, Y.L., Martel, N., Pennisi, D.J., Little, M.H., Wilkinson, L., 2013. Distinct sites of
renal fibrosis in Crim1 mutant mice arise from multiple cellular origins. J. Pathol.
229, 685–696. http://dx.doi.org/10.1002/path.4155.
Piera-Velazquez, S., Mendoza, F.A., Jimenez, S.A., 2016. Endothelial to mesenchymal
transition (EndoMT) in the pathogenesis of human fibrotic diseases. J. Clin. Med. (4),
5. http://dx.doi.org/10.3390/jcm5040045. pii: E45.
Quan, T.E., Cowper, S., Wu, S.P., Bockenstedt, L.K., Bucala, R., 2004. Circulating fi-
brocytes: collagen-secreting cells of the peripheral blood. Int. J. Biochem. Cell Biol.
36, 598–606. http://dx.doi.org/10.1016/j.biocel.2003.10.005.
Raghu, G., Scholand, M.B., de Andrade, J., Lancaster, L., Mageto, Y., Goldin, J., Brown,
K.K., Flaherty, K.R., Wencel, M., Wanger, J., Neff, T., Valone, F., Stauffer, J., Porter,
S., 2016. FG-3019 anti-connective tissue growth factor monoclonal antibody: results
of an open-label clinical trial in idiopathic pulmonary fibrosis. Eur. Respir. J. 47,
1481–1491. http://dx.doi.org/10.1183/13993003.01030-2015.
Raghu, G., 2017. Pharmacotherapy for idiopathic pulmonary fibrosis: current landscape
and future potential. Eur. Respir. Rev. (145), 26. http://dx.doi.org/10.1183/
16000617.0071-2017.
Raghu, G., Brown, K.K., Collard, H.R., Cottin, V., Gibson, K.F., Kaner, R.J., Lederer, D.J.,
Martinez, F.J., Noble, P.W., Song, J.W., Wells, A.U., Whelan, T.P., Wuyts, W.,
Moreau, E., Patterson, S.D., Smith, V., Bayly, S., Chien, J.W., Gong, Q., Zhang, J.J.,
O'Riordan, T.G., 2017. Efficacy of simtuzumab versus placebo in patients with idio-
pathic pulmonary fibrosis: a randomised, double-blind, controlled, phase 2 trial.
Lancet Respir Med 5, 22–32. http://dx.doi.org/10.1016/S2213-2600(16)30421-0.
Reddy, A.T., Lakshmi, S.P., Zhang, Y., Reddy, R.C., 2014. Nitrated fatty acids reverse
pulmonary fibrosis by dedifferentiating myofibroblasts and promoting collagen up-
take by alveolar macrophages. Faseb. J. 28, 5299–5310. http://dx.doi.org/10.1096/
fj.14-256263.
Ren, J., Wold, L.E., 2008. Mechanisms of alcoholic heart disease. Ther Adv Cardiovasc Dis
2, 497–506. http://dx.doi.org/10.1177/1753944708095137.
Reyes-Gordillo, K., Shah, R., Arellanes-Robledo, J., Hernández-Nazara, Z., Rincón-
Sánchez, A.R., Inagaki, Y., Rojkind, M., Lakshman, M.R., 2014. Mechanisms of action
of acetaldehyde in the up-regulation of the human α2(I) collagen gene in hepatic
stellate cells: key roles of Ski, SMAD3, SMAD4, and SMAD7. Am. J. Pathol. 184,
1458–1467. http://dx.doi.org/10.1016/j.ajpath.2014.01.020.
Richter, K., Kietzmann, T., 2016. Reactive oxygen species and fibrosis: further evidence of
a significant liaison. Cell Tissue Res. 365, 591–605. http://dx.doi.org/10.1007/
s00441-016-2445-3.
Rinkevich, Y., Walmsley, G.G., Hu, M.S., Maan, Z.N., Newman, A.M., Drukker, M.,
Januszyk, M., Krampitz, G.W., Gurtner, G.C., Lorenz, H.P., Weissman, I.L., Longaker,
M.T., 2015. Skin fibrosis. Identification and isolation of a dermal lineage with in-
trinsic fibrogenic potential. Science 348http://dx.doi.org/10.1126/science.aaa2151.
aaa2151.
Rock, J.R., Barkauskas, C.E., Cronce, M.J., Xue, Y., Harris, J.R., Liang, J., Noble, P.W.,
Hogan, B.L., 2011. Multiple stromal populations contribute to pulmonary fibrosis
without evidence for epithelial to mesenchymal transition. Proc. Natl. Acad. Sci. U. S.
A. 108, E1475–E1483. http://dx.doi.org/10.1073/pnas.1117988108.
Romero, F., Shah, D., Duong, M., Penn, R.B., Fessler, M.B., Madenspacher, J., Stafstrom,
W., Kavuru, M., Lu, B., Kallen, C.B., Walsh, K., Summer, R., 2015. A pneumocyte-
macrophage paracrine lipid axis drives the lung toward fibrosis. Am. J. Respir. Cell
Mol. Biol. 53, 74–86. http://dx.doi.org/10.1165/rcmb.2014-0343OC.
Rosenbloom, J., Macarak, E., Piera-Velazquez, S., Jimenez, S.A., 2017. Human fibrotic
diseases: current challenges in fibrosis research. Meth. Mol. Biol. 1627, 1–23. http://
dx.doi.org/10.1007/978-1-4939-7113-8_1.
Rotman, Y., Sanyal, A.J., 2017. Current and upcoming pharmacotherapy for non-alco-
holic fatty liver disease. Gut 66, 180–190. http://dx.doi.org/10.1136/gutjnl-2016-
312431.
Rygiel, K.A., Robertson, H., Marshall, H.L., Pekalski, M., Zhao, L., Booth, T.A., Jones, D.E.,
Burt, A.D., Kirby, J.A., 2008. Epithelial-mesenchymal transition contributes to portal
tract fibrogenesis during human chronic liver disease. Lab. Invest. 88, 112–123.
http://dx.doi.org/10.1038/labinvest.3700704.
Sánchez-Valle, V., Chávez-Tapia, N.C., Uribe, M., Méndez-Sánchez, N., 2012. Role of
oxidative stress and molecular changes in liver fibrosis: a review. Curr. Med. Chem.
19, 4850–4860. http://dx.doi.org/10.2174/092986712803341520.
Schon, H.T., Bartneck, M., Borkham-Kamphorst, E., Nattermann, J., Lammers, T., Tacke,
F., Weiskirchen, R., 2016. Pharmacological intervention in hepatic stellate cell acti-
vation and hepatic fibrosis. Front. Pharmacol. 7, 33. http://dx.doi.org/10.3389/
fphar.2016.00033.
R. Weiskirchen et al.
Shull, M.M., Ormsby, I., Kier, A.B., Pawlowski, S., Diebold, R.J., Yin, M., Allen, R.,
Sidman, C., Proetzel, G., Calvin, D., et al., 1992. Targeted disruption of the mouse
transforming growth factor-β1 gene results in multifocal inflammatory disease.
Nature 359, 693–699. http://dx.doi.org/10.1038/359693a0.
Strutz, F., Okada, H., Lo, C.W., Danoff, T., Carone, R.L., Tomaszewski, J.E., Neilson, E.G.,
1995. Identification and characterization of a fibroblast marker: FSP1. J. Cell Biol.
130, 393–405.
Su, H., Lei, C.T., Zhang, C., 2017. Interleukin-6 signaling pathway and its role in kidney
disease: an update. Front. Immunol. 8, 405. http://dx.doi.org/10.3389/fimmu.2017.
00405.
Sun, M., Chen, M., Dawood, F., Zurawska, U., Li, J.Y., Parker, T., Kassiri, Z., Kirshenbaum,
L.A., Arnold, M., Khokha, R., Liu, P.P., 2007. Tumor necrosis factor-alpha mediates
cardiac remodeling and ventricular dysfunction after pressure overload state.
Circulation 115, 1398–1407. http://dx.doi.org/10.1161/CIRCULATIONAHA.106.
643585.
Sundberg, C., Ivarsson, M., Gerdin, B., Rubin, K., 1996. Pericytes as collagen-producing
cells in excessive dermal scarring. Lab. Invest. 74, 452–466.
Svegliati-Baroni, G., Inagaki, Y., Rincon-Sanchez, A.R., Else, C., Saccomanno, S.,
Benedetti, A., Ramirez, F., Rojkind, M., 2005. Early response of α2(I) collagen to
acetaldehyde in human hepatic stellate cells is TGF-β independent. Hepatology 42,
343–352. http://dx.doi.org/10.1002/hep.20798.
Swirski, F.K., Nahrendorf, M., 2013. Leukocyte behavior in atherosclerosis, myocardial
infarction, and heart failure. Science 339, 161–166. http://dx.doi.org/10.1126/
science.1230719.
Szabo, G., Momen-Heravi, F., 2017. Extracellular vesicles in liver disease and potential as
biomarkers and therapeutic targets. Nat. Rev. Gastroenterol. Hepatol. 14, 455–466.
http://dx.doi.org/10.1038/nrgastro.2017.71.
Tacke, F., Trautwein, C., 2015. Mechanisms of liver fibrosis resolution. J. Hepatol. 63,
1038–1039. http://dx.doi.org/10.1016/j.jhep.2015.03.039.
Tacke, F., 2017. Targeting hepatic macrophages to treat liver diseases. J. Hepatol. 66,
1300–1312. http://dx.doi.org/10.1016/j.jhep.2017.02.026.
Tacke, F., 2018. Cenicriviroc for the treatment of non-alcoholic steatohepatitis and liver
fibrosis. Expet Opin. Invest. Drugs 27, 301–311. http://dx.doi.org/10.1080/
13543784.2018.1442436.
Tan, Y., Ge, G., Pan, T., Wen, D., Gan, J., 2014. A pilot study of serum microRNAs panel as
potential biomarkers for diagnosis of nonalcoholic fatty liver disease. PLoS One 9 (8).
http://dx.doi.org/10.1371/journal.pone.0105192. e105192.
Tang, L., Tanaka, Y., Marumo, F., Sato, C., 1994. Phenotypic change in portal fibroblasts
in biliary fibrosis. Liver 14, 76–82. http://dx.doi.org/10.1111/j.1600-0676.1994.
tb00051.x.
Tecklenborg, J., Clayton, D., Siebert, S., Coley, S.M., 2018. The role of the immune system
in kidney disease. Clin. Exp. Immunol. http://dx.doi.org/10.1111/cei.13119. Feb 17.
Thanigaimani, S., Lau, D.H., Agbaedeng, T., Elliott, A.D., Mahajan, R., Sanders, P., 2017.
Molecular mechanisms of atrial fibrosis: implications for the clinic. Expert Rev.
Cardiovasc Ther. 15, 247–256. http://dx.doi.org/10.1080/14779072.2017.1299005.
Tomankova, T., Kriegova, E., Liu, M., 2015. Chemokine receptors and their therapeutic
opportunities in diseased lung: far beyond leukocyte trafficking. Am. J. Physiol. Lung
Cell Mol. Physiol. 308, L603–L618. http://dx.doi.org/10.1152/ajplung.00203.2014.
Troeger, J.S., Mederacke, I., Gwak, G.Y., Dapito, D.H., Mu, X., Hsu, C.C., Pradere, J.P.,
Friedman, R.A., Schwabe, R.F., 2012. Deactivation of hepatic stellate cells during
liver fibrosis resolution in mice. Gastroenterology 143, 1073–1083. http://dx.doi.
org/10.1053/j.gastro.2012.06.036. e22.
Tsuchida, T., Friedman, S.L., 2017. Mechanisms of hepatic stellate cell activation. Nat.
Rev. Gastroenterol. Hepatol. 14, 397–411. http://dx.doi.org/10.1038/nrgastro.
2017.38.
Tuchweber, B., Desmouliere, A., Bochaton-Piallat, M.L., Rubbia-Brandt, L., Gabbiani, G.,
1996. Proliferation and phenotypic modulation of portal fibroblasts in the early
stages of cholestatic fibrosis in the rat. Lab. Invest. 74, 265–278.
Vanhaverbeke, M., Gal, D., Holvoet, P., 2017. Functional role of cardiovascular exosomes
in myocardial injury and atherosclerosis. Adv. Exp. Med. Biol. 998, 45–58. http://dx.
doi.org/10.1007/978-981-10-4397-0_3.
Vilar-Gomez, E., Chalasani, N., 2018. Non-invasive assessment of non-alcoholic fatty liver
disease: clinical prediction rules and blood-based biomarkers. J. Hepatol. 68,
305–315. http://dx.doi.org/10.1016/j.jhep.2017.11.013.
Wang, H., Chen, X., Su, Y., Paueksakon, P., Hu, W., Zhang, M.Z., Harris, R.C., Blackwell,
T.S., Zent, R., Pozzi, A., 2015. p47(phox) contributes to albuminuria and kidney
14
Molecular Aspects of Medicine xxx (xxxx) xxx–xxx
fibrosis in mice. Kidney Int. 87, 948–962. http://dx.doi.org/10.1038/ki.2014.386.
Weiskirchen, R., Meurer, S.K., 2013. BMP-7 counteracting TGF-β1 activities in organ fi-
brosis. Front. Biosci. 18, 1407–1434. http://dx.doi.org/10.2741/4189.
Weiskirchen, R., Tacke, F., 2014. Cellular and molecular functions of hepatic stellate cells
in inflammatory responses and liver immunology. Hepatobiliary Surg. Nutr. 3,
344–363. http://dx.doi.org/10.3978/j.issn.2304-3881.2014.11.03.
Weiskirchen, R., Tacke, F., 2016. Liver fibrosis: from pathogenesis to novel therapies. Dig.
Dis. 34, 410–422. http://dx.doi.org/10.1159/000444556.
Weiskirchen, R., 2016. Hepatoprotective and anti-fibrotic agents: it's time to take the next
step. Front. Pharmacol. 6, 303. http://dx.doi.org/10.3389/fphar.2015.00303.
Weiskirchen, R., Tacke, F., 2017. Interleukin-33 in the pathogenesis of liver fibrosis:
alarming ILC2 and hepatic stellate cells. Cell. Mol. Immunol. 14, 143–145. http://dx.
doi.org/10.1038/cmi.2016.62.
Willis, B.C., Liebler, J.M., Luby-Phelps, K., Nicholson, A.G., Crandall, E.D., du Bois, R.M.,
Borok, Z., 2005. Induction of epithelial-mesenchymal transition in alveolar epithelial
cells by transforming growth factor-beta1: potential role in idiopathic pulmonary
fibrosis. Am. J. Pathol. 166, 1321–1332. http://dx.doi.org/10.1016/S0002-9440(10)
62351-6.
Wu, J., Montaniel, K.R., Saleh, M.A., Xiao, L., Chen, W., Owens, G.K., Humphrey, J.D.,
Majesky, M.W., Paik, D.T., Hatzopoulos, A.K., Madhur, M.S., Harrison, D.G., 2016.
Origin of matrix-producing cells that contribute to aortic fibrosis in hypertension.
Hypertension 67, 461–468. http://dx.doi.org/10.1161/HYPERTENSIONAHA.115.
06123.
Wu, L., Luo, Z., Zheng, J., Yao, P., Yuan, Z., Lv, X., Zhao, J., Wang, M., 2018 Feb 7. IL-33
can promote the process of pulmonary fibrosis by inducing the imbalance between
MMP-9 and TIMP-1. Inflammation. http://dx.doi.org/10.1007/s10753-018-0742-6.
Wynn, T.A., 2004. Fibrotic disease and the TH1/TH2 paradigm. Nat. Rev. Immunol. 4,
583–594. http://dx.doi.org/10.1038/nri1412.
Xu, J., Gonzalez, E.T., Iyer, S.S., Mac, V., Mora, A.L., Sutliff, R.L., Reed, A., Brigham, K.L.,
Kelly, P., Rojas, M., 2009. Use of senescence-accelerated mouse model in bleomycin-
induced lung injury suggests that bone marrow-derived cells can alter the outcome of
lung injury in aged mice. J Gerontol A Biol Sci Med Sci. 64, 731–739. http://dx.doi.
org/10.1093/gerona/glp040.
Yang, A.H., Chen, J.Y., Lin, J.K., 2003. Myofibroblastic conversion of mesothelial cells.
Kidney Int. 63, 1530–1539. http://dx.doi.org/10.1046/j.1523-1755.2003.00861.x.
Yang, J., Savvatis, K., Kang, J.S., Fan, P., Zhong, H., Schwartz, K., Barry, V., Mikels-
Vigdal, A., Karpinski, S., Kornyeyev, D., Adamkewicz, J., Feng, X., Zhou, Q., Shang,
C., Kumar, P., Phan, D., Kasner, M., López, B., Diez, J., Wright, K.C., Kovacs, R.L.,
Chen, P.S., Quertermous, T., Smith, V., Yao, L., Tschöpe, C., Chang, C.P., 2016.
Targeting LOXL2 for cardiac interstitial fibrosis and heart failure treatment. Nat.
Commun. 7, 13710. http://dx.doi.org/10.1038/ncomms13710.
Yazdani, S., Bansal, R., Prakash, J., 2017. Drug targeting to myofibroblasts: implications
for fibrosis and cancer. Adv. Drug Deliv. Rev. 121, 101–116. http://dx.doi.org/10.
1016/j.addr.2017.07.010.
Ying, Q., Wu, G., 2017. Molecular mechanisms involved in podocyte EMT and con-
comitant diabetic kidney diseases: an update. Ren. Fail. 39, 474–483. http://dx.doi.
org/10.1080/0886022X.2017.1313164.
Zaffanello, M., Tardivo, S., Cataldi, L., Fanos, V., Biban, P., Malerba, G., 2011. Genetic
susceptibility to renal scar formation after urinary tract infection: a systematic review
and meta-analysis of candidate gene polymorphisms. Pediatr. Nephrol. 26,
1017–1029. http://dx.doi.org/10.1007/s00467-010-1695-7.
Zeisberg, M., Yang, C., Martino, M., Duncan, M.B., Rieder, F., Tanjore, H., Kalluri, R.,
2007. Fibroblasts derive from hepatocytes in liver fibrosis via epithelial to me-
senchymal transition. J. Biol. Chem. 282, 23337–23347. http://dx.doi.org/10.1074/
jbc.M700194200.
Zhang, W., Zhou, X., Zhang, H., Yao, Q., Liu, Y., Dong, Z., 2016. Extracellular vesicles in
diagnosis and therapy of kidney diseases. Am. J. Physiol. Ren. Physiol. 311,
F844–F851. http://dx.doi.org/10.1152/ajprenal.00429.2016.
Zhu, J., Carver, W., 2012. Effects of interleukin-33 on cardiac fibroblast gene expression
and activity. Cytokine 58, 368–379. http://dx.doi.org/10.1016/j.cyto.2012.02.008.
Zimmer, V., Lammert, F., 2011. Genetics in liver disease: new concepts. Curr. Opin.
Gastroenterol. 27, 231–239. http://dx.doi.org/10.1097/MOG.0b013e3283444862.
Zlotnik, A., Yoshie, O., 2000. Chemokines: a new classification system and their role in
immunity. Immunity 12, 121–127. http://dx.doi.org/10.1016/S1074-7613(00)
80165-X.