ATP-binding cassette transporter A1 (ABCA1) plays a crucial role in exporting cholesterol from macrophages, a function relevant to its involvement in the prevention of atherosclerosis. Quercetin, one of flavonoids, has been described to reduce atherosclerotic lesion formation. This study is aimed to investigate the effect of quercetin on regulation of ABCA1 expression and to explore its underlying mechanisms in macrophages. The results show that quercetin markedly enhanced cholesterol efflux from macrophages in a concentration-dependent manner, which was associated with an increase in ABCA1 mRNA and protein expression. Remarkably, quercetin is able to stimulate the phosphorylation of p38 by up to 234-fold at 6 h via an activation of the transforming growth factor β-activated kinase 1 (TAK1) and mitogen-activated kinase kinase 3/6 (MKK3/6). Inhibition of p38 with a pharmacological inhibitor or small hairpin RNA (shRNA) suppressed the stimulatory effects of quercetin on ABCA1 expression and cholesterol efflux. Moreover, knockdown of p38 reduced quercetin-enhanced ABCA1 promoter activity and the binding of specificity protein 1 (Sp1) and liver X receptor α (LXRα) to the ABCA1 promoter using chromatin immunoprecipitation assays. These findings provide evidence that p38 signaling is essential for the regulation of quercetin-induced ABCA1 expression and cholesterol efflux in macrophages.
ATP-binding cassette transporter A1 (ABCA1) plays a crucial role in exporting cholesterol from macrophages, a function relevant to its involvement in the prevention of atherosclerosis. Quercetin, one of flavonoids, has been described to reduce atherosclerotic lesion formation. This study is aimed to investigate the effect of quercetin on regulation of ABCA1 expression and to explore its underlying mechanisms in macrophages. The results show that quercetin markedly enhanced cholesterol efflux from macrophages in a concentration-dependent manner, which was associated with an increase in ABCA1 mRNA and protein expression. Remarkably, quercetin is able to stimulate the phosphorylation of p38 by up to 234-fold at 6 h via an activation of the transforming growth factor β-activated kinase 1 (TAK1) and mitogen-activated kinase kinase 3/6 (MKK3/6). Inhibition of p38 with a pharmacological inhibitor or small hairpin RNA (shRNA) suppressed the stimulatory effects of quercetin on ABCA1 expression and cholesterol efflux. Moreover, knockdown of p38 reduced quercetin-enhanced ABCA1 promoter activity and the binding of specificity protein 1 (Sp1) and liver X receptor α (LXRα) to the ABCA1 promoter using chromatin immunoprecipitation assays. These findings provide evidence that p38 signaling is essential for the regulation of quercetin-induced ABCA1 expression and cholesterol efflux in macrophages.
Quercetin, one of widely distributed flavonoids in plants, is found abundantly in onions,
apples, berries, broccoli, Ginkgo biloba, and red wine (1). Like other members of flavonoids, quercetin has
wide range of biological functions associated with the modulation of oxidative stress and
inflammatory processes (2–4). In addition to these properties, it has been
reported that quercetin is able to reduce plasma cholesterol levels in hyperlipidemia
animals (5–7). Hypercholesterolemia is one of the major risk factors for the development
and progression of atherosclerosis (8, 9). It seems that quercetin may play an essential role
in the prevention of atherosclerosis. Hypercholesterolemia promotes the entry and retention
of cholesterol-rich low-density lipoprotein (LDL) within the arterial wall. The accumulated
oxidized LDL (oxLDL) in the subendothelial space of vessels is taken up by macrophages
through scavenger receptors. However, unlimited uptake of oxLDL results in foam cell
formation, a pathological hallmark of early atherosclerosis. Cholesterol efflux from
macrophages is a key mechanism to prevent the development of atherosclerosis (10–13). Despite the importance of cholesterol accumulation in the development of
atherosclerosis, little is known about the biological effects and molecular mechanisms of
quercetin on cholesterol transportation in macrophages.ATP-binding cassette transporter A1 (ABCA1), a member of the ATP-binding cassette
transporter family, is involved in the control of apolipoprotein AI (apoAI)-mediated
cholesterol efflux from macrophages (14, 15). A previous study has shown that overexpression
of ABCA1 in LDL receptor-deficient mice reduces lipid accumulation in the arterial wall
(16). Thus, induction of ABCA1 expression is
considered an attractive approach to preventing excessive cholesterol accumulation and
atherosclerosis. The expression of ABCA1 is transcriptionally regulated by nuclear
transcription factor liver X receptor (LXR) and retinoid X receptor (RXR) (17, 18).
When LXR is activated by its natural ligand, oxysterols, it forms heterodimers with RXR and
binds to the ABCA1 promoter to activate gene expression. Thymiakou et al. found that
transcription factor specificity protein 1 (Sp1) regulated ABCA1 expression via physical
interaction with the LXR/RXR heterodimer in humanhepatoma cells treated with oxysterols
and retinoids (19). In addition, Sp1 has been
reported to be involved in quercetin-regulated gene expression (20, 21); however, the
involvement of Sp1 and LXR in quercetin-induced ABCA1 transcription is still to be
elucidated.In addition to transcription factor-mediated ABCA1 gene regulation,
mitogen-activated protein kinase (MAPK) signaling cascades have been reported to modulate
ABCA1 expression (22–24). The MAPK family comprises extracellular signal-regulated kinases
1/2 (ERK1/2), c-Jun N-terminal kinase 1/2 (JNK1/2), and p38 (25). Inhibition of ERK activation leads to increase ABCA1 mRNA and
protein stabilities, which results in the activation of ABCA1 expression (22). Activation of p38 has been reported to modulate
ABCA1 expression in vascular smooth muscle cells and macrophages (23, 24). Nevertheless,
little is known about the contribution of the MAPK signaling cascades to quercetin-mediated
ABCA1 gene regulation.The aim of the study was to investigate whether quercetin stimulates cholesterol efflux via
the induction of ABCA1 expression in macrophages, as well as to explore its molecular
mechanisms. Our results show that quercetin markedly increases apoAI-mediated cholesterol
efflux via elevation of ABCA1 gene expression. Furthermore, quercetin
activates the p38 signaling cascade via stimulating phosphorylation of transforming growth
factor β-activated kinase 1 (TAK1) and mitogen-activated protein kinase kinase 3/6
(MKK3/6), the upstream kinases of p38. Moreover, quercetin enhances p38-mediated binding of
Sp1 and LXRα to the corresponding binding sites located within −250/−1
region of the ABCA1 promoter. Our results provide a new insight into the mechanisms
underlying the biological effect of quercetin on cholesterol efflux.
MATERIALS AND METHODS
Materials
SB203580 (p38 inhibitor) and 5Z-7-Oxozeaenol (TAK1 inhibitor) were obtained from
Calbiochem (San Diego, CA). Antibodies recognizing ABCA1, α-tubulin,
LXRα, B23, and rabbit control IgG were purchased from Abcam (Cambridge, UK).
Antibodies against phospho-p38, phospho-ERK1/2, phospho-JNK1/2, phospho-MKK3/6,
phospho-TAK1, total p38, total ERK1/2, total JNK1/2, and total MKK3 were obtained
from Cell Signaling Technology (Beverly, MA). Total TAK1 antibody was purchased from
Santa Cruz Biotechnology (Santa Cruz, CA). Sp1 antibody was obtained from Millipore
(Temecula, CA).
Cell culture
Murine macrophage cell line RAW264.7 was originally obtained from the American Type
Culture Collection (Manassas, VA). Cells were grown in Dulbecco's modified
Eagle's medium (DMEM; Hyclone Laboratories, Logan, UT) supplemented with 10%
fetal bovine serum (FBS; PAA Laboratories, Linz, Austria), 100 units/ml penicillin,
and 100 μg/ml streptomycin. All cell experiments were performed in a humidified
atmosphere at 37°C with 5% CO2. Bone marrow-derived macrophages (BMDM)
were isolated and cultured from 6- to 12-week-old C57BL/6 mice (Jackson Laboratories,
Bar Harbor, ME) as previously described (26). The animal experiments conformed to the PHS policy and approved by the
Animal Care and Utilization committee of National Yang-Ming University. Briefly, bone
marrow cells isolated from femurs were cultured for 7 days in Petri dishes with DMEM
containing 20% FBS, 100 units/ml penicillin, 100 μg/ml streptomycin, and 50 ng/ml
macrophage colony-stimulating factor (M-CSF; R and D Systems, Minneapolis, MN) at
37°C in a 5% CO2 atmosphere. On day 7, adherent BMDM were obtained and
cultured in DMEM supplemented with 10% FBS, 100 units/ml penicillin, 100 μg/ml
streptomycin, and 50 ng/ml M-CSF. Quercetin dihydrate (Sigma-Aldrich, St. Louis, MO)
was first dissolved in dimethyl sulfoxide (DMSO) and diluted by medium containing 2%
FBS to achieve the final concentration. Medium containing 0.05% DMSO was used as the
control group.
Cholesterol efflux
RAW264.7 macrophages or BMDM plated on 24-well plates were radiolabeled with 0.5
μCi/ml [1,2-3H]cholesterol (PerkinElmer, Boston, MA) in DMEM containing
0.2% BSA (BSA; Sigma-Aldrich) for 24 h. To deliver macrophages with more cholesterol,
cells were also treated with cholesterol (Wako Pure Chemical Industries, Osaka,
Japan) dissolved in ethanol and diluted into serum-free medium at the appropriate
concentrations. RAW264.7 macrophages were incubated in 0.2% BSA-containing DMEM with
10 μg/ml of acetylated low-density lipoprotein (AcLDL; Molecular Probes, Eugene,
OR) or 30 μg/ml of cholesterol in the presence of 0.5 μCi/ml
[1,2-3H]cholesterol for 24 h. Subsequently, cells were washed and
incubated with quercetin in indicated concentrations for another 24 h. To perform
apoAI-mediated cholesterol efflux, the medium was replaced with fresh medium
containing 0.2% BSA with or without 10 μg/ml lipid-free humanapoAI
(Sigma-Aldrich) for 24 h. The efflux medium was then collected and centrifuged to
remove cell debris. Cells were lysed in 0.1 N NaOH, and radioactivities of the medium
and the cell lysate were measured by liquid scintillation counting. Cholesterol
efflux was expressed as the percentage of counts in the medium relative to the total
counts (medium and cells). ApoAI-specific cholesterol efflux was obtained by
subtracting the nonspecific efflux that occurred in apoAI-free medium. For TAK1
inhibition study, RAW264.7 macrophages or BMDM were pretreated with 5 μM
5Z-7-Oxozeaenol for 1 h and then treated with 100 μM quercetin for 24 h.
RNA extraction and quantitative real-time PCR analysis
Total cellular RNA was extracted by TRI Reagent (Sigma-Aldrich) following the
manufacturer's protocol. Reverse transcription was carried out with 2 μg
total RNA using moloney murine leukemia virus reverse transcriptase (MMLV;
Invitrogen, Carlsbad, CA). Quantitative real-time PCR was assessed using SYBR Green
PCR Master Mix (Finnzymes, Espoo, Finland) on a Roche LightCycler system (Roche
Diagnostics, Mannheim, Germany). The primer sequences were as follows: ABCA1 (forward
5′-GGTTTGGAGATGGTTATACAATAGTTGT-3′ and reverse
5′-CCCGGAAACGCAAGTCC-3′) and glyceraldehyde 3-phosphate dehydrogenase
(GAPDH, forward 5′-GTATGACTCCACTCACGGCAAA-3′ and reverse
5′-GGTCTCGCTCCTGGAAGATG-3′). GAPDH was used for the internal
normalization.
Western blot analysis
Cells were lysed with lysis buffer [20 mM Tris-HCl, pH 7.5, 150 mM NaCl, 1 mM EDTA, 1
mM EGTA, 1% Triton X-100, 50 mM dithiothreitol, complete protease inhibitor cocktail
(Roche Diagnostics) and phosphatase inhibitor cocktail I and II (Sigma-Aldrich)]. The
cell lysates were centrifuged and the supernatants were collected. The protein
concentration was assayed using Bradford reagent (Bio-Rad, Hercules, CA) with BSA as
the standard. Equal amounts of protein were analyzed by SDS-polyacrylamide gel, and
transferred to nitrocellulose membranes (Pall, Glen Cove, NY). The immunoblots were
blocked with 5% nonfat milk in PBST (5.8 mM
Na2HPO4·7H2O, 130 mM NaCl and 0.05%
Tween-20) for 1 h at room temperature, and then incubated with first antibodies
overnight at 4°C. After PBST wash, the blots were incubated with horseradish
peroxidase (HRP)-conjugated secondary antibodies (Sigma-Aldrich), and the target
protein bands were visualized by using enhanced chemiluminescence system (ECL;
PerkinElmer). The blots were then stripped for further probing with α-tubulin
or B23 antibody as internal controls for the total cellular or nuclear proteins,
respectively. Relative intensities of protein bands were quantified by densitometry
using Image Quant software (Molecular Dynamics, Sunnyvale, CA).
Lentivirus-mediated RNA interference
Knockdown of p38 expression was performed by the lentivirus-packaged small hairpin
RNA (shRNA) approach. Two different clones expressing p38-targeting shRNAs were
obtained from the National RNAi Core Facility of Academia Sinica (Taiwan). The
targeting sequences of these two clones were as follows: p38 shRNA-1
(5′-CCTCTTGTTGAAAGATTCCTT-3′) and p38 shRNA-2
(5′-GCTGAATTGGATGCACTATAA-3′). Luciferase shRNA was used as a control
shRNA. Briefly, lentiviral-containing shRNAs at an MOI of 3 were used to infect
RAW264.7 macrophages in the presence of 8 μg/ml polybrene (Sigma-Aldrich). After
24 h, the infected cells were selected with 2 μg/ml puromycin (Sigma-Aldrich) for
two weeks to generate stable-knockdown cells. The knockdown efficiency of p38 was
examined by Western blot analysis using anti-total p38 antibody.
Construction of ABCA1 promoter-driven luciferase reporter plasmids
Various lengths of the mouseABCA1 promoter sequences were amplified by PCR using the
primers as indicated ().
Each PCR fragment was subsequently cloned into the
XhoI/HindIII restriction sites of the luciferase
reporter plasmid pGL3-basic vector (Promega, Madison, WI). To introduce site-specific
mutations in putative transcription factor binding sites within −250/−1
region of the ABCA1 promoter, site-directed mutagenesis was performed using the
QuickChange Site-Directed Mutagenesis Kit (Stratagene, La Jolla, CA) according to the
manufacturer's instructions. The DNA sequences of the constructs were verified
by automated DNA sequencing. The mousep38 expression plasmid (pRcCMV-p38) was a gift
from Professor Fung-Fang Wang's lab (National Yang-Ming University, Taipei,
Taiwan).
Restriction enzyme cutting sites are underlined. Mutations are indicated by
lowercase letters.
Primers used for the plasmid constructionsRestriction enzyme cutting sites are underlined. Mutations are indicated by
lowercase letters.
Transient transfection and luciferase assay
Transient transfection was performed using Lipofectamine LTX and PLUS reagents
(Invitrogen, Carlsbad, CA) according to the manufacturer's instructions. Cells
were cotransfected with 1 μg of ABCA1 promoter-driven luciferase reporter plasmid
and 0.5 μg of pCMV-β-galactosidase expression plasmid in serum-free DMEM.
After 6 h of transfection, the medium was replaced with fresh DMEM containing 10% FBS
and incubated for further 18 h at 37°C. Cells were then treated with 100 μM
quercetin for 24 h and lysed with lysis buffer (70 mM K2HPO4,
2.1 mM MgCl2, 55 mM Tris-HCl, pH 7.8, 0.7 mM dithiothreitol, and 1% Triton
X-100). Cell lysates were harvested by centrifugation. Luciferase activity was
quantified with a VICTOR2 Multilabel Reader (PerkinElmer).
β-galactosidase activity was measured by incubating cell extracts with
o-nitrophenyl-β-D-galactopyranoside (Sigma-Aldrich).
Relative luciferase activity was presented as firefly luciferase values normalized to
β-galactosidase activity.
Nuclear protein extraction
Cells were lysed by hypotonic lysis buffer [20 mM HEPES, pH 7.4, 10 mM KCl, 1 mM
MgCl2, 0.5% NP-40, 0.5 mM dithiothreitol, and complete protease
inhibitor cocktail (Roche Diagnostics)]. Nuclei were pelleted by centrifugation and
lysed by high salt nuclear extraction buffer [20 mM HEPES, pH 7.4, 10 mM KCl, 1 mM
MgCl2, 400 mM NaCl, 0.5 mM dithiothreitol, and complete protease
inhibitor cocktail (Roche Diagnostics)]. The nuclear proteins were harvested after
centrifugation.
Chromatin immunoprecipitation
Chromatin immunoprecipitation (ChIP) experiments were performed according to the
manufacturer's instructions (Cell Signaling Technology, Beverly, MA) with some
modifications. RAW264.7 macrophages were treated with or without 100 μM quercetin
for 3 h, harvested, and crosslinked with 1% formaldehyde at 37°C for 10 min.
Crosslinking was stopped by adding glycine to 125 mM for 5 min at room temperature.
Cells were washed twice with ice-cold PBS, and then lysed with hypotonic cell lysis
buffer [5 mM HEPES, pH 8.0, 85 mM KCl, 0.5% NP-40, 1 mM dithiothreitol, and complete
protease inhibitor cocktail (Roche Diagnostics)]. After centrifugation, nuclear
pellets were collected and resuspended in micrococcal nuclease (MNase) digestion
buffer [50 mM Tris-HCl, pH 7.4, 0.32 M sucrose, 4 mM MgCl2, 1 mM
CaCl2, and complete protease inhibitor cocktail (Roche Diagnostics)].
Chromatin was digested into fragments of 150–900 bp by MNase (New England
Biolabs, Beverly, MA), and this was followed by sonication to disrupt nuclear
membrane. For immunoprecipitation, 15–25 μg of chromatin was incubated with
1 μg of antibodies against Sp1 or LXRα. Nonimmune IgG was used as a negative
control. Antibody-protein-DNA complexes were pulled down with 50% protein A agarose
beads/salmon sperm DNA slurry (Millipore, Temecula, CA). Precipitated chromatin
complexes were eluted with elution buffer (1% SDS and 0.1 M NaHCO3).
Crosslinking was reversed with 250 mM NaCl and proteinase K overnight at 65°C.
DNA was purified by phenol/chloroform extraction and isopropanol precipitation in the
presence of glycogen. The fragments of the ABCA1 promoter containing the predicted
Sp1 and LXRα binding sites were detected by PCR using the primers as follows:
forward 5′-GGCGGGCCATGTCTCCACG-3′ and reverse
5′-GCTCGCTCGCCCTCGGAATT-3′. The PCR products were separated on a 2%
agarose gel and visualized by ethidium bromide staining.
Statistical analysis
Data are expressed as mean ± SEM of at least three independent experiments.
Statistical analysis was performed using Student t-test or one-way
ANOVA with the Tukey's method as a posthoc test. A value of P
< 0.05 was considered statistically significant.
RESULTS
Quercetin enhances cholesterol efflux and ABCA1 expression in macrophages
To determine whether quercetin may influence cholesterol homeostasis, we first
investigated the role of quercetin in the control of apoAI-mediated cholesterol
efflux from macrophages. The results in showed that quercetin concentration-dependently enhanced
apoAI-mediated cholesterol efflux from RAW264.7 macrophages and primary macrophages,
BMDM. We also treated RAW264.7 macrophages with AcLDL or cholesterol to examine the
effect of quercetin on cholesterol efflux from the cholesterol-loaded macrophages. As
shown in Fig. 1B, quercetin increased
apoAI-mediated cholesterol efflux from AcLDL- or cholesterol-loaded macrophages in a
dose-dependent manner. As the importance of ABCA1 in apoAI-mediated cholesterol
efflux has been established (14, 15), we next examined the effect of quercetin
on the mRNA level of ABCA1 by quantitative real-time PCR. The results revealed that
quercetin also upregulated the ABCA1 mRNA level in a dose-dependent manner up to
6-fold at 100 μM quercetin treatment (Fig.
1C). We then investigated whether the elevated ABCA1 mRNA level resulted in
an increased expression of ABCA1 protein. As shown in Fig. 1D, ABCA1 protein level was increased in a concentration-dependent
manner up to 8-fold when cells were subjected to 100 μM quercetin treatment. These
results suggest that quercetin-induced ABCA1 is a facilitating factor in the
stimulation of cholesterol efflux from macrophages.
Fig. 1.
Quercetin enhances cholesterol efflux and expression of ABCA1 in macrophages.
A: [3H]cholesterol-labeled RAW264.7 macrophages or BMDM were treated
with quercetin as indicated concentrations for 24 h. ApoAI-dependent
cholesterol efflux was measured by incubating
[3H]cholesterol-labeled macrophages with or without 10 μg/ml
apoAI for 24 h. Cholesterol efflux was expressed as the percentage of
radioactivity in the medium relative to the total radioactivity (medium and
cells). B: RAW264.7 macrophages were loaded with 10 μg/ml of acetylated
low-density lipoprotein (AcLDL) or 30 μg/ml cholesterol in the presence of
[3H]cholesterol for 24 h. Cholesterol efflux was measured as
described in Materials and Methods. C: After cells were treated with quercetin
for 18 h, mRNA levels of ABCA1 were detected by quantitative real-time PCR and
normalized to GAPDH. D: Cells were treated with quercetin for 24 h, and then
total cell extracts were harvested. ABCA1 protein expressions were measured by
Western blot analysis and α-tubulin was utilized as a loading control.
The normalized level of mRNA or protein from cells without quercetin treatment
was set as 1. Results are expressed as mean ± SEM (n =
3–5). *P < 0.05,
**P < 0.01 versus control group.
Quercetin enhances cholesterol efflux and expression of ABCA1 in macrophages.
A: [3H]cholesterol-labeled RAW264.7 macrophages or BMDM were treated
with quercetin as indicated concentrations for 24 h. ApoAI-dependent
cholesterol efflux was measured by incubating
[3H]cholesterol-labeled macrophages with or without 10 μg/ml
apoAI for 24 h. Cholesterol efflux was expressed as the percentage of
radioactivity in the medium relative to the total radioactivity (medium and
cells). B: RAW264.7 macrophages were loaded with 10 μg/ml of acetylated
low-density lipoprotein (AcLDL) or 30 μg/ml cholesterol in the presence of
[3H]cholesterol for 24 h. Cholesterol efflux was measured as
described in Materials and Methods. C: After cells were treated with quercetin
for 18 h, mRNA levels of ABCA1 were detected by quantitative real-time PCR and
normalized to GAPDH. D: Cells were treated with quercetin for 24 h, and then
total cell extracts were harvested. ABCA1 protein expressions were measured by
Western blot analysis and α-tubulin was utilized as a loading control.
The normalized level of mRNA or protein from cells without quercetin treatment
was set as 1. Results are expressed as mean ± SEM (n =
3–5). *P < 0.05,
**P < 0.01 versus control group.
Quercetin induces phosphorylation of p38, TAK1, and MKK3/6
To investigate the mechanisms underlying the regulation of ABCA1 expression by
quercetin, we assessed the effect of quercetin on the phosphorylation of p38, ERK,
and JNK. Quercetin time-dependently induced the phosphorylation of p38 by 168-fold to
234-fold at 2 to 6 h ().
However, there were no significant differences in the levels of phosphorylated ERK
and JNK among the groups at various times compared with the 0 h group. As TAK1 and
MKK3/6 are upstream kinases of p38 (27), we
next examined the effect of quercetin on the activation of TAK1 and MKK3/6. The
levels of phosphorylated TAK1 and MKK3/6 were significantly increased after quercetin
treatment for 0.5 to 6 h (Fig. 2B). Therefore,
we next assessed the effect of 5Z-7-Oxozeazenol (5Z-7-Oxo), a specific TAK1
inhibitor, on the quercetin-induced phosphorylation of p38, TAK1, and MKK3/6. As
shown in Fig. 2B, the phosphorylation levels
of p38, TAK1, and MKK3/6 were markedly suppressed by 5Z-7-Oxo. Moreover, we
investigated the effect of 5Z-7-Oxo on quercetin-induced cholesterol efflux from
RAW264.7 macrophages or BMDM. 5Z-7-Oxo significantly reversed the induction of
cholesterol efflux by quercetin (Fig. 2C, D).
These results indicate that TAK1-MKK3/6-p38 signaling cascade is essential for the
regulation of quercetin-stimulated cholesterol efflux from macrophages.
Fig. 2.
Quercetin activates p38 via the TAK1-MKK3/6 signaling cascade. A: The proteins
from total cell lysates were separated by SDS-PAGE and immunoblotted with
anti-phospho-MAPK antibodies. Immunoblots were reprobed with total MAPK
antibodies for internal normalization. B: RAW264.7 macrophages were pretreated
with 5 μM 5Z-7-Oxo for 1 h, and then treated with 100 μM quercetin as
indicated time to determine whether the p38 activation was via phosphorylation
of TAK1 and MKK3/6. An arrow indicates MKK3 band. Histograms show the relative
intensity of normalized phospho-MAPK, phospho-TAK1, and phospho-MKK3/6 over the
0 h group. Data represent mean ± SEM (n = 3–5).
**P < 0.01 versus 0 h group,
#P < 0.05 versus 2 h group. C, D:
Analyses were performed to determine the effect of 5Z-7-Oxo on cholesterol
efflux in RAW264.7 macrophages (C) or BMDM (D) as described in Materials and
Methods. Bars are mean ± SEM (n = 3–4).
**P < 0.01,
##P < 0.01.
Quercetin activates p38 via the TAK1-MKK3/6 signaling cascade. A: The proteins
from total cell lysates were separated by SDS-PAGE and immunoblotted with
anti-phospho-MAPK antibodies. Immunoblots were reprobed with total MAPK
antibodies for internal normalization. B: RAW264.7 macrophages were pretreated
with 5 μM 5Z-7-Oxo for 1 h, and then treated with 100 μM quercetin as
indicated time to determine whether the p38 activation was via phosphorylation
of TAK1 and MKK3/6. An arrow indicates MKK3 band. Histograms show the relative
intensity of normalized phospho-MAPK, phospho-TAK1, and phospho-MKK3/6 over the
0 h group. Data represent mean ± SEM (n = 3–5).
**P < 0.01 versus 0 h group,
#P < 0.05 versus 2 h group. C, D:
Analyses were performed to determine the effect of 5Z-7-Oxo on cholesterol
efflux in RAW264.7 macrophages (C) or BMDM (D) as described in Materials and
Methods. Bars are mean ± SEM (n = 3–4).
**P < 0.01,
##P < 0.01.
p38 activation is crucial for the regulation of quercetin-induced ABCA1
expression
To understand the mechanisms of quercetin-induced regulation of ABCA1 expression, we
addressed whether the p38 signaling pathway was necessary for ABCA1 induction.
RAW264.7 macrophages were pretreated with SB203580, a pharmacological inhibitor of
p38, followed by treatment with quercetin. Quercetin-induced ABCA1 mRNA and protein
expression were remarkably attenuated in cells treated with SB203580 (, B). Moreover, a significant
reduction in p38 was observed when p38 shRNA-1- and p38 shRNA-2-expressing cells
(RAW264.7 macrophages were infected with lentivirus containing p38-targeting shRNAs)
were examined (Fig. 3C). Luciferase shRNA was
used as a control shRNA. Importantly, both mRNA and protein levels of ABCA1 induced
by quercetin were significantly suppressed in p38 shRNA-expressing cells (Fig. 3D, E). In line with the inhibitory effect
of p38 knockdown on ABCA1 expression, quercetin-induced cholesterol efflux was also
suppressed in p38 shRNA-expressing cells (Fig.
3F). Together, these results support the critical role of p38 in the
induction of ABCA1 expression by quercetin and the subsequent changes in cholesterol
efflux in macrophages.
Fig. 3.
p38 is involved in the quercetin-induced ABCA1 expression and cholesterol
efflux. RAW264.7 macrophages were pretreated with 20 μM SB203580 (p38
inhibitor), and then treated with 100 μM quercetin. A: The ABCA1 mRNA levels
were measured by quantitative real-time PCR and normalized to GAPDH. B: The
ABCA1 protein levels were detected by Western blot analysis and α-tubulin
was utilized as a loading control. The normalized level of mRNA or protein from
cells without quercetin treatment was set as 1. RAW264.7 macrophages were
infected with lentivirus expressing p38 shRNA-1 or p38 shRNA-2 to confirm the
effects of p38 on quercetin-induced ABCA1 expression and cholesterol efflux.
Luciferase shRNA (Luc. shRNA) was used as a control shRNA. C: The knockdown
efficiency of p38 was checked by Western blot analysis. D, E: The effect of p38
knockdown on quercetin-induced ABCA1 mRNA (D) and protein (E) expression was
examined by quantitative real-time PCR and Western blot analysis, respectively.
The normalized level of mRNA or protein from parental cells without quercetin
treatment was given as 1. F: Cholesterol efflux from p38 knockdown cells to
media was measured in the presence of 10 μg/ml apoAI. Cholesterol efflux was
expressed as the percentage of radioactivity in the medium relative to the
total radioactivity (medium and cells). Values are mean ± SEM (n
= 3–6). *P < 0.05,
**P < 0.01,
#P < 0.05,
##P < 0.01.
p38 is involved in the quercetin-induced ABCA1 expression and cholesterol
efflux. RAW264.7 macrophages were pretreated with 20 μM SB203580 (p38
inhibitor), and then treated with 100 μM quercetin. A: The ABCA1 mRNA levels
were measured by quantitative real-time PCR and normalized to GAPDH. B: The
ABCA1 protein levels were detected by Western blot analysis and α-tubulin
was utilized as a loading control. The normalized level of mRNA or protein from
cells without quercetin treatment was set as 1. RAW264.7 macrophages were
infected with lentivirus expressing p38 shRNA-1 or p38 shRNA-2 to confirm the
effects of p38 on quercetin-induced ABCA1 expression and cholesterol efflux.
Luciferase shRNA (Luc. shRNA) was used as a control shRNA. C: The knockdown
efficiency of p38 was checked by Western blot analysis. D, E: The effect of p38
knockdown on quercetin-induced ABCA1 mRNA (D) and protein (E) expression was
examined by quantitative real-time PCR and Western blot analysis, respectively.
The normalized level of mRNA or protein from parental cells without quercetin
treatment was given as 1. F: Cholesterol efflux from p38 knockdown cells to
media was measured in the presence of 10 μg/ml apoAI. Cholesterol efflux was
expressed as the percentage of radioactivity in the medium relative to the
total radioactivity (medium and cells). Values are mean ± SEM (n
= 3–6). *P < 0.05,
**P < 0.01,
#P < 0.05,
##P < 0.01.
Identification of the quercetin-responsive region within the ABCA1
promoter
The results in Fig. 1B implies that quercetin
may regulate ABCA1 expression at the transcription level. To define the
quercetin-responsive region within the ABCA1 promoter, we generated five
5′-serial deletion constructs, wild-type (WT)-1550, WT-1100, WT-700, WT-400,
and WT-250, that contained the ABCA1 promoter region between −1550 and −1
bp. All fragments of the ABCA1 promoter constructs were analyzed for luciferase
activity in RAW264.7 macrophages treated in the absence or presence of 100 μM
quercetin. As shown in ,
the luciferase activity of the constructs from −1550 to −250 sites showed
significantly higher luciferase activity (WT-250, 6.1 ± 0.5-fold; WT-400, 6.6
± 0.6-fold; WT-700, 6.5 ± 0.6-fold; WT-1100, 5.9 ± 0.4-fold; and
WT-1550, 4.8 ± 0.2-fold) compared with the promoter activity in the
transfected cells without treatment of quercetin (WT-250, 2.3 ± 0.2-fold;
WT-400, 2.5 ± 0.2-fold; WT-700, 2.8 ± 0.2-fold; WT-1100, 2.4 ±
0.1-fold; and WT-1550, 1.9 ± 0.2-fold). These observations imply that the main
quercetin-responsive region required for ABCA1 promoter activity is located in the
region between −250 and −1 bp.
Fig. 4.
Characterization of quercetin-responsive domains in the ABCA1 promoter.
Schematic diagram of putative binding sites for transcription factors and
serial deletion constructs of ABCA1 promoter are shown. RAW264.7 macrophages
were transiently cotransfected with 1 μg of indicated constructs and 0.5
μg of pCMV β-galactosidase expression plasmid, and then treated with
100 μM quercetin (Q100) for 24 h. Luciferase activity was normalized with
β-galactosidase activity. Results are shown as fold changes in luciferase
activity relative to the untreated pGL3-basic vector group. The level of
luciferase activity without quercetin treatment in pGL3-basic vector group was
given the value of 1. Bars are mean ± SEM (n = 3).
**P < 0.01 versus quercetin-treated
pGL3-basic vector group.
Characterization of quercetin-responsive domains in the ABCA1 promoter.
Schematic diagram of putative binding sites for transcription factors and
serial deletion constructs of ABCA1 promoter are shown. RAW264.7 macrophages
were transiently cotransfected with 1 μg of indicated constructs and 0.5
μg of pCMV β-galactosidase expression plasmid, and then treated with
100 μM quercetin (Q100) for 24 h. Luciferase activity was normalized with
β-galactosidase activity. Results are shown as fold changes in luciferase
activity relative to the untreated pGL3-basic vector group. The level of
luciferase activity without quercetin treatment in pGL3-basic vector group was
given the value of 1. Bars are mean ± SEM (n = 3).
**P < 0.01 versus quercetin-treated
pGL3-basic vector group.
The Sp1 and LXR binding sites are critical for the regulation of
quercetin-induced ABCA1 promoter activity
The potential binding sites for Sp1, E-box, AP1, and LXR/RXR within the
−250/−1 region of the ABCA1 promoter were predicted by using the TRANSFAC
program (28) (Fig. 4). To address the importance of these transcription factor
binding sites in quercetin-induced ABCA1 promoter activities, we generated several
mutated constructs (mSp1a, mE-box, mAP1, mSp1b, and mlXR) by site-directed
mutagenesis as shown in .
The results showed that mutagenesis of the Sp1b or LXR sites attenuated
quercetin-induced ABCA1 promoter activity compared with the level of WT-250 promoter.
Moreover, a construct containing double mutations of Sp1b and LXR sites (mSp1b/mLXR)
was generated to validate whether these two sites were essential for the regulation
of quercetin-induced ABCA1 promoter activity. It is clear that quercetin-induced
promoter activity of mSp1b/mLXR showed a more significant decrease compared with that
of Sp1b or LXR mutation alone (Fig. 5A). We
thus assume that Sp1b and LXR sites are both required for the regulation of
ABCA1 gene expression in cells under quercetin treatment.
Fig. 5.
Sp1 and LXR binding sites are quercetin-responsive elements within the ABCA1
promoter. A: Six mutation constructs of ABCA1 promoter in the potential Sp1a,
E-box, AP1, Sp1b, and LXR recognition sites were generated using site-directed
mutatgenesis. RAW264.7 macrophages were transiently cotransfected with 1 μg
of indicated mutant constructs and 0.5 μg of pCMV β-galactosidase
expression plasmid, and then treated with 100 μM quercetin (Q100) for 24 h.
Luciferase activity was normalized with β-galactosidase activity and
expressed as fold changes in luciferase activity compared with those of the
control. The level of luciferase activity without quercetin treatment was given
the value of 1. WT-250, −250/−1 region of ABCA1 promoter.
mSp1b/mLXR, double mutations at Sp1b and LXR sites. B: Cells were treated with
quercetin for 3 h, and nuclear extracts were harvested. The nuclear expression
levels of Sp1 and LXR were analyzed by Western blot analysis. The arrow
indicates Sp1 band. B23 was used as nuclear loading control, and
α-tubulin was used to exclude cytosolic contamination. The level of Sp1
or LXR without quercetin treatment was given the value of 1. C: ChIP assays
were performed to observe the binding of Sp1 and LXRα to the ABCA1
promoter in quercetin-treated cells as described in Materials and Methods.
Nonimmune IgG was used as the negative control. The results of the ChIP assays
were evaluated by PCR and gel electrophoresis. Values are quantified by
densitometer and expressed as ratio relative to inputs. Results are mean
± SEM (n = 3–4). **P <
0.01, #P < 0.05,
##P < 0.01.
Sp1 and LXR binding sites are quercetin-responsive elements within the ABCA1
promoter. A: Six mutation constructs of ABCA1 promoter in the potential Sp1a,
E-box, AP1, Sp1b, and LXR recognition sites were generated using site-directed
mutatgenesis. RAW264.7 macrophages were transiently cotransfected with 1 μg
of indicated mutant constructs and 0.5 μg of pCMV β-galactosidase
expression plasmid, and then treated with 100 μM quercetin (Q100) for 24 h.
Luciferase activity was normalized with β-galactosidase activity and
expressed as fold changes in luciferase activity compared with those of the
control. The level of luciferase activity without quercetin treatment was given
the value of 1. WT-250, −250/−1 region of ABCA1 promoter.
mSp1b/mLXR, double mutations at Sp1b and LXR sites. B: Cells were treated with
quercetin for 3 h, and nuclear extracts were harvested. The nuclear expression
levels of Sp1 and LXR were analyzed by Western blot analysis. The arrow
indicates Sp1 band. B23 was used as nuclear loading control, and
α-tubulin was used to exclude cytosolic contamination. The level of Sp1
or LXR without quercetin treatment was given the value of 1. C: ChIP assays
were performed to observe the binding of Sp1 and LXRα to the ABCA1
promoter in quercetin-treated cells as described in Materials and Methods.
Nonimmune IgG was used as the negative control. The results of the ChIP assays
were evaluated by PCR and gel electrophoresis. Values are quantified by
densitometer and expressed as ratio relative to inputs. Results are mean
± SEM (n = 3–4). **P <
0.01, #P < 0.05,
##P < 0.01.As depicted in Fig. 5B, the nuclear levels of
Sp1 and LXR were increased in cells treated with quercetin, suggesting that both Sp1
and LXR may be involved in the regulation of quercetin-induced ABCA1
gene expression. The binding properties of Sp1 and LXRα to the ABCA1 promoter
were also examined by ChIP assays. Antibodies against Sp1 or LXRα were used to
immunoprecipitate the protein-chromatin complex. It was found that the interaction of
Sp1 and LXRα with the −250/−1 region of ABCA1 promoter was
significantly increased (Fig. 5C). These
results are consistent with those of the mutagenesis study, indicating that quercetin
stimulates ABCA1 promoter activity via the binding of Sp1 and LXRα to the ABCA1
promoter region between −250 and −1 bp. These observations confirm the
essential role of Sp1 and LXRα activation in quercetin-induced
ABCA1 gene expression.
The binding of Sp1 and LXRalpha to the ABCA1 promoter is mediated through p38
activation
We also investigated whether the stimulatory effect of quercetin on
ABCA1 gene expression was mediated through p38 signaling in p38
shRNA-expressing cells. As shown in , attenuation of quercetin-induced ABCA1 promoter activity was
observed in the p38 knockdown cells. In addition, we conducted rescue experiments
using macrophages that overexpressed p38. The results showed that overexpression of
p38 rescued the promoter activity when compared with the p38 knockdown cells (Fig. 6A). Together, these findings suggest that
p38 plays an essential role in the quercetin-induced ABCA1 promoter activity.
Moreover, the binding of Sp1 and LXRα to the ABCA1 promoter induced by
quercetin was greatly reduced in p38 knockdown cells using ChIP assays (Fig. 6B). These observations confirm that p38 is
required for the binding of Sp1 and LXRα to the ABCA1 promoter, suggesting that
p38-mediated Sp1 and LXRα activation is involved in the regulation of
quercetin-induced ABCA1 gene expression.
Fig. 6.
Effect of p38 knockdown by shRNA on the attenuation of Sp1 and LXRα
binding to the ABCA1 promoter. A: Parental cells or p38 knockdown cells were
transiently cotransfected with 0.5 μg of WT-250 construct, 0.5 μg of
pRcCMV vector, and 0.5 μg of pCMV β-galactosidase plasmid. For p38
overexpression, p38 knockdown cells were transiently cotransfected with 0.5
μg of WT-250 construct, 0.5 μg of pRcCMV-p38 plasmid, and 0.5 μg of
pCMV β-galactosidase plasmid. After transfection, cells were treated with
100 μM quercetin (Q100) for 24 h. Luciferase activity was normalized with
β-galactosidase activity and expressed as fold changes in luciferase
activity compared with respective control groups. The level of luciferase
activity without quercetin treatment was given the value of 1. WT-250,
−250/−1 region of ABCA1 promoter. B: ChIP assays were performed to
observe the binding of Sp1 and LXRα to the ABCA1 promoter in p38
knockdown cells as described in Materials and Methods. Nonimmune IgG was used
as the negative control. The results of ChIP assays were evaluated by PCR and
gel electrophoresis. Values are quantified by densitometer and expressed as
ratio relative to inputs. Bars are mean ± SEM (n = 3).
**P < 0.01,
#P < 0.05,
##P < 0.01.
Effect of p38 knockdown by shRNA on the attenuation of Sp1 and LXRα
binding to the ABCA1 promoter. A: Parental cells or p38 knockdown cells were
transiently cotransfected with 0.5 μg of WT-250 construct, 0.5 μg of
pRcCMV vector, and 0.5 μg of pCMV β-galactosidase plasmid. For p38
overexpression, p38 knockdown cells were transiently cotransfected with 0.5
μg of WT-250 construct, 0.5 μg of pRcCMV-p38 plasmid, and 0.5 μg of
pCMV β-galactosidase plasmid. After transfection, cells were treated with
100 μM quercetin (Q100) for 24 h. Luciferase activity was normalized with
β-galactosidase activity and expressed as fold changes in luciferase
activity compared with respective control groups. The level of luciferase
activity without quercetin treatment was given the value of 1. WT-250,
−250/−1 region of ABCA1 promoter. B: ChIP assays were performed to
observe the binding of Sp1 and LXRα to the ABCA1 promoter in p38
knockdown cells as described in Materials and Methods. Nonimmune IgG was used
as the negative control. The results of ChIP assays were evaluated by PCR and
gel electrophoresis. Values are quantified by densitometer and expressed as
ratio relative to inputs. Bars are mean ± SEM (n = 3).
**P < 0.01,
#P < 0.05,
##P < 0.01.
DISCUSSION
In this study, we investigated the molecular mechanisms underlying quercetin-regulated
ABCA1 expression and cholesterol efflux in macrophages. As illustrated in , our results show that quercetin
induces apoAI-mediated cholesterol efflux through activation of ABCA1 mRNA and protein
expression in RAW264.7 macrophages. It is clear that quercetin-induced ABCA1 expression
and cholesterol efflux are mediated by activating the TAK1-MKK3/6-p38 signaling cascade.
Moreover, activated p38 signaling increases the binding of Sp1 and LXRα to their
corresponding cis-elements within the −250/−1 region of the
ABCA1 promoter, which in turn increases ABCA1 gene expression in
macrophages.
Fig. 7.
A model describing the mechanisms of quercetin-induced cholesterol efflux in
macrophages. Quercetin elicits the TAK1-MKK3/6 signaling cascade to activate p38.
Activated p38 subsequently increases the binding of Sp1 and LXRα to the
ABCA1 promoter, which in turn enhances the expression of ABCA1 as well as
cholesterol efflux from macrophages.
A model describing the mechanisms of quercetin-induced cholesterol efflux in
macrophages. Quercetin elicits the TAK1-MKK3/6 signaling cascade to activate p38.
Activated p38 subsequently increases the binding of Sp1 and LXRα to the
ABCA1 promoter, which in turn enhances the expression of ABCA1 as well as
cholesterol efflux from macrophages.Over the past decade, some in vitro and in vivo studies have shown that quercetin has
anti-oxidative and anti-inflammatory effects (2,
3, 29). Other researchers have indicated that quercetin reduces plasma
cholesterol levels and atherosclerotic progression in rabbits and hamsters fed with a
high-fat diet, which implies that quercetin may also have anti-lipidemia and
anti-atherosclerotic properties (6, 7). Cholesterol efflux from cholesterol-loaded
macrophages is a key atheroprotective mechanism that counteracts cholesterol uptake
(10, 11). Several lines of evidence indicate that induction of cholesterol efflux
retards the development of atherosclerosis in apolipoprotein E (apoE) knockout mice and
LDL receptor knockout mice (30, 31). Our results showed that quercetin treatment
markedly induced apoAI-mediated cholesterol efflux in primary macrophages and
cholesterol-loaded macrophages, which seems to provide a new explanation for the effect
of quercetin on the amelioration of atherosclerotic plaques. In this study, we also
explored the molecular mechanisms that affect cholesterol transportation in macrophages.
The concentration of quercetin used in our present study was similar to that used in
other studies (32, 33). A previous study showed that rats, fed 0.2% quercetin diet
for 10 days, maintain 100 μM concentration of quercetin in the plasma (34). Moreover, the concentrations of quercetin in
plasma are positively correlated with the intake of quercetin in diet. In the animal
study, it seems that the intake of quercetin between 40 and 1,900 mg/kg/day is a safe
range for clinical use (35–38).The importance of ABCA1 in apoAI-mediated cholesterol efflux has been well established
(14). Transplantation of bone marrow
containing ABCA1-overexpressing macrophages leads to an inhibition of atherosclerotic
lesion progression (16). On the other hand,
macrophages lacking ABCA1 are defective in cholesterol efflux in vivo (39, 40).
Increasing evidence points to induced expression of ABCA1 or promoted function of
cholesterol efflux, which is responsible for the reduction of cholesterol accumulation
in macrophages treated with dietary flavonoids, such as wogonin and procyanidin (41, 42).
Our results suggest that the upregulation of ABCA1 expression, both at mRNA and protein
levels, by quercetin may be beneficial because it increases the cholesterol efflux from
macrophages, thereby resulting in atherosclerotic protection. Moreover, this study is
the first to show molecular mechanisms involved in quercetin-mediated
ABCA1 gene regulation and cholesterol efflux.The sequence required for humanABCA1 promoter activity is located in the
−175/+224 region (43). This region
includes one LXR binding site (position −62) and two Sp1 binding sites (positions
−90 and −156). Additionally, a number of other transcription factor binding
sites have been predicted in this region and are conserved in both humans and mice
(44). Thymiakou et al. reported that both
the LXR site and the two Sp1 binding sites were required for the induction of
ABCA1 gene transcription in humanhepatoma cells treated with
oxysterols and retinoids (19). We observed that
only the proximal Sp1 binding site (Sp1b, position −99) was involved in
quercetin-stimulated ABCA1 promoter activity. This observation is in agreement with
those of Zhao et al. and Chen et al., who found that this Sp1 binding motif (position
−99) is essential for ABCA1 promoter activity in apoE- or LDL-treated RAW264.7
macrophages (45, 46). It has been reported that LXR also participates in the
regulation of ABCA1 gene expression (17). Similar results were reported by Sevov et al. showing that resveratrol
upregulates LXRα expression to induce ABCA1 expression in human macrophages (47). Our results indicated that quercetin
increased the binding of both LXRα and Sp1 to the ABCA1 promoter in murine cell
line RAW264.7 macrophages.We also found that quercetin potently induced p38 phosphorylation in RAW264.7
macrophages. This result is consistent with the previous finding that quercetin induces
p38 activation and Sp1 binding to the promoters of tissue-type plasminogen activator
(21) and filamin A (48). These observations suggest that p38 can increase Sp1 promoter
binding activity and induce gene transcription. We therefore tested hypothesis that
quercetin modulates ABCA1 promoter activity through p38 signaling pathway. This
hypothesis was confirmed by a promoter assay showing that quercetin-induced ABCA1
promoter activity was suppressed in p38 knockdown RAW264.7 macrophages. Kaplan et al.
reported that lipopolysaccharide-induced ABCA1 expression was through the p38 signaling
pathway in human monocytic leukemia cells (24).
In contrast, a high concentration of glucose induces p38 activation, but it suppresses
ABCA1 expression in vascular smooth muscle cells (23). In this study, we found that quercetin induced the TAK1-MKK3/6-p38
signaling cascade and upregulated ABCA1 expression in RAW264.7 macrophages. Moreover, we
showed that the quercetin-induced binding of Sp1 to the ABCA1 promoter is suppressed in
the p38 knockdown cells. A recent study has shown that a p38 inhibitor, SB202190,
inhibits the induction of ABCA1 mRNA expression by LXR ligand in prostate cancer
epithelial cells (49), implying that p38 could
regulate LXR-mediated gene transcription. We also found that the quercetin-induced
binding of LXRα to the ABCA1 promoter was attenuated in p38 knockdown RAW264.7
macrophages. Collectively, our results indicate that quercetin enhances p38 signaling
and subsequently this potentiates the binding of Sp1 and LXRα to the ABCA1
promoter, which in turn increases ABCA1 expression and cholesterol efflux in
macrophages.In conclusion, this study provides novel insights into the protective effect of
quercetin on enhancing cholesterol efflux via upregulating ABCA1 expression, which is
mediated by increasing p38-dependent Sp1 and LXRα binding to the ABCA1 promoter in
macrophages. Quercetin may therefore be a promising therapeutic agent for the prevention
of atherosclerotic progression.
Authors: Robert Kleemann; Lars Verschuren; Martine Morrison; Susanne Zadelaar; Marjan J van Erk; Peter Y Wielinga; Teake Kooistra Journal: Atherosclerosis Date: 2011-05-05 Impact factor: 5.162
Authors: Xun Wang; Heidi L Collins; Mollie Ranalletta; Ilia V Fuki; Jeffrey T Billheimer; George H Rothblat; Alan R Tall; Daniel J Rader Journal: J Clin Invest Date: 2007-08 Impact factor: 14.808