Abdul Malik Tyagi1, Mingcan Yu1, Trevor M Darby2, Chiara Vaccaro1, Jau-Yi Li1, Joshua A Owens2, Emory Hsu1, Jonathan Adams1, M Neale Weitzmann3, Rheinallt M Jones2, Roberto Pacifici4. 1. Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, GA, USA. 2. Department of Pediatrics, Emory University, Atlanta, GA, USA. 3. Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA. 4. Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, GA, USA; Immunology and Molecular Pathogenesis Program, Emory University, Atlanta, GA, USA. Electronic address: roberto.pacifici@emory.edu.
Abstract
Nutritional supplementation with probiotics can prevent pathologic bone loss. Here we examined the impact of supplementation with Lactobacillus rhamnosus GG (LGG) on bone homeostasis in eugonadic young mice. Micro-computed tomography revealed that LGG increased trabecular bone volume in mice, which was due to increased bone formation. Butyrate produced in the gut following LGG ingestion, or butyrate fed directly to germ-free mice, induced the expansion of intestinal and bone marrow (BM) regulatory T (Treg) cells. Interaction of BM CD8+ T cells with Treg cells resulted in increased secretion of Wnt10b, a bone anabolic Wnt ligand. Mechanistically, Treg cells promoted the assembly of a NFAT1-SMAD3 transcription complex in CD8+ cells, which drove expression of Wnt10b. Reducing Treg cell numbers, or reconstitution of TCRβ-/- mice with CD8+ T cells from Wnt10b-/- mice, prevented butyrate-induced bone formation and bone mass acquisition. Thus, butyrate concentrations regulate bone anabolism via Treg cell-mediated regulation of CD8+ T cell Wnt10b production.
Nutritional supplementation with probiotics can prevent pathologic bone loss. Here we examined the impact of supplementation withLactobacillus rhamnosus GG (LGG) on bone homeostasis in eugonadic young mice. Micro-computed tomography revealed that LGG increased trabecular bone volume in mice, which was due to increased bone formation. Butyrate produced in the gut following LGG ingestion, or butyrate fed directly to germ-free mice, induced the expansion of intestinal and bone marrow (BM) regulatory T (Treg) cells. Interaction of BM CD8+ T cells withTreg cells resulted in increased secretion of Wnt10b, a bone anabolic Wnt ligand. Mechanistically, Treg cells promoted the assembly of a NFAT1-SMAD3 transcription complex in CD8+ cells, which drove expression of Wnt10b. Reducing Treg cell numbers, or reconstitution of TCRβ-/- mice withCD8+ T cells from Wnt10b-/- mice, prevented butyrate-induced bone formation and bone mass acquisition. Thus, butyrate concentrations regulate bone anabolism via Treg cell-mediated regulation of CD8+ T cell Wnt10b production.
<span class="Disease">Fractures due to <span class="Disease">osteoporosis have devastating consequences, with
complications of hip fractures leading to mortality rates of 24%–30% during
the first year following injury, and almost 50% rates of permanent disability (Burge et al., 2007). Many FDA-approved drugs
are used for the treatment of osteoporosis. However, most cases of osteoporosis
remain untreated or ineffectively treated due to the cost and side effects of
presently available drugs (Khosla and Shane,
2016). Therefore, there is an exigent need to identify and substantiate
new, inexpensive, safe, and effective interventions for boththe prevention and
treatment of osteoporosis.
Nutritional supplementation wi<span class="Chemical">th probiotics, defined as viable microorganisms
that confer a health benefit when administered in adequate quantities, may represent
one such strategy. Indeed, small-scale human studies report positive results from
supplementing the diet of osteoporoticpatients with probiotics (Jafarnejad et al., 2017; Nilsson et al., 2018). In animals, probiotics prevent the bone loss
induced by periodontal disease (Messora et al.,
2013), diabetes (Zhang et al.,
2015), and estrogen deficiency (Li et
al., 2016; Ohlsson et al., 2014).
In spite of these reports, knowledge is still scant on whether probiotics can
improve postnatal skeletal development or delay skeletal involution in healthy
subjects. Earlier investigations by our group report that the widely used probiotic
Lactobacillus rhamnosus GG (LGG) protects mice from
ovariectomy-induced stimulated bone resorption and bone loss (Li et al., 2016). In the same study, we observe that LGG
drives bone formation and increases bone volume in eugonadic mice (Li et al., 2016), although the functional elements
responsible for this response remained enigmatic.
<span class="Chemical">The enzymatic activity harbored wi<span class="Chemical">thin some taxa of gut microbiota can digest
carbohydrates to generate millimolar concentrations of the short-chain fatty acids
(SCFAs) butyrate, propionate, and acetate (Bach
Knudsen, 2015). Although LGG alone, does not produce SCFAs, LGG expands
intestinal butyrate-producing bacteria (Berni Canani
et al., 2016), indicating that LGG may indirectly increase production of
SCFAs by the gut microbiota. SCFAs selectively support the development of peripheral
regulatory T (Treg) cells (Arpaia et al.,
2013; Furusawa et al., 2013; Smith et al., 2013). Reports highlight the
bone-regulating capacities of Treg cells, describing mechanisms where Treg cells
blunt bone resorption (Kelchtermans et al.,
2009; Kim et al., 2007), stimulate
bone formation by promoting the differentiation of osteoblasts (Lei et al., 2015), and are pivotal for parathyroid
hormone (PTH)-stimulated bone formation (Yu et al.,
2018).
Here we examined <span class="Chemical">the role of <span class="Species">LGG-induced butyrate in the regulation of bone
homeostasis in young eugonadic mice. We found that LGG supplementation increased
intestinal and systemic butyrate concentrations and stimulated bone formation.
Increased butyrate also resulted in higher numbers of Treg cells. Examination of the
role of Treg cells in bone formation revealed a pathway whereby interaction of Treg
cells with BM CD8+ T cells regulated the production of Wnt10b, which acts
on stromal cells and osteoblasts to promote bone formation.
RESULTS
LGG Supplementation Increases Butyrate Levels and the Number of Treg
Cells
Conventionally raised 10-week-old female <span class="Species">mice were supplemented by oral
gavage wi<span class="Chemical">th 1 × 109 CFU LGG or vehicle control for 4 weeks.
LGG supplementation resulted in a change in microbial diversity in the
intestinal lumen and an expansion in the proportion of SCFA producing clostridia
(Figures 1A and 1B). Furthermore, LGG
supplementation of mice induced the enrichment of transcripts of a bacterial
gene coding for butyryl-CoA: acetate CoA-transferase (Figure 1C), an enzyme involved in butyrate
production by lactate-utilizing bacteria in the gut (Duncan et al., 2004; Hippe et al., 2011). Consistent withthese findings, elevated levels
of butyrate but not propionate were detected in small intestine (SI) tissue and
in the serum of LGG-treated mice (Figures
1D–1G). Butyrate induces Treg cell differentiation (Arpaia et al., 2013; Furusawa et al., 2013; Smith et al., 2013). Accordingly, we found that
feeding of LGG or butyrate increased the absolute and relative number of BM and
splenic Treg cells (Figures 1H–1K
and S1A). Because CD25
antibody (Ab) depletes Treg cells in vivo (Setiady et al., 2010; Yu et al., 2018), Treg cells induction was blunted in mice injected
with an anti-CD25 Ab but not in control mice injected withirrelevant Ab (Irr.
Ab) (Figures 1H–1K). Moreover,
treatment withLGG or butyrate increased the CD4/CD8+ BM T cell
ratio, both in mice treated withIrr. Ab and those treated with anti-CD25 Ab
(Figures S1B and
S1C), indicating that LGG and butyrate independently regulated Treg
cell differentiation and CD4+/CD8+ T cell ratio.
Figure 1.
LGG Increases the Relative Frequency of Clostridia in the Gut, the Levels of
Butyrate (But) in the Small Intestine and Serum, and the Number of BM and
Splenic Treg Cells
(A and B) Detailed relative abundance of bacterial taxa at the class
level within fecal pellets collected from mice treated with LGG or vehicle
control for 4 weeks. (legend continued on next page)
(C) Measurement of transcript levels of butyryl-CoA:acetate
CoA-transferase in the luminal contents of the ileum in mice administered LGG or
vehicle control for 4 weeks.
(D–G) Butyrate and propionate concentrations in small intestine
tissue and serum of mice administered LGG or vehicle control for 4 weeks.
(H and I) Relative and absolute frequency of BM Treg cells.
(J and K) Relative and absolute frequency of splenic Treg cells.
Data were expressed as mean ± SEM. All data were normally
distributed according to the Shapiro-Wilk normality test. n = 6–7 mice
per group in (A) and (B); n = 9 mice per group in (C)–(G); n =
12–13 mice per group in (H)–(K). Data (B–G) were analyzed
by unpaired t tests. All other data were analyzed by two-way ANOVA and post hoc
tests applying the Bonferroni correction for multiple comparisons. *p <
0.05, **p < 0.01, ***p < 0.001, and ****p < 0.0001 compared
to the indicated group. ns = not significant.
Partial Treg Cell Depletion by Anti-CD25 Ab Abrogates the Bone Anabolic
Activity of Butyrate
In vivo prospective μCT measurements of <span class="Chemical">the
spine revealed that in mice treated withIrr. Ab, administration of LGG or
butyrate caused a marked increase in bone volume fraction (BV/TV) compared to
baseline, at both 2 and 4 weeks of treatment. By contrast, neither LGG nor
butyrate increased BV/TV in mice depleted of Treg cells by anti-CD25 Ab (Figure 2A). Moreover, LGG or butyrate
supplementation induced significant changes in the vertebral indices of bone
structure: trabecular number (Tb.N), trabecular separation (Tb.Sp), and
trabecular thickness (Tb.Th), in Irr. Ab-treated mice but not in anti-CD25
Ab-treated mice (Figures
S2A–S2C). Tb.N is a measure of the number of trabecular rods
within trabecular bone, Tb.Th is a measure of the average thickness of the
trabecular rods, while Tb.Sp is a measure of the average distance between rods.
In vitro μCT analysis of femurs harvested at
sacrifice confirmed that LGG and butyrate equally increased femoral BV/TV in
mice treated withIrr. Ab but not in mice treated with anti-CD25 Ab (Figure 2B). Femoral Tb.N and Tb.Sp were also
altered by LGG and butyrate in mice treated with control Ab but not in those
treated with antiCD25 Ab (Figures S2D and S2E). However, LGG and butyrate failed to increase
femoral Tb.Th (Figure
S2F) and indices of cortical structure (Figures S2G–S2J), indicating
that LGG and butyrate had no effects on cortical bone, but rather improved
trabecular bone volume by increasing the number of trabeculae.
Figure 2.
Treatment with Anti-CD25 Ab Abrogates the Bone Anabolic Activity of LGG and
Butyrate (But)
(A) Prospective measurements of vertebral trabecular bone volume
fraction (BV/TV) by in vivo μCT scanning.
(B) Cross-sectional measurements of femoral BV/TV by in
vitro mCT scanning.
(C) Mineral apposition rate (MAR).
(D) Bone formation rate per mm bone surface (BFR/BS).
(E) Number of osteoclasts per mm bone surface (N.Oc/BS).
(F) Percentage of bone surface covered by osteoclasts (Oc.S/BS).
(G) Serum levels of P1NP, a marker of bone formation.
(H) Serum levels of type 1 cross-linked C-telopeptide (CTX), a marker of
bone resorption.
(I–K) Wnt10b mRNA levels in whole BM, BM
CD8+ T cells, and BM CD4+ T cells.
n = 10–17 mice per group. Data were expressed as mean ±
SEM. All data were normally distributed according to the Shapiro-Wilk normality
test. Data in (A) were analyzed by ANOVA for repeated-measures. ****p <
0.0001 compared to baseline, ####p < 0.0001 compared to Irr. Ab vehicle.
All other data were analyzed by two-way ANOVA and post hoc tests applying the
Bonferroni correction for multiple comparisons. *p < 0.05, **p <
0.01, ***p < 0.001, and ****p < 0.0001 compared to the indicated
group. ns = not significant. Irr. Ab = Irrelevant antibody.
Analysis of femoral cancellous bone by histomorphometry revealed <span class="Chemical">that
<span class="Species">LGG and butyrate increased the indices of bone formation: mineral apposition
rate (MAR), bone formation rate (BFR/ BS), osteoblast number (N.Ob/BS), and
osteoblast surfaces (Ob.S/BS) in control mice but not in those treated with
antiCD25 Ab (Figures 2C, 2D, S2K, and S2L). Indices of
bone resorption (N.Oc/BS and Oc.S/BS) were not affected by LGG and butyrate in
all groups (Figures 2E and 2F). However,
Treg cell-depleted groups did have higher indices of resorption as compared to
Treg cell-replete mice, supporting previous reports that Treg cells also
function to suppress bone resorption. Serum P1NP, a marker of bone formation,
was increased by LGG and butyrate in Treg cell-replete mice (Figure 2G). Serum CTX, a marker of bone resorption,
did not increase in response to LGG or butyrate, although Treg cell-depleted
mice did have higher levels of CTX, confirming the capacity of Treg cells to
suppress bone resorption (Figure 2H).
Moreover, LGG or butyrate did not alter the expression of RANKL mRNA in BM or
sorted Treg cells (Figures S3A
and S3B), nor did they alter the expression of OPG in the BM (Figure S3C), all of which
are critical regulators of osteoclastogenesis and bone resorption. Another
factor produced by Treg cells that regulates bone resorption is
IL-10. We found that LGG or butyrate did not alter the
transcript levels of IL-10 in the BM or in sorted Treg cells
(Figures S3D and
S3E).
Osteoblasts derive from BM stromal cells (SCs). Administration of ei<span class="Chemical">ther
<span class="Species">LGG or butyrate increased the proliferation of SCs in mice treated withIrr. Ab
but not in mice treated with anti-CD25 Ab (Figure S3F), while no effects on
the rate of SC apoptosis were detected in these groups (Figure S3G). Measurement of
transcript enrichment of SC genes involved in osteoblast differentiation,
including type 1 collagen (Col-I), runt related transcription factor 2 (Runx2),
osterix (Osx), bone sialoprotein (BSP), and osteocalcin (OCN), revealed that LGG
and butyrate treatment amplified osteoblast differentiation in Treg cell-replete
mice, while inducing no response on SCs in Treg cell-depleted mice (Figure S3H). Transcript
levels of seven measured Wntresponsive genes were amplified by LGG or butyrate
in SCs of Treg cell-replete mice, but not in SCs from mice where Treg cells were
diminished by anti-CD25 Ab treatment (Figure S3I). These data indicated
that LGG and butyrate activated Wnt signaling in SCs, through a Treg
cell-dependent mechanism. A potent activator of Wnt signaling is the Wnt ligand
Wnt10b, and CD8+ T cells are a major source of Wnt10b in the BM
(Bedi et al., 2012; Terauchi et al., 2009). We found that bothbutyrate
and LGG increased Wnt10b transcript levels in whole BM (Figure 2I). This response was ascribed to
CD8+ T cells (Figure 2J) but
not to conventional CD4+ T cells (Figure 2K). The LGG or butyrate-induced responses on Wnt10b
production were inhibited by anti-CD25 Ab treatment (Figures 2I–2K). Increased Wnt10b transcript
levels were also detected in CD8+ T cells (eGFP-CD8+ T
cells) but not in conventional CD4+ cells (eGFP-CD4+ T
cells) or in Treg cells (eGFP+CD4+ T cells) sorted from
Foxp3.eGFP reporter mice treated withLGG or butyrate (Figures S3J–S3L).
Since some inflammatory cytokines blunt bone formation, <span class="Chemical">the capacity of
anti-<span class="Gene">CD25 Ab treatment to block LGG- and buty-rate-induced bone anabolism could
be ascribed to increased production of inflammatory cytokines, rather than the
detected increase in Treg cell differentiation and the resulting Wnt10b
secretion by CD8+ T cells. This possibility is unlikely because BM
cells from groups of mice treated with anti-CD25 Ab expressed similar levels of
IL-1β, TNFα, IL-6, IL-17A, IL-4, and
IFNγ mRNAs, as BM cells from mice treated withIrr Ab (Figure S3M). In addition, evidence
against a nonspecific inhibitory effect of partial Treg cell depletion on bone
formation was corroborated by the finding that treatment with anti-CD25 Ab did
not decrease bone formation in vehicle-treated mice (Figures 2C, 2D, and 2G).
Partial Treg Cell Depletion in DEREG Mice Prevents the Bone Activity of
Butyrate
Additional experiments were conducted using DEREG <span class="Species">mice, a strain that
expresses a fusion protein of the human diphtheria toxin (DT) receptor (hDTR)
and eGFP under the control of the Foxp3 promoter (Lahl et al., 2007). Foxp3+ Treg cells can
be selectively depleted upon DT administration to DEREG mice, whereas Treg cells
in WT mice are insensitive to DT. Furthermore, DT is known to not cause toxic
effects in mice (Klingenberg et al.,
2013). Whereas Treg cell ablation in DEREG mice causes scurfy-like
symptoms in newborn animals, older mice do not develop autoimmune diseases
(Klingenberg et al., 2013). We
treated DEREG mice with DT (0.5 μg/mouse, i.p. 2 times per week for 4
weeks), a dose titrated to block the increase in Treg cells induced by LGG and
butyrate. Mice were also treated with vehicle, LGG, or butyrate for 4 weeks.
Controls included DEREG mice not treated with DT and WT littermate (LM) mice
treated with DT. LGG and butyrate expanded the number of BM Treg cells, splenic
Treg cells, and Peyer’s patches (PP) Treg cells in control mice, but not
in DEREG + DT mice (Figures 3A–3C).
Since the calculation of the absolute number of PP Treg cells is inaccurate
because of the variability of the size of the collected PP tissue, PP Treg cells
were shown only as percentage.
Figure 3.
Treatment of DEREG Mice but Not of WT Littermates (WTLM) with Diphtheria
Toxin (DT) Prevents the Increase in the Number of Treg Cells and the Bone
Anabolic Activity Induced by LGG and Butyrate (But)
(A and B) Absolute number of Treg cells in the BM and the spleen.
(C) Relative number of Treg cells in Peyer’s patches (PP). Since
the enumeration of the absolute number of PP Treg cells is inaccurate, PP Treg
cells are shown as percentage.
(D) Prospective measurements of vertebral trabecular bone volume
fraction (BV/TV) by in vivo μCT scanning.
(E) Cross-sectional measurements of femoral BV/TV by in
vitro μCT scanning.
(F) Mineral apposition rate (MAR).
(G) Bone formation rate (BFR).
(H) The number of osteoclasts per mm bone surface (N.Oc/BS).
(I) The percentage of bone surface covered by osteoclasts (Oc.S/BS).
(J) Serum levels of osteocalcin (OCN), a marker of bone formation.
(K) Serum levels of type 1 cross-linked C-telopeptide of collagen (CTX),
a marker of bone resorption.
(L) Wnt10b mRNA levels in whole BM.
(M) Wnt10b mRNA levels in BM CD8+ T
cells.
For this assay, samples from 2 mice per group were randomly pooled
together to generate a sufficient amount of mRNA. n = 6–13 mice per
group. Data were expressed as mean ± SEM. All data were normally
distributed according to the Shapiro-Wilk normality test. Data in (A) were
analyzed by ANOVA for repeatedmeasures. *p < 0.05, **p < 0.01,
***p < 0.001, and ****p < 0.0001 compared to baseline, #p <
0.05, ##p < 0.01, ###p < 0.001, and ####p < 0.0001 compared
to Irr. Ab vehicle. Data in (B)–(L) were analyzed by two-way ANOVA and
post hoc tests applying the Bonferroni correction for multiple comparisons. *p
< 0.05, **p < 0.01, ***p < 0.001, and ****p < 0.0001
compared to the indicated group. ns = not significant.
In vivo prospective μCT measurements revealed
<span class="Chemical">that <span class="Species">LGG and butyrate increased vertebral BV/TV, Tb.N, Tb.Sp, and Tb.Th compared
to baseline in control mice, but not in DEREG mice treated with DT (Figures 3D and S4A). Analysis by μCT of
femurs harvested at sacrifice showed that LGG and butyrate increased BV/TV in
the two control groups but not in DT-treated DEREG mice (Figure 3E). Tb.N and Tb.Th were increased by LGG and
butyrate in Treg cells replete but not in Treg cell-depleted mice. By contrast,
LGG and butyrate failed to increase Tb.Sp and indices of cortical structure in
all groups of mice (Figure
S4B). Analysis of femoral cancellous bone by histomorphometry
revealed that LGG and butyrate increased bone formation in the two control
groups but not in DT-treated DEREG Treg cell-depleted mice (Figures 3F, 3G, and S4C). Indices of bone resorption
were higher in DEREG + DT mice compared to controls due to the partial Treg cell
depletion, whereas LGG and butyrate did not further increase bone resorption in
any group of mice (Figures 3H and 3I).
Measurement of biochemical markers of bone formation and resorption generated
results similar to the histomorphometric analysis. In fact, DEREG + DT mice had
lower osteocalcin levels and higher CTX levels than control mice (Figures 3J and 3K), due to the partial Treg cell
depletion. Moreover, LGG and butyrate increased osteocalcin levels in control
but not DEREG + DT mice, although not affecting CTX levels in any group of mice.
Finally, LGG and butyrate could not increase the expression of
Wnt10b in whole BM or CD8+ T cell in DEREG + DT
mice, whereas they induce significant increases in Wnt10b
transcript levels in BM and CD8+ T cells in Treg cell-replete control
groups (Figures 3L and 3M). Altogether,
these data supported the conclusion that an increase in the number of BM Treg
cell is required for LGG and butyrate to enhance bone formation.
The Bone Anabolic Activity of LGG Requires the Presence of Gut Flora
Since <span class="Chemical">butyrate exerted a bone anabolic activity equal to that of LGG,
the data suggested that LGG supplementation may result in increased production
of butyrate, which in turn stimulates bone formation. However, an indirect
mechanism is likely because LGG does not produce butyrate, nor does it harbor
genes in its chromosome coding for enzymes that generate butyrate (Douillard et al., 2013; Kankainen et al., 2009). To test the hypothesis that
the presence of SCFA-generating bacteria in the intestine was required for LGG
to induce bone anabolism, germ-free (GF) mice were treated withLGG or butyrate
for 4 weeks. Analysis of femurs harvested at sacrifice by μCT revealed
that butyrate increased BV/TV, while LGG did not (Figure 4A). In addition, serum levels of osteocalcin (Figure 4B) and the number of Treg cells in the BM and
spleen were also increased by butyrate but not by LGG (Figures 4C and 4D). The pool of PP Treg cells was
expanded by bothLGG and butyrate, but the activity of butyrate was
significantly greater than that of LGG (Figure
4E). Analysis of whole BM and BM CD8+ T cells harvested
from GF mice at sacrifice revealed that butyrate increased Wnt10b transcript
levels, whereas LGG did not (Figures 4F and
4G). These findings demonstrate that LGG requires the presence of
intestinal flora to induce bone anabolism.
Figure 4.
Butyrate (But), but Not LGG Induces Bone Anabolic Effects in Germ-Free
Mice
(A) Femoral trabecular bone volume fraction (BV/TV) as measured by in
vitro mCT scanning.
(B) Serum levels of osteocalcin, a marker of bone formation.
(C and D) Absolute number of Treg cells in the BM and the spleen.
(E) Relative number of Treg cells in Peyer’s patches (PP). Since
the enumeration of the absolute number of PP Treg cells is inaccurate, PP Treg
cells are shown as percentage.
(F) Wnt10b mRNA levels in whole BM.
(G) Wnt10b mRNA levels in BM CD8+ T
cells.
For (G), samples from 2 mice per group were randomly pooled together to
generate a sufficient amount of mRNA. n = 5–10 mice per group. Data are
expressed as mean ± SEM. All data were normally distributed according to
the Shapiro-Wilk normality test. Data were analyzed by one-way ANOVA and post
hoc tests applying the Bonferroni correction for multiple comparisons. *p
< 0.05, **p < 0.01, and ****p < 0.0001 compared to the
indicated group. ns = not significant.
Butyrate Increases Bone Volume through T Cell-Produced Wnt10b
To conclusively demonstrate <span class="Chemical">that <span class="Gene">Wnt10b produced by CD8+ T
cells mediates the anabolic activity of LGG and butyrate, we assessed the
effects of LGG and butyrate in mice specifically lacking Wnt10b production by
CD8+ T cells. In these experiments,
TCRβ−/− mice, a strain completely devoid of
ab T cells, were reconstituted with sorted CD8+ T cells from global
Wnt10b−/− mice and CD4+
T cells from WT mice. These mice are herein referred to as
Wnt10bCD4ΔCD8mice. Controls included
non-reconstituted TCRβ−/− mice and
TCRβ−/− mice reconstituted with WT
CD4+ T cells and WT CD8+ T cells
(Wnt10bCD4CD8mice). Two weeks after adoptive
transfer, which is a period sufficient for engraftment and expansion of both WT
and Wnt10b−/− T cells (Li et al., 2014), all mice were treated with either
vehicle, LGG, or butyrate for 4 weeks. LGG or butyrate increased whole BM
Wnt10b transcript levels in
Wnt10bCD4CD8mice, but not in
Wnt10bCD4ΔCD8, or in non-reconstituted
TCRβ−/− mice (Figure 5A). These findings indicated that LGG and butyrate
specifically regulate CD8+ T cell production of
Wnt10b. Confirming this hypothesis, measurements of
Wnt10b transcript levels in BM CD8+ T cells
sorted at the end of the treatment period revealed that LGG and butyrate
increased Wnt10b transcript levels in CD8+ T cells
purified from Wnt10bCD4CD8mice (Figure 5B). As expected, Wnt10b
transcripts were undetectable in CD8+ T cells sorted from
Wnt10bCD4ΔCD8mice. LGG and butyrate
treatment equally increased the numbers of Treg cells in the BM, spleen, and PPs
of Wnt10bCD4CD8mice and
Wnt10bCD4ΔCD8mice (Figure S5A), demonstrating that LGG
and butyrate expand Treg cells via a Wnt10b-independent mechanism. However,
despite increasing Treg cells numbers, in vivo prospective μCT
measurements revealed that LGG and butyrate only caused a significant increase
in BV/TV in Wnt10bCD4CD8mice and not in
Wnt10bCD4ΔCD8mice nor in
TCRβ−/− mice (Figure 5C). These findings indicated that CD8+ T
cell-produced Wnt10b is required for the bone anabolic activity
of bothLGG and butyrate. Furthermore, LGG and butyrate supplementation
increased vertebral Tb.N and decreased Tb.Sp in
Wnt10bCD4CD8mice, but not in
Wnt10bCD4ΔCD8mice and
TCRb−/− mice. By contrast, LGG and butyrate did not
alter Tb.Th in all groups of mice (Figure S5B). Analysis of distal
femurs by in vitro μCT confirmed that LGG and butyrate
increase femoral BV/TV in Wnt10bCD4CD8mice but not
in Wnt10bCD4DCD8mice and
TCRβ−/− mice (Figure 5D). In the femur, Tb.N was increased by LGG and butyrate in
Wnt10bCD4CD8mice but not in
Wnt10bCD4ΔCD8mice and
TCRβ−/− mice (Figure S5C). LGG and butyrate did
not increase femoral Tb.Th, Tb.Sp, or indices of cortical structure in all
groups of mice (Figure
S5C). Finally, attesting to a link between Wnt10b and bone formation,
LGG and butyrate increased serum osteocalcin in
Wnt10bCD4CD8mice but not in
Wnt10bCD4ΔCD8mice and
TCRβ−/− mice (Figure 5E). Together, these data showed that LGG and
butyrate-induced bone anabolism was dependent on a functional
Wnt10b gene within CD8+ cells.
Figure 5.
LGG and Butyrate (But) Do Not Induce Bone Anabolic Effects in Mice that Are
Deficient in T Cell Production of Wnt10b
TCRβ−/− mice were adoptively
transferred with WT CD4+ T cells and WT CD8+ T cells, or
WT CD4+ T cells and
Wnt10b−/− CD8+ T
cells.
(A) Whole BM Wnt10b transcript levels.
(B) Wnt10b transcript levels in CD8+ T
cells purified from reconstituted TCRβ−/− mice
at the end of the LGG or butyrate (but) treatment period.
(C) Prospective measurements of vertebral trabecular bone volume
fraction (BV/TV) by in vivo μCT scanning.
(D) Femoral BV/TV as measured by in vitro μCT scanning at the
end of the treatment period.
(E) Serum levels of osteocalcin, a marker of bone formation.
n = 5–12 mice per group. In (B), samples from 2 mice were pooled
together. Data are expressed as mean ± SEM. All data were normally
distributed according to the Shapiro-Wilk normality test. Data were analyzed by
two-way ANOVA for repeated-measures and post hoc tests applying the Bonferroni
correction for multiple comparisons. *p < 0.05, **p < 0.01, and
****p < 0.0001 compared to the indicated group, or baseline. ##p <
0.01, ###p < 0.001 compared to vehicle. ns = not significant.
Wnt10b Production Is Induced by NFAT and SMAD Signaling in CD8+ T
Cells
<span class="Chemical">The <span class="Gene">Wnt10b gene promoter region harbors three DNA
binding motifs for NFAT transcription factors located adjacent to binding sites
for SMADs, the TGFβ signaling proteins. This organization suggests that
Wnt10b transcription may be regulated by the binding of
NFAT/SMAD dimers to the Wnt10b promoter. To assess the function
of SMADs and NFATs in the control of Wnt10b gene expression, we
first measured Wnt10b transcript levels in purified splenic CD8+ T
cells after in vitro stimulation withthe SMAD inducer
TGFβ and the NFAT activator ionomycin. We found that concurrent
stimulation of both TGFβ and ionomycin synergistically increased
Wnt10b transcript levels, whereas stimulation with either
TGFβ or ionomycin alone had a significant but less potent inducing effect
(Figure 6A), indicating a potential
cooperative function for SMAD and NFAT in the induction of
Wnt10b gene expression. Indeed, ChIP assays carried out
using BM CD8+ T cells isolated from mice treated in
vivo withLGG or butyrate, and/or anti-CD25 Ab, revealed that
CD8+ T cells from LGG- and butyrate-treated mice had higher
binding of NFAT1 and SMAD3 to the Wnt10b promoter, compared to CD8+ T
cells from vehicle-treated mice (Figures
6B–6E). By contrast, and attesting to specificity, LGG and
butyrate did not increase the binding of NFAT2 and SMAD2 to the
Wnt10b promoter. Blockade of the increase in the number of
Treg cells by treatment with anti-CD25 Ab prevented LGG and butyrate from
increasing the binding of NFAT1 and SMAD3 to the Wnt10b
promoter, indicating that elevated numbers of Treg cells are required for LGG
and butyrate to stimulate the binding of these transcription factors to the
Wnt10b promoter.
Figure 6.
LGG and Butyrate (But) Increase Wnt10b Transcription by
Promoting the Binding of NFAT/SMAD Complexes to the Wnt10b
Promoter
(A) Measurement of Wnt10b transcript levels in splenic
CD8+ T cells treated with the NFAT activator ionomycin and
TGFβ.
(B–E) ChIP assays measuring LGG and butyrate induced binding of
NFAT1, SMAD3, NFAT2, and SMAD2, to the Wnt10b promoter in BM
CD8+ T cells. Cells from 4–5 mice were pooled to generate
1 sample.
(F) Diagrammatic representation of the Wnt10b promoter
and effects of Wnt10b promoter deletion on the activity of
Wnt10b-luciferase reporter constructs in primary splenic
CD8+ T cells. Cells were stimulated with ionomycin (500 ng/mL)
and TGFβ1 (5 ng/mL) for 24 hr to induce reporter activity. n = 3 samples
per group.
(G) Effects of mutation of the SMAD and NFAT binding sites on the
Wnt10b promoter on the activity of a
luciferase-Wnt10b reporter construct in primary splenic
CD8+ T cells.
Data were expressed as mean ± SEM. Data were analyzed by
Kruskal-Wallis and Dunn’s multiple comparisons non-parametric tests, as
they were not normally distributed as assessed by Shapiro-Wilk normality test.
In (A), n = 5 per group, **p < 0.01 and ****p < 0.0001 compared to
the indicated groups. In (B)–(F), n = 3 samples per group, *p <
0.05, **p < 0.01, ***p < 0.001, and ****p < 0.0001 compared
to Veh Irr.Ab or empty vector. In (G), n = 3 samples per group, ****p <
0.0001 compared to all other groups.
To investigate <span class="Chemical">the functional relevance of NFAT/SMAD binding to the
Wnt10b promoter, we cloned a 2,000-bp upstream region of
Wnt10b, including the region harboring the three putative
NFAT/SMAD binding sites, into a luciferase reporter plasmid. The
Wnt10b-luc reporter plasmid and the TK-pRL renilla
transfection efficiency control vector were transfected into primary murineCD8+ T cells. Transfected cells were stimulated withionomycin
and TGFb for 24 hr to activate Wnt10b transcription. Cell
lysates were then assessed by luciferase assay, as an index of promoter
activity. We found that stimulation withionomycin and TGFβ increased
Wnt10b promoter activity in the full length cloned 2,000-bp WT promoter (Figure 6F). Deletion of the two most distal
NFAT/SMAD binding sites did not alter the activity of the reporter. However,
deletion of all three NFAT/SMAD binding sites abolished the activity of the
reporter, suggesting that the NFAT/SMAD binding site critical for Wnt10b
transcription is located between bases 705 and 272 of the Wnt10b promoter
region. Site-directed mutagenesis experiments confirmed that the critical
binding sites are located between 705 bp and 272 bp in the
Wnt10b promoter (Figure
6G). Mutation of the NFAT binding site alone, the SMAD site alone, or
of boththe SMAD and the NFAT sites lowered the activity of the
Wnt10-bluc reporter in primary murineCD8+ T
cells to baseline levels.
We next investigated how <span class="Species">LGG and <span class="Chemical">butyrate regulate NFAT and SMAD
signaling. Sorting of BM cells from Foxp3.eGFP reporter mice revealed that LGG
and butyrate treatment increased TGFβ1 levels in Treg cells
(eGFP+CD4+ cells) and conventional CD4+
cells (eGFPCD4+ T cells) but not in CD8+ T cells
(eGFPCD8+ T cells) (Figures
7A–7C). These data indicated that LGG and butyrate increased
the amount of TGFβ produced by Treg cells and conventional
CD4+ T cells within their microenvironments and thus the amount
of TGFβ available to increase SMAD levels in the nuclei of adjacent
CD8+ T cells. Moreover, LGG and butyrate increased the nuclear
levels of pSMAD2, pSMAD3, and NFAT1, but not NFAT2, in BM CD8+ T
cells (Figure 7D), while treatment with
anti-CD25 Ab blocked these responses, confirming that Treg cells play an
essential role in activating NFAT and SMAD signaling in CD8+ T
cells.
Figure 7.
Effects of LGG and Butyrate (But) on TGFb1 Production by BM T Cells, on
NFAT1/2 and SMAD2/3 Activation, and on PI3K and Akt Signaling in BM
CD8+ T Cells
(A–C) TGFb1 mRNA expression by FACS-sorted BM conventional
eGFPCD4+ T cells, eGFPCD8+ T cells, and
eGFP+ Treg cells. DEREG (eGFP.Foxp3) reporter mice were treated
with vehicle, LGG, or butyrate for 4 weeks. BM cells were sorted at the end of
the treatment period.
(D) Immunoblot analysis for the detection of NFAT1, NFAT2, pSMAD2, and
pSMAD3 in purified BM CD8+ T cells.
(E) Immunoblot analysis for the detection of c-Jun and c-Fos in
purified BM CD8+ T cells.
(D and E) Fresh BM CD8+ T cells were pooled together and
then used for obtaining nuclear and cytoplasmic fractions. Laminin B1 was used
as nuclear loading control. Tubulin was used as cytoplasmic loading control.
(F) Immunoblot analysis for the detection of Phospho-PI3K p85 in the
whole lysate from BM CD8+ T cells.
(G and H) pAKT levels in BM CD8+ T cells and percent of
pAKT+ BM CD8+ T cells, as determined by flow
cytometry.
(D–F) Conventionally raised WT mice were treated with vehicle,
LGG, or butyrate for 4 weeks. BM CD8+ T cells were purified at the
end of the treatment period using the EasySep Mouse CD8+ T Cell
Isolation Kit. One representative experiment of 3 experiments.
Data were expressed as mean ± SEM, n = 5–10 mice per
group in (A)–(C), (G), and (H). Data were analyzed by two-way ANOVA and
post hoc tests applying the Bonferroni correction for multiple comparisons. **p
< 0.01, ***p < 0.001, and ****p < 0.0001 compared to
vehicle or the indicated group. ns = not significant.
In activated T cells, which express AP-1 at high levels, AP-1 acts as
<span class="Chemical">the preferred partner of NFAT. <span class="Chemical">Treg cells lowers the production of AP-1, forcing
NFAT to bind to other partners such as SMADs (Macian, 2005). Accordingly, we found that LGG and butyrate did not
increase the nuclear levels of c-Fos and c-Jun proteins in CD8+ T
cells (Figure 7E). By contrast, treatment
with anti-CD25 Ab resulted in higher nuclear levels of c-Fos and c-Jun in all
groups, suggesting that an increase in Treg cells favored the association of
NFAT with SMADs, and antagonized the association of NFAT with AP-1.
<span class="Chemical">Treg cells suppress conventional T cell activation via numerous
mechanisms (Shevach, 2009). Among them is
the capacity of Treg cells to blunt CD28 signaling (Wing et al., 2008). LGG and butyrate reduced the
level of phosphorylated PI3K (Figure 7F)
and pAKT in BM CD8+ T cells (Figures 7G
and 7H), which are kinases downstream of CD28 (Mosenden and Taske´ n, 2011). These effects
were prevented by treatment with anti-CD25 Ab, suggesting that the increase in
Treg cells induced by LGG and butyrate may blunt CD28 signaling in
CD8+ T cells. Furthermore, LGG and butyrate decreased the number
of CD80+ mature dendritic cells (DCs)
(CD11c+MHC-II+CD40+CD80+ cells)
and the number of CD86+ mature DCs
(CD11c+MHC-II+CD40+ CD86+ cells)
(Figures
S6A–S6D). This was relevant because repression of the CD28
ligands, CD80/86 in DCs is a mechanism whereby Treg cells blunt CD28 signaling
(Shevach, 2009).
<span class="Chemical">The <span class="Gene">CD8+ T cells of OT-I mice all carry a transgenic TCR
responsive to ovalbumin (OVA) peptide. To further investigate the role of Treg
cells, OT-I CD8+ T cells were co-cultured for 24 hr withOVA
peptide-pulsed CD11c+ DCs, both in the presence and absence of Treg
cells. ChIP assays revealed that in these in vitro conditions,
the addition of Treg cells to the co-cultures resulted in a significant increase
in the binding of NFAT1, NFAT2, and SMAD3, but not of SMAD2, to the
Wnt10b promoter region (Figures S7A–S7D). Moreover,
the inclusion of Treg cells to the co-cultures caused an increase in the
production of Wnt10b by CD8+ T cells (Figure S7E). In this
coculture system, the effects of Treg cell number on Wnt10b
transcript level was dose dependent (Figure S7F), indicating that
CD8+ T cells are regulated primarily by the number of Treg cells.
Together, the data further supported the hypothesis that Treg cells increase
Wnt10b gene expression by recruiting NFATs and SMAD3 to the
Wnt10b promoter.
In addition, OT-I <span class="Gene">CD8+ T cells were co-cultured for 24 hr
wi<span class="Chemical">th OVA peptide-pulsed CD11c+ DCs with or without CTLA-4-Ig, an
inhibitor of CD28 co-stimulation (Najafian and
Sayegh, 2000). ChIP assays revealed that CTLA-4Ig treatment mimicked
the effects of Treg cells, as it increased the binding of NFAT1, NFAT2, and
SMAD3, but not of SMAD2, to the Wnt10b promoter (Figures S7G–S7J).
Moreover, we found that CTLA-4Ig treatment also increased
Wnt10b transcript levels (Figure S7K). These findings suggest
that blunting of CD28 signaling stimulates NFAT-and SMAD-driven
Wnt10b gene expression.
To investigate whe<span class="Chemical">ther <span class="Chemical">butyrate may have additional direct regulatory
effects on the production of Wnt10b, resting and in
vitro activated CD8+ T cells were cultured withbutyrate
for 24 hr. At dose up to 250 μM, butyrate did not increase
Wnt10b transcript levels (Figure S7L), suggesting that
butyrate does not directly regulate Wnt10b expression in
CD8+ T cells.
DISCUSSION
We reported <span class="Chemical">that oral delivery of <span class="Species">LGG or butyrate to eugonadic young mice
increased trabecular bone volume due to stimulation of bone formation. We also
showed that LGG supplementation increased the levels of butyrate in the gut and in
serum. This critical SCFA elevated the number of Treg cells in the BM, leading to
increase production of the Wnt ligand Wnt10b, via enhanced binding
of NFAT1 and SMAD3 to the Wnt10b promoter. Wnt10b is an established
enhancer of osteoblast differentiation and is critical for post-natal bone
development. These findings provided proof of principle that LGG and butyrate may
represent a therapeutic strategy to enhance bone anabolism. Moreover, LGG is a
lactobacillus, which is the most common genus of bacteria with reported probiotic
activities. Therefore, the mechanism of action of LGG is likely to be generalizable
to lactic acid-generating bacteria.
<span class="Chemical">Butyrate was equally active in GF and conventional <span class="Species">mice, while LGG did not
increase bone mass in GF mice. These findings indicated that a key mechanism whereby
LGG-induced bone anabolism is by indirectly increasing production of butyrate in the
small intestine. LGG is known to expand bacteria of the clostridia taxonomic class,
which are recognized as the central generators of butyrate in the intestine (Flint et al., 2015; Louis et al., 2010). In agreement withthese reports, we
found that LGG altered the diversity of the microbiome resulting in higher abundance
of SCFAs generating Clostridia. We further found that LGG increased the levels of
butyrate, but not propionate, in the small intestine and serum. We thus concluded
that LGG exerted its anabolic effects by acting in concert withthe extant
microbiome to generate butyrate. The effects of LGG on acetate and other SCFAs and
the contribution of these metabolites to the bone anabolic activity of LGG remain to
be determined.
Emerging reports describe skeletal effect of <span class="Chemical">SCFAs, including stimulation of
the osteogenic differentiation of SCs (Chen et al.,
2007) and enhancement of bone density (Weaver et al., 2011). Propionate or butyrate increase bone volume in
normal mice and prevent ovariectomy and inflammation-induced bone loss by
suppressing osteoclast formation, via enhancement of glycolysis at the expense of
oxidative phosphorylation (Lucas et al.,
2018). This metabolic reprogramming of osteoclast precursors causes cell
stress, thereby preventing osteoclast differentiation (Lucas et al., 2018). We found that in intact female mice,
which have a lower rate of bone turnover than ovariectomized mice, LGG and butyrate
increased bone volume by stimulating bone formation. Whereas the anti-resorptive
activity of propionate or butyrate described by Lucas et al. (2018) is T cell independent, we found the bone anabolic
activity of butyrate and LGG to be dependent on Treg cells and CD8+ T
cells. Although the reasons for these differences are yet unknown, in the study of
Lucas et al. (2018) mice are younger and
are supplemented with a higher dose of propionate or butyrate for a longer period.
Furthermore, the C57BL/6 mice used in this study almost certainly had different
microbiota diversity as compared to the C57BL/6 mice used by Lucas et al. (2018), as they were purchased from
different vendors, housed in different facilities, and fed a different diet. In
fact, Lucas et al. (2018) purchased their
mice from Charles River, which harbor segmented filamentous bacteria (SFB) in their
gut, which are potent activators of Th17 cells (Ivanov et al., 2009), a highly osteoclastogenic T cell population (Komatsu and Takayanagi, 2012). By contrast, we
used SFB-negative mice from Jackson Laboratories.
<span class="Chemical">The link between <span class="Chemical">Treg cells and the bone anabolic activity of LGG and
butyrate was established using two experimental models: treating WT mice with
anti-CD25 Ab and treating DEREG mice with DT. In both experiments, partial Treg
cells blockade prevented the increase in bone volume and bone formation induced by
LGG or butyrate, demonstrating that an enlargement of the pool of inducible BM Treg
cells was required for the bone anabolic activity of LGG and butyrate. Partial Treg
cell blockade also prevented the increase in Wnt10b production by CD8+ T
cells induced by LGG and butyrate. These findings were significant because Wnt10b
activates Wnt signaling in osteoblastic cells, leading to osteoblast proliferation
(Kato et al., 2002), differentiation
(Bodine and Komm, 2006), and survival
(Almeida et al., 2005; Bodine et al., 2005).
We also found <span class="Chemical">that <span class="Species">LGG and butyrate increased the frequency of
CD4+ T cells, thus altering the CD4+:CD8+ T
cell ratio in the BM. However, interventions that prevented the increase in the
number of Treg cells blocked the bone anabolic activity of LGG or butyrate but did
not prevent the increase in the CD4+:CD8+ T cell ratio,
indicating that the bone activity of LGG or buty-rate was not driven by an increase
in the CD4+:CD8+ T cell ratio.
We did not find <span class="Species">LGG and <span class="Chemical">butyrate to increase the production of IL-10 by Treg
cells, nor to potentiate the activity of Treg cells. However, at least in an
in vitro coculture system, Treg cells increased
Wnt10b expression in CD8+ T cells in a
dose-dependent manner. Accordingly, we hypothesize that LGG or butyrate increased
the production of Wnt10b by CD8+ T cells solely by a
mechanism involving an expansion of the numbers of Treg cells.
We sought direct evidence of <span class="Chemical">the pivotal role of <span class="Gene">Wnt10b by
investigating the effects of LGG and butyrate in T cell-deficient
TCRβ−/− reconstituted withWnt10b−/− T cells. This approach was
preferred to directly treating Wnt10b/ mice withLGG and butyrate,
because of the confounding effect of the low baseline bone mass of
Wnt10b−/− mice (Bennett et al., 2005). By contrast,
Wnt10b−/− T cells engraft and expand
normally after transfer (Li et al., 2014).
These experiments revealed that LGG and butyrate did not induce bone anabolism in
mice lacking ab T cells or CD8+ T cell production of
Wnt10b, demonstrating that the effects of LGG and butyrate were
mediated by CD8+ T cells and specifically by their production of
Wnt10b. We did not find butyrate to directly stimulate the
expression of Wnt10b in BM CD8+ T cells in vitro,
suggesting that butyrate stimulated Wnt10b expression and thus bone
formation, indirectly, by enlarging the pool of BM Treg cells. However, we could not
exclude the possibility that butyrate may have had additional effects on T cells or
other BM cells, unrelated to Wnt10b generation, that may have
contributed to the bone anabolic activity of LGG or butyrate.
Based on <span class="Chemical">the current and previous studies (Roser-Page et al., 2014), it is likely that TCR activation is required
for CD8+ T cells to express Wnt10b. In vivo, CD8 T cell
activation was likely to result from mildly autoreactive CD8+ T cells
that are activated in response to homeostatic T cell renewal functions (Surh and Sprent, 2000), as well as endogenous
antigens of microbial origin that are physiologically absorbed from the gut. In the
context of T cell activation, the preferred partner of NFAT is AP-1 (Fehr et al., 2010; Macia´ n et al., 2002). Treg cells lower the production of AP-1
and favor the binding of NFAT to SMADs (Macian,
2005). Our ChIP data indeed demonstrated that LGG and butyrate increased
the binding of NFAT1 and SMAD3 to the Wnt10b promoter, but only
when the number of Treg cells was increased. We further found NFAT2 to bind to the
Wnt10b promoter in activated OT-1 CD8+ T cells but
not in WT CD8+ T cells from mice treated withLGG or butyrate. This
reflected the higher levels of activation of OT-1 cells as compared to WT
CD8+ T cells.
Recently, attempts have been made to manipulate Treg cells for clinical
purposes (Di Ianni et al., 2011; Trzonkowski et al., 2009). An increase in the
number of Treg cells is achievable by nutritional supplementation withthe probiotic
LGG, butyrate or other SCFAs. Thus, an increase in the number of Treg cells via
nutritional supplementation may represent a therapeutic modality for increasing bone
mass and preventing osteoporosis. Moreover, the use of probiotics or butyrate to
increase the number of Treg cells may find wider applications, such as in transplant
medicine or as a treatment for inflammatory and autoimmune conditions.
STAR⋆METHODS
CONTACT FOR REAGENT AND RESOURCE SHARING
Fur<span class="Chemical">ther information and requests for resources and reagents should be
directed to and will be fulfilled by the Lead Contact, Roberto Pacifici, MD
(roberto.pacifici@emory.edu). The mouse lines obtained from
other laboratories are described below and may require a Material Transfer
Agreement (MTA) withthe providing scientists.
EXPERIMENTAL MODEL AND SUBJECT DETAILS
Experimental Animals
All <span class="Chemical">the treatment and surgical procedures were approved by the
Institutional Animal Care and Use Committee of Emory University. All
in vivo experiments were carried out in female mice.
In vitro experiments were conducted using primary cells
from female mice. Conventionally raised C57BL/6 WT,
TCRβ−/−, OT-1, and DEREG mice were purchased from
Jackson Laboratories east coast facility (Bar Harbor, ME). To control for
facility variation, each batch of C57BL/6 mice were sourced from the same
Jackson Laboratory vivarium. Female C57BL6 Germ Free (GF) mice were
purchased from Taconic biosciences (Rensselaer, NY). All conventionally
raised mice entering Emory University were shipped to the same room in the
same vivarium within the Whitehead Biomedical Research Building. All
conventionally raised mice were maintained under general housing environment
and fed sterilized food (5V5R chow) and autoclaved water ad
libitum. GF mice were housed in a Tecniplast ISOcage P -
Bioexclusion System within the Emory Gnotobiotic Animal Core. All mice were
acclimatized within our facility for 3 days before experimentation.
Littermates of the same sex were randomly assigned to experimental groups.
Mice were enrolled in the studies at 10 weeks of age and treated with
vehicle, LGG or butyrate for 4 weeks and then sacrificed.
METHODS DETAILS
SCFAs extraction and derivatization
Measurement of <span class="Chemical">Propionate and <span class="Chemical">Butyrate levels were done by the Emory
Integrated Lipidomics Core (EILC), a member core of the Emory Integrated
Core Facilities (EICF), Briefly, to extract the SCFAs from the SI tissues,
40 mg of sample was homogenized with 1 mL of acetonitrile-water (1:1, v/v)
(Fisher Chemical # A955, # A4522 HPLC grade) using the Bead Ruptor 24 Elite
(Omni International, USA) with 1.4 mm ceramic beads (Fisher Scientific #
15340153). To extract the SCFAs from serum, 150 μL of serum samples
was vortexed for 5 min with 1 μL of acetonitrile-water (1:1, v/v).
The homogenates were centrifuged at 4000 rpm for 10 min, and the
supernatants containing the SCFAs were collected. The extracted SCFAs as
well as the butyrate standard (Sigma # 08089) were derivatized to their
3-nitrophenylhydrazones using 3-nitrophenylhydrazine hydrochloride (Sigma
#N21804). Specifically, 2 volumes of the SCFA extracts were mixed with 1
volume of 200 mM 3-nitrophenylhydrazine hydrochloride in acetonitrile-water
(1:1, v/v) and 1 volume of 120 mM
N-(3-dimethylaminopropyl)-N”-ethylcarbodiimide hydrochloride (Sigma #
03449 HPLC) in acetonitrile-water (1:1, v/v) containing 6% pyridine (Sigma #
270407). The reactions were incubated at 40C for 30 min and then diluted to
1 mL withacetonitrile.
Butyrate measurements by LC MS/MS
<span class="Chemical">The ExionLC AC system coupled to a triple quadrupole mass
spectrometer QTRAP5500 (ABSciex, USA) was used. Chromatographic separation
was established using a C18-reverse phase HPLC Accucore column (4.6 ×
100mm, 2.6μm, ThermoScientific, USA) at a flow rate of 0.5 mL/min at
40°C during a 15 min gradient (0 min 15% B, 2 min 15% B, 6min 55% B,
8min 100% B, 10 min 100% B, 13 min 0% B 15 min 0% B). The mobile phase
consisted of solvent A (water, 0.1% formic acid (Thermo scientific # 85178
LC-MS grade) and Solvent B (acetonitrile, 0.1% formic acid). The MRM
transition of m/z 222.1 → 137.1 was used for butyrate
identification. Nitrogen was used as the nebulizing and desolvation gas.
Electrospray ionization was performed in the negative ion mode with
optimized parameters: curtain gas 20, ionization spray voltage 4500, T probe
heat temperature 650°C, ion source gas 1 60, ion source gas 2 50,
declustering potential 60, collision energy 25, collision cell exit
potential 11, entrance potential 10. A calibration curve was generated withthe derivatized butyrate standard (6 different concentrations) to determine
the concentration of the corresponding butyrate species within the samples.
Peak determination, peak area integration and calibration curves for
standards were performed withthe MultiQuant 3.0.2 software (AB Sciex,
USA).
Microbiota analysis
C57BL/6 were purchased from Jackson Laboratories, hence derived from
a common origin, and acclimatized at Emory University for <span class="Chemical">three days.
Thereafter, the microbiome of mice was equalized for two weeks by exchange
of bedding. When mice were 10-weeks old, they were randomly assigned to
treatment groups. Mice were fed 1×109 CFU
Lactobacillus rhamnosus GG or PBS five times a week for
4 weeks. After 4 weeks feeding, fecal pellets were collected from mice and
DNA extracted from fecal samples using the MoBio DNA isolation kit. The V4
region of the 16S genes will be amplified using the methods of Caporaso et
al. (Caporaso et al., 2011).
Amplicons were sequenced on an Illumina MiSeq instrument at the Emory
Integrated Genomics Core (EIGC). Analysis of the sequencing reads were done
by the Emory Integrated Computational Core (EICC) using standard methodology
for microbiome analysis. Briefly, the raw sequence was processed via QIIME,
using closed-reference OTU picking and the Greengenes reference database.
The resulting files were then moved into R, and analyzed using the phyloseq
package. Data processing involved demultiplexing, QC filtering (Edgar et al., 2011), OTU representation
(Edgar, 2010), taxonomy
assignment via a reference database (Caporaso et al., 2010a; McDonald
et al., 2012; Wang et al.,
2007), and phylogeny and diversity analysis (Lozupone et al., 2007) using the QIIME (Caporaso et al., 2010b) and
MOTHUR(Schloss et al., 2009)
pipelines.
LGG and butyrate treatment
Mice were treated wi<span class="Chemical">thLGG, 1 X 109 total bacteria, 5
days a week by oral gavage for 4 weeks starting at 10 weeks of age.
Conventionally raised mice were treated with 100mM butyrate (Cayman
Chemicals, Ann Arbor, MI) dissolved in drinking water for 4 weeks, which
resulted in an average intake of 36 mg of butyrate/per mouse/per day. Since
GF mice disliked the taste of butyrate containing water, GF mice were
treated withbutyrate dissolved in drinking water in increasing doses (1mM
during the first week, 2.5mM in the second week, and 10mM in the last two
weeks of treatment) to accustom the animals to the taste.
μCT measurements
μCT scanning and analysis was performed as reported
previously (Li et al., 2015; Li et al., 2014; Robinson et al., 2015), using Scanco
μCT-40 and Scanco vivaCT 40 scanners. Voxel size was 12
mm3 for in vitro measurements of femurs and
21 mm3 for in vivo measurements of the spine.
For the femoral trabecular region, we analyzed 70 slices, beginning 50
slices below the distal growth plate. Femoral cortical bone was assessed
using 80 continuous CT slides located at the femoral midshaft. In
vivo measurements of spinal trabecular bone contours along the
periosteal surfaces were drawn encompassing 50 slices of the L4 vertebra,
starting at the beginning of trabecular bone within the spinal body, as
described (Li et al., 2016). X-ray
tube potential was 70 kVp, 114 mA, and integration time was 350 ms for the
in vivo measurements and 200 ms for the in vitro
measurements. We used the thresholding approach described by Bouxsein et al.
(Bouxsein et al., 2010), which is
recommended by Scanco, the μCT-40 manufacturer, and involves a visual
inspection and comparison of preview and slice-wise gray scale 2D images.
The same threshold value was used for all measurements.
Anti-CD25 Ab treatment
WT <span class="Species">mice were injected wi<span class="Chemical">th anti-CD25 Ab (clone PC61,
500μg/mouse/injection IP) or isotype matched irrelevant Ab (BioXCell,
West Lebanon, NH) on days 2, 0, 5, 7, 12, 14, 19 and 21. Mice were further
treated with Vehicle, LGG (1X 109 CFU/mice/day 5 days/week and
Butyrate (100mM).
DT treatment
Diphtheria Toxin (DT) was purchased from Merck (catalog number
322326), and each lot was tested for <span class="Disease">toxicity in WT mice and titrated for
potency in DEREG mice prior to use. DEREG and littermate control mice were
administered 0.5 mg DT intraperitoneally on two consecutive days each week
for total of four weeks, as previously described (Yu et al., 2018).
T cell purification and adoptive transfer
Splenic <span class="Gene">CD4+ and CD8+ T cells were purified by negative selection
with EasySep MouseCD4+ and CD8+ T Cell Isolation Kit (StemCell
Technologies, Auburn, CA) and transferred into 4 weeks old
TCRβ−/− recipient mice by IV injection
(3 3 106 cells per mouse). Recipient mice were treated with
vehicle, LGG or butyrate for 4 weeks starting 2 weeks after the T cell
transfer.
Excision of Peyer’s patches (PP) from small intestine and
preparation of single cell suspension by mechanical dislocation
Peyer’s patches (PP) cell isolation was performed as
described (Lefrancois and Lycke,
2001). Briefly, <span class="Chemical">the small intestine was removed and flushed of fecal
content. <span class="Chemical">PPs were excised and collected in 1 mL cooled RPMI1640. PPs were
dissociated using the plunger of a 2.5 mL syringe and gently forced through
a 70 μm cell strainer placed over a 50 mL tube. A single cell
suspension was used for measuring the number of Treg cells in PP by flow
cytometry.
Quantitative bone histomorphometry
<span class="Chemical">The measurements, terminology and units used for histomorphometric
analysis, were <span class="Chemical">those recommended by the Nomenclature Committee of the
American Society of Bone and Mineral Research75. Longitudinal
sections of the femur were prepared and analyzed as described
previously74 using the Bioquant Image Analysis System
(R&M Biometrics). Briefly, mice were injected subcutaneously with
calcein at day 7 and day 2 before sacrifice. Non-consecutive longitudinal
sections (5 mm thick) were cut from methyl methacrylate plastic-embedded
blocks along the frontal plane using a Leica RM2155 microtome and stained
with Goldner’s trichrome stain for the static measurements.
Additional 10 mm thick sections were left unstained for dynamic
(fluorescent) measurements. Measurements were obtained in an area of
cancellous bone that measured ≈2.5 mm2 and contained only
secondary spongiosa, which was located 0.5–2.5 mm proximal to the
epiphyseal growth cartilage of the femurs.
ELISAs
P1NP, <span class="Gene">osteocalcin and <span class="Gene">CTX were measured by ELISA (Immunodiagnostic
Systems Ltd. (Boldon, UK).
Stromal cell purification
BM SCs were purified as previously described (Bedi et al., 2012; Gao et al., 2008). Briefly, unfractionated BM
cells were cultured for 7 days in α-MEM medium containing 10% FBS to
allow <span class="Chemical">the proliferation of SCs. After discarding non-adherent cells,
adherent macrophages were eliminated from the rest of the adherent cells by
positive immunoselection by MACS Microbeads (Miltenyi Biotec, Auburn, CA,
USA) coupled to anti-CD11c antibody. This marker is expressed on
non-adherent dendritic cells and adherent monocytes and macrophages. The
remaining adherent cells were defined as SCs because they express ALP,
type-I collagen (COLI), and RUNX2, and have the capacity to form
mineralization nodules when further cultured under mineralizing
conditions.
BrdU incorporation studies
SCs proliferation was assessed by <span class="Chemical">BrdU incorporation assay as
previously described(Bedi et al.,
2012; Gao et al., 2008), using
a <span class="Chemical">BrdU ELISA kit from Roche Diagnostics. SCs were pulsed withbromodeoxyuridine (BrdU) for 4 hours and assayed using a BrdU ELISA kit
(Roche Diagnostics) according to the manufacturer’s instructions. SCs
proliferation was measured at 450 nm with reference wavelength at 690
nm.
SC apoptosis assay
<span class="Chemical">The activity of <span class="Gene">caspase-3, the key protease in the induction of
apoptosis, was measured in SCs using a CaspACE Assay System (Promega
Corporation) according to the manufacturer’s protocol. In Brief, SC
extract was prepared by lysing and centrifuging SCs in lysis buffer provided
by the kit. Prepared extracts were assayed by measuring absorbance at 405
nm.
Real-time RT-PCR
Total RNA was extracted from whole BM cells and purified BM T cells
using <span class="Chemical">Trizol (Invitrogen). cDNA was synthesized from 1 mg total RNA withthe
Revert AidTM H Minus first strand cDNA synthesis kit (Invitrogen). The mRNA
expression levels of genes were analyzed by RT-PCR using an ABI Prism 7000
or One Step Plus Sequence Detection System and SYBR GREEN PCR Master Mix
(Applied Biosystems, Foster City, CA, USA). Changes in relative gene
expression between groups were calculated using the 2
–ΔΔCt method with normalization to 18S
rRNA as previously described. All the primers used were designed by Primer
Express Software v2.0 (Applied Biosystems) and most were validated in
previous investigations (Li et al.,
2016; Li et al., 2015;
Yu et al., 2018). The primer
sequences are provided in Table S1.
Flow cytometry
<span class="Chemical">The following anti-<span class="Species">mouse antibodies were used for cell surface
staining: purified CD16/32, BV 421-TCRb (clone H57–597),
PerCP/Cy5.5-CD4 (clone RM4–5), PE-CD25 (clone PC61), BV 711-CD8
(clone 53–6.7), PerCP/Cy5.5-F4/80 (clone BM8), BV 421-CD11c (clone
N418), Alexa Fluor 700-I-A/I-E (clone M5/114.15.2), PE-CD40 (clone 3/23),
APC-CD80 (clone 16–10A1) (Biolegend, San Diego, CA) and BV650-CD86
(clone GL1, BD Biosciences). For intracellular Foxp3 staining, cells were
washed, fixed and permeabilized using BD Transcription Factor Buffer Set (BD
Biosciences). Cells were then incubated with APC-anti-Foxp3 (clone FJK-16 s,
eBioscience) antibody. For phospho-epitope analysis, fresh total BM cells
were fixed in BD Cytofix Fixation Buffer for 10 min at 37°C,
permeabilized with BD Phosflow Perm Buffer III for 30 min on ice, and
stained with PE anti-AKT (pS473) (BD Biosciences) and cell surface
antibodies. Flow cytometry was performed on a LSR II system (BD Biosciences,
Franklin Lakes, NJ), the live cells were discriminated by LIVE/DEAD Fixable
Yellow Dead Cell Stain Kit (ThermoFisher) and data were analyzed using
FlowJo software (Tree Star, Inc., Ashland, OR).
Cell sorting by Flow cytometry
DEREG (eGFP.<span class="Gene">Foxp3) reporter <span class="Species">mice were used for cell sorting. Single
cell suspensions were obtained from BM and stained withCD16/32,BV
421-TCRβ (clone H57–597), PerCP/Cy5.5-CD4 (clone
RM4–5), PE-CD25 (clone PC61) and BV 711-CD8-(clone 53–6.7)
(Biolegend, San Diego, CA). 1 X106 cells were sorted on a BD Arya
cell sorter. The sorted cells were collected in complete RPMI-1640 media.
Purified cells were then collected by centrifugation and dissolved in Trizol
reagent for RNA isolation.
Western Blotting
<span class="Chemical">The nuclear and cytoplasmic fractions of fresh BM <span class="Gene">CD8+ T cells were
obtained using NE-PER Nuclear and Cytoplasmic Extraction Reagents
(ThermoFisher Scientific). The proteins in lysates were protected by Halt
Protease and Phosphatase Inhibitor Cocktail (ThermoFisher Scientific).
Lysates were cleared by centrifugation and the supernatants were boiled in
SDS loading buffer. The same amounts of proteins were separated on 10%
Mini-PROTEAN TGX Precast Gels (Bio-rad) and electroblotted to nitrocellulose
membrane (ThermoFisher Scientific). Proteins were detected by anti-NFAT1
(catalog no.MA1–025), anti-c-Jun (catalog no. 397500) (ThermoFisher
Scientific), anti-NFAT2 (catalog no. sc-7294), anti-c-Fos (catalog no.
sc-52-G) (Santa Cruz Biotechnology), anti-phospho-Smad2 (Ser465/467)
(catalog no. 3108) or anti-phospho-Smad3 (Ser423/425) (catalog no. 9520)
(Cell Signaling Technology, Danvers, MA), anti-Smad3 (phosphor S423+ S425)
(catalog no. ab52903, Abcam) antibodies. Anti-beta Tubulin (catalog no.
6046, Abcam) and anti-Lamin B1 (catalog no. 12586, Cell Signaling
Technology, Danvers, MA) antibodies were used to confirm the purity of
subcellular fractionations, respectively. Anti-beta actin (catalog no.
sc-1616) antibody was used as the loading control for the testing of
phospho-PI3K p85 (catalog no. 4257) (Cell Signaling Technology, Danvers, MA)
in the whole lysate from BM CD8+ T cells. Western blot analysis was
conducted using Luminata Crescendo Western HRP substrate (EMD Millipore).
Band intensities were quantified with Quantity One 1D Analysis Software
(Bio-Rad Laboratories) and expressed relative to Lamin B1 or beta actin.
In vitro generation of induced Treg cells
<span class="Chemical">Treg cells were induced in vitro as described (Fantini et al., 2007). Briefly, purified splenic
<span class="Gene">CD4+CD25- T cells from 6–8 weeks old WT mice were cultured in
RPMI-1640 medium were in plates coated with anti-CD3 Ab (10 μg/mL) in
the presence of recombinant humanIL-2 (100 U/mL), TGFβ1 (20 ng/mL)
and trans-retinoic acid (1 pmol/mL) for 4 days. The percentage of total
CD4+cells found to be Foxp3+ by flow cytometry at the end of the culture
period was 95%.
Plasmids and site-directed mutagenesis
A plasmid containing 2000 to +216 bp DNA sequence of <span class="Species">mouse
<span class="Gene">Wnt10b promoter was constructed by inserting a PCR
product of mouse genomic DNA into the pGL3.0 vector (Promega, Madison, WI).
mwnt10b-luc (a plasmid containing 705 to +216 bp DNA
sequence of mouseWnt10b promoter constructed by inserting a PCR product of
mouse genomic DNA into the pGL3.0 vector) was a gift from Dr. D. J. Klemm,
University of Colorado, Denver. Other shortened constructs were subcloned
based on the construct of mwnt10b-luc (2000 bp to +216 bp).
The amplification template for all mutations is the
mwnt10b-luc (705 to +216 bp). The NFAT binding site
(5′-AGGAAAA-3′) at 282 to 276 bp was changed to
5′-AGcttAA-3′ using the Q5 Site-Directed Mutagenesis Kit (New
England BioLabs). Similarly, the SMAD binding site
(5′-GTCTAGA-3′) at 341 to 335 bp was mutated to
5′-catagcg-3′. The primers used are provided in Table S1.
Wnt10b promoter reporter gene assays
Freshly purified spleen <span class="Gene">CD8+ T cells were transfected wi<span class="Chemical">th either
3.6 μg pGL3 basic vector or 3.6 mg Wnt10b-luc
(including WT or mutant DNA segments) reporter constructs together with 0.4
μg TK-pRL transfection control vector using the Amaxa Nucleofector
system and Amaxa Mouse T Cell Nucleofector Kit (Lonza). Cells were left
unstimulating for 24 h and cultured withionomycin (0.5 mg/mL, Sigma) plus
TGFβ1 (5 ng/mL, Biolegend) for another 24 h. Luciferase activity was
determined by the Dual-Luciferase reporter assay kit (Promega BioSciences,
San Luis Obispo, CA).
APC assay and in vitro CTLA-4Ig treatment
The APC assay was performed as previously described (Roser-Page et al., 2014). Splenic CD11c+
dendritic cells (DCs) sorted by immunomagnetic beads (Miltenyi Biotech) were
used as antigen presenting cells. CD8+ T cells expressing a monoclonal
ovalbumin (OVA)-specific transgenic TCR were purified from the spleens of
OT-I mice by negative selection. CD11c+ DCs were pulsed for 4 hours with 1
μM antigen (OVA peptide) (SIINFEKL, InvivoGen). After two washes with
medium, cells were used for APC assay. For induced Treg cells cocultures,
OVA presenting dendritic cells at 150,000/well were incubated with splenic
OT-I CD8+ T cells (1 million/well) with or without induced Treg cells (1
million/well or increasing dose of Treg cells from 0.5 to 4 million/well)
for 24 h. CD8+ T cells were separated by EasySep MouseCD8a positive
Selection Kit II (StemCell Technologies, Auburn, CA) and dissolved in TRIzol
reagent for RNA isolation and real time RT-PCR of Wnt10b
mRNA. For ChIP assay, the time of coculture of OVA presenting dendritic
cells, CD8+ T cells and induced Treg cells was 4 h. During CTLA-4Ig
treatment, OVA presenting dendritic cells at 150,000/ well were incubated
with splenic OT-I CD8+ T cells (1 million/well) with or without CTLA-4Ig
(100 μg/mL) for 4h or 24 h.
ChIP Assays
ChIP assays were performed using a kit and following <span class="Chemical">the
manufacturer’s instructions (Pierce Agarose ChIP Kit, ThermoFisher
Scientific). Fresh purified BM CD8+ T cells were fixed in 1% formaldehyde
for 10 min. Chromatin was digested by micrococcal nuclease to an average
length of 200–1000 bp. The similar amounts of chromatin were
immunoprecipitated with 2 μg of anti-NFAT1 (clone 25A10.D6D2,
ThermoFisher Scientific), anti-NFAT2 (clone 7A6, Santa Cruz Biotechnology),
anti-Smad3 (catalog no. 28379, ChIP grade, Abcam), anti-Smad2 (clone D43B4,
Cell Signaling Technology, Danvers, MA) or control rabbit IgG. Isolated DNAs
were quantitated using ABI SYBR Green PCR master mix (Applied Biosystems) on
an ABI StepOnePlus Real-Time PCR System and calculated as fold enrichment
compared with background signal.
QUANTIFICATION AND STATISTICAL ANALYSIS
All data are expressed as Mean ± SEM. When data were normally
distributed according to <span class="Chemical">the Shapiro-Wilk normality test, they were analyzed as
follows. Prospective data were analyzed by analysis-of-variance (ANOVA) for
repeated-measures. Cross-sectional data were analyzed by unpaired two tailed t
tests, one-way ANOVA or two-way ANOVA as appropriate. This analysis included the
main effects for animal strain and treatment plus the statistical interaction
between animal strain and treatment. When the statistical interaction was
statistically significant (p < 0.05) or suggestive of an important
interaction, then t tests were used to compare the differences between the
treatment means for each animal strain, applying the Bonferroni correction for
multiple comparisons. Data that were not normally distributed (as tested by
Shapiro-Wilk normality test) were analyzed by Kruskal-Wallis non-parametric
tests.
pGL3.0 –2000 to +216 bp DNA sequence of
mouse Wnt10b
Roberto Pacifici, Emory University SOM (This
Paper)
N/A
pGL3.0
Promega
N/A
mWnt10b-luc (a plasmid containing 705 to +216
bp DNA sequence of mouse Wnt10b promoter constructed by inserting a PCR
product of mouse genomic DNA into the pGL3.0 vector)
Gift from Dr. D. J. Klemm,University of
Colorado,Denver. (PMID:18957421)
Authors: J Gregory Caporaso; Christian L Lauber; William A Walters; Donna Berg-Lyons; Catherine A Lozupone; Peter J Turnbaugh; Noah Fierer; Rob Knight Journal: Proc Natl Acad Sci U S A Date: 2010-06-03 Impact factor: 11.205
Authors: Jau-Yi Li; Patrizia D'Amelio; Jerid Robinson; Lindsey D Walker; Chiara Vaccaro; Tao Luo; Abdul Malik Tyagi; Mingcan Yu; Michael Reott; Francesca Sassi; Ilaria Buondonno; Jonathan Adams; M Neale Weitzmann; Giovanni Carlo Isaia; Roberto Pacifici Journal: Cell Metab Date: 2015-10-08 Impact factor: 27.287
Authors: Roberto Berni Canani; Naseer Sangwan; Andrew T Stefka; Rita Nocerino; Lorella Paparo; Rosita Aitoro; Antonio Calignano; Aly A Khan; Jack A Gilbert; Cathryn R Nagler Journal: ISME J Date: 2015-09-22 Impact factor: 10.302
Authors: Sébastien Lucas; Yasunori Omata; Jörg Hofmann; Martin Böttcher; Aida Iljazovic; Kerstin Sarter; Olivia Albrecht; Oscar Schulz; Brenda Krishnacoumar; Gerhard Krönke; Martin Herrmann; Dimitrios Mougiakakos; Till Strowig; Georg Schett; Mario M Zaiss Journal: Nat Commun Date: 2018-01-04 Impact factor: 14.919
Authors: Matteo M Pusceddu; Patricia J Stokes; Alice Wong; Melanie G Gareau; Damian C Genetos Journal: J Orthop Res Date: 2019-07-26 Impact factor: 3.494
Authors: Naiomy Deliz Rios-Arce; Jonathan D Schepper; Andrew Dagenais; Laura Schaefer; Connor S Daly-Seiler; Joseph D Gardinier; Robert A Britton; Laura R McCabe; Narayanan Parameswaran Journal: Bone Date: 2020-02-21 Impact factor: 4.398