Article | Published:

Role of telomere dysfunction in cardiac failure in Duchenne muscular dystrophy

Nature Cell Biology volume 15, pages 895904 (2013) | Download Citation

Abstract

Duchenne muscular dystrophy (DMD), the most common inherited muscular dystrophy of childhood, leads to death due to cardiorespiratory failure. Paradoxically, mdx mice with the same genetic deficiency of dystrophin exhibit minimal cardiac dysfunction, impeding the development of therapies. We postulated that the difference between mdx and DMD might result from differences in telomere lengths in mice and humans. We show here that, like DMD patients, mice that lack dystrophin and have shortened telomeres (mdx/mTRKO) develop severe functional cardiac deficits including ventricular dilation, contractile and conductance dysfunction, and accelerated mortality. These cardiac defects are accompanied by telomere erosion, mitochondrial fragmentation and increased oxidative stress. Treatment with antioxidants significantly retards the onset of cardiac dysfunction and death of mdx/mTRKO mice. In corroboration, all four of the DMD patients analysed had 45% shorter telomeres in their cardiomyocytes relative to age- and sex-matched controls. We propose that the demands of contraction in the absence of dystrophin coupled with increased oxidative stress conspire to accelerate telomere erosion culminating in cardiac failure and death. These findings provide strong support for a link between telomere length and dystrophin deficiency in the etiology of dilated cardiomyopathy in DMD and suggest preventive interventions.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

References

  1. 1.

    & Molecular genetics and genomics of heart failure. Nat. Rev. Genet. 5, 811–825 (2004).

  2. 2.

    , & Dystrophin: the protein product of the Duchenne muscular dystrophy locus. Cell 51, 919–928 (1987).

  3. 3.

    , , , & Dystrophin protects the sarcolemma from stresses developed during muscle contraction. Proc. Natl Acad. Sci. USA 90, 3710–3714 (1993).

  4. 4.

    , & 107th ENMC international workshop: the management of cardiac involvement in muscular dystrophy and myotonic dystrophy. 7th–9th June 2002, Naarden, the Netherlands. Neuromuscul. Disord. 13, 166–172 (2003).

  5. 5.

    Treatment of the heart in Duchenne muscular dystrophy. Dev. Med. Child Neurol. 48, 163 (2006).

  6. 6.

    Challenges and opportunities in dystrophin-deficient cardiomyopathy gene therapy. Human Mol. Genet. 15 (Spec No 2), R253–R261 (2006).

  7. 7.

    New approaches in the therapy of cardiomyopathy in muscular dystrophy. Annu. Rev. Med. 58, 75–88 (2007).

  8. 8.

    Heart failure: future treatment approaches. Am. J. Hypertens. 13, 74S–78S (2000).

  9. 9.

    et al. Angiotensin II type 1 receptor blockade attenuates TGF- β-induced failure of muscle regeneration in multiple myopathic states. Nat. Med. 13, 204–210 (2007).

  10. 10.

    , , & X chromosome-linkedmuscular dystrophy (mdx) in the mouse. Proc. Natl Acad. Sci. USA 81, 1189–1192 (1984).

  11. 11.

    The association of cardiac muscle necrosis and inflammation with the degenerative and persistent myopathy of MDX mice. J. Neurol. Sci. 72, 147–157 (1986).

  12. 12.

    & The mutant mdx : inherited myopathy in the mouse. Morphological studies of nerves, muscles and end-plates. Brain 110 (pt 2), 269–299 (1987).

  13. 13.

    & The telomere terminal transferase of Tetrahymena is a ribonucleoprotein enzyme with two kinds of primer specificity. Cell 51, 887–898 (1987).

  14. 14.

    & Hypervariable ultra-long telomeres in mice. Nature 347, 400–402 (1990).

  15. 15.

    & Wild-derived inbred mouse strains have short telomeres. Nucleic Acids Res. 28, 4474–4478 (2000).

  16. 16.

    et al. Essential role of mouse telomerase in highly proliferative organs. Nature 392, 569–574 (1998).

  17. 17.

    et al. Short telomeres and stem cell exhaustion model Duchenne muscular dystrophy in mdx/mTR mice. Cell 143, 1059–1071 (2010).

  18. 18.

    et al. Evidence for cardiomyocyte renewal in humans. Science 324, 98–102 (2009).

  19. 19.

    et al. Telomere shortening and tumor formation by mouse cells lacking telomerase RNA. Cell 91, 25–34 (1997).

  20. 20.

    et al. Differential expression of dystrophin isoforms in strains of mdx mice with different mutations. Human Mol. Genet. 5, 1149–1153 (1996).

  21. 21.

    Population frequencies of inherited neuromuscular diseases—A world survey. Neuromuscul. Disord. 1, 19–29 (1991).

  22. 22.

    & The heart in human dystrophinopathies. Cardiology 99, 1–19 (2003).

  23. 23.

    & Cardiac conduction abnormalities in children with Duchenne’s progressive muscular dystrophy: electrocardiographic features and morphologic correlates. Circulation 66, 853–863 (1982).

  24. 24.

    et al. Fast, high-resolution in vivo cine magnetic resonance imaging in normal and failing mouse hearts on a vertical 11.7 T system. J. Magn. Reson. Imaging 18, 691–701 (2003).

  25. 25.

    et al. The longest telomeres: a general signature of adult stem cell compartments. Genes Dev. 22, 654–667 (2008).

  26. 26.

    , , & Telomerase-deficient mice with short telomeres are resistant to skin tumorigenesis. Nat. Genet. 26, 114–117 (2000).

  27. 27.

    & Recent advances in telomere biology: implications for human cancer. Curr. Opin. Oncol. 16, 32–38 (2004).

  28. 28.

    et al. Telomere length assessment in human archival tissues: combined telomere fluorescence in situ hybridization and immunostaining. Am. J. Pathol. 160, 1259–1268 (2002).

  29. 29.

    et al. Telomere shortening occurs in subsets of normal breast epithelium as well as in situ and invasive carcinoma. Am. J. Pathol. 164, 925–935 (2004).

  30. 30.

    et al. Telomere dysfunction induces metabolic and mitochondrial compromise. Nature 470, 359–365 (2011).

  31. 31.

    & Cardiac mitochondria and arrhythmias. Cardiovasc. Res. 88, 241–249 (2010).

  32. 32.

    , , & Mitochondrial fission and autophagy in the normal and diseased heart. Curr. Hypertens. Rep. 12, 418–425 (2010).

  33. 33.

    , , & NADPH oxidase-dependent redox signalling in cardiac hypertrophy, remodelling and failure. Cardiovasc. Res. 71, 208–215 (2006).

  34. 34.

    et al. Oxidant stress from nitric oxide synthase-3 uncoupling stimulates cardiac pathologic remodeling from chronic pressure load. J. Clin. Invest. 115, 1221–1231 (2005).

  35. 35.

    et al. Downregulation of apoptosis-inducing factor inharlequin mutant mice sensitizes the myocardium to oxidative stress-related cell death and pressure overload-induced decompensation. Circ. Res. 96, e92–e101 (2005).

  36. 36.

    Oxidative stress in heart failure: what are we missing? Am. J. Med. Sci. 342, 120–124 (2011).

  37. 37.

    , , & Reversible oxidative modification: implications for cardiovascular physiology and pathophysiology. Trends Cardiovasc. Med. 20, 85–90 (2010).

  38. 38.

    et al. Antioxidant amelioration of dilated cardiomyopathy caused by conditional deletion of NEMO/IKK γ in cardiomyocytes. Circ. Res. 106, 133–144 (2010).

  39. 39.

    , & Urinary 8-hydroxy-2’-deoxyguanosine as a biological marker of in vivo oxidative DNA damage. Proc. Natl Acad. Sci. USA 86, 9697–9701 (1989).

  40. 40.

    et al. Abnormal mitochondrial dynamics, mitochondrial loss and mutant huntingtin oligomers in Huntington’s disease: implications for selective neuronal damage. Human Mol. Genet. 20, 1438–1455 (2011).

  41. 41.

    et al. Cytosolic, but not mitochondrial, oxidative stress is a likely contributor to cardiac hypertrophy resulting from cardiac specific GLUT4 deletion in mice. FEBS J. (2011).

  42. 42.

    , , & An ultrastructural basis for electrocardiographic alterations associated with Duchenne’s progressive muscular dystrophy. Circulation 57, 1122–1129 (1978).

  43. 43.

    et al. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am. J. Respir. Crit. Care Med. 170, 456–465 (2004).

  44. 44.

    et al. Utrophin-dystrophin-deficient mice as a model for Duchenne muscular dystrophy. Cell 90, 717–727 (1997).

  45. 45.

    et al. Severe cardiomyopathy in mice lacking dystrophin and MyoD. Proc. Natl Acad. Sci. USA 96, 220–225 (1999).

  46. 46.

    et al. Severe muscular dystrophy in mice that lack dystrophin and α7 integrin. J. Cell Sci. 119, 2185–2195 (2006).

  47. 47.

    et al. Role for α-dystrobrevin in the pathogenesis of dystrophin-dependent muscular dystrophies. Nat. Cell Biol. 1, 215–220 (1999).

  48. 48.

    et al. A human-specific deletion in mouse Cmah increases disease severity in the mdx model of Duchenne muscular dystrophy. Sci. Transl. Med. 2, 42ra54 (2010).

  49. 49.

    et al. Short telomeres and ataxia-telangiectasia mutated deficiency cooperatively increase telomere dysfunction and suppress tumorigenesis. Cancer Res. 63, 8188–8196 (2003).

  50. 50.

    et al. Telomere dysfunction and Atm deficiency compromises organ homeostasis and accelerates ageing. Nature 421, 643–648 (2003).

  51. 51.

    Duchenne muscular dystrophy models show their age. Cell 143, 1040–1042 (2010).

  52. 52.

    & The pathology of the heart in progressive muscular dystrophy: epimyocardial fibrosis. Hum. Pathol. 7, 375–386 (1976).

  53. 53.

    , , , & Mitochondrial disease in mouse results in increased oxidative stress. Proc. Natl Acad. Sci. USA 96, 4820–4825 (1999).

  54. 54.

    et al. Adenine nucleotide translocase 1 deficiency results in dilated cardiomyopathy with defects in myocardial mechanics, histopathological alterations, and activation of apoptosis. JACC Cardiovasc. Imaging 4, 1–10 (2011).

  55. 55.

    , , , & White cell telomere length and risk of premature myocardial infarction. Arterioscler. Thromb. Vasc. Biol. 23, 842–846 (2003).

  56. 56.

    et al. Molecular and physiological characterization of RV remodeling in a murine model of pulmonary stenosis. Am. J. Physiol. Heart Circ. Physiol. 295, H1351–H1368 (2008).

  57. 57.

    et al. Modulation of angiotensin II-mediated cardiac remodeling by the MEF2A target gene Xirp2. Circ. Res. 106, 952–960 (2010).

  58. 58.

    , , , & Use of tibial length to quantify cardiac hypertrophy: application in the aging rat. Am. J. Physiol. Heart Circ. Physiol. 243, H941–H947 (1982).

Download references

Acknowledgements

We thank E. Ashley (Director, Stanford Center for Inherited Cardiovascular Disease), J. Cooke (Associate Director of Cardiovascular Institute, Stanford), M. V. McConnell (Cardiovascular Medicine, Stanford), A. Connolly (Pathology, Stanford), S. Artandi (Medicine-Hematology, Stanford) and J. Pomerantz (Center of Regeneration Medicine and Stem Cell Research, UCSF) for insightful discussions and critical comments. We greatly appreciate the input and thoughtful discussions from all Blau laboratory members and would like to especially thank S. Sampath for critical comments on the manuscript and A.T. Van Ho for help with the final formatting of the Supplementary Videos. We are grateful to D. Regula (Department of Pathology, Stanford) for providing the control cardiac samples, and M. Halushka (Department of Pathology, Johns Hopkins), A. H. Beggs (Harvard University) and H. Lidov (Department of Pathology, Boston Children’s Hospital) for providing us with DMD cardiac samples. Moreover, we are grateful to Muscular Dystrophy Center Core Laboratories at University of Minnesota, the Department of Pathology at Boston Children’s Hospital, and the DMD patients and their families who contribute to the tissue repository. We thank: E. Neri (Data Manager, Stanford) for computational algorithms for analysis of telomere lengths, A. Olson at the NMS (Stanford Neuroscience Microscopy Service, supported by NIH NS069375), K. Koleckar (Blau laboratory), and P. Chu (Comparative Medicine, Stanford), L. J. Pisani (MIPS MRI Physicist, Stanford Small Imaging Facility), J. Perrino (Electron Microscopy Facility, Stanford) as well as R. Zasio and E. Florendo (Stanford Mouse Facility) for excellent technical assistance. This work was supported by: the American Heart Association Scientist Development Grant 10SDG3510024 (F.M.); NIH/NIAMS P30 grants AR057220 (J.W.D.) and R01CA84628 (R.A.D.); NIH grants HL061535 (D.B.), P50CA058236 (W. Nelson) and NIHSPORE in ProstateCancer (A.K.M.); grants from the Robert A. and Renee E. Belfer Foundation (R.A.D., A.M. and A.P.); NIH grants HL096113, HL100397, AG020961 and AG009521 (H.M.B.); MDA grant 4320 (H.M.B.); and the Baxter Foundation (H.M.B.).

Author information

Affiliations

  1. Baxter Laboratory for Stem Cell Biology, Department of Microbiology and Immunology, Institute for Stem Cell Biology and Regenerative Medicine, Clinical Sciences Research Center, Stanford University School of Medicine, Stanford, California 94305, USA

    • Foteini Mourkioti
    • , Jackie Kustan
    • , Peggy Kraft
    •  & Helen M. Blau
  2. Department of Neurology, Stanford School of Medicine, Stanford, California 94305, USA

    • John W. Day
  3. Department of Pediatrics (Cardiology), Stanford University, Stanford, California 94305, USA

    • Ming-Ming Zhao
    •  & Daniel Bernstein
  4. Institute for Applied Cancer Science, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, Texas 77030, USA

    • Maria Kost-Alimova
    •  & Alexei Protopopov
  5. Department of Cancer Biology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, Texas 77030, USA

    • Ronald A. DePinho
  6. Department of Pathology, Department of Oncology, Johns Hopkins Medical Institution, Baltimore, Maryland 21231, USA

    • Alan K. Meeker

Authors

  1. Search for Foteini Mourkioti in:

  2. Search for Jackie Kustan in:

  3. Search for Peggy Kraft in:

  4. Search for John W. Day in:

  5. Search for Ming-Ming Zhao in:

  6. Search for Maria Kost-Alimova in:

  7. Search for Alexei Protopopov in:

  8. Search for Ronald A. DePinho in:

  9. Search for Daniel Bernstein in:

  10. Search for Alan K. Meeker in:

  11. Search for Helen M. Blau in:

Contributions

F.M. designed the studies and performed the experiments, J.K. performed mouse work, histology, immunohistochemistry, mitochondrial quantification analysis and design of schematic diagrams, P.K. maintained the mouse colony and performed histological sections, F.M., A.K.M., M.K-A. and R.A.D. aided with telomere analyses in mouse samples, F.M. and A.K.M. performed the telomere analysis in human samples, F.M. and D.B. performed the ECG analyses, F.M. and M-M.Z. performed the osmotic minipump experiments, J.W.D. provided human cardiac samples, and F.M. and H.M.B. designed the experiments, discussed and interpreted the results, and wrote the paper with input from A.K.M., R.A.D. and D.B.

Competing interests

The authors declare no competing financial interests.

Corresponding author

Correspondence to Helen M. Blau.

Integrated supplementary information

Supplementary information

PDF files

  1. 1.

    Supplementary Information

    Supplementary Information

Excel files

  1. 1.

    Supplementary Table 1

    Supplementary Information

Videos

  1. 1.

    Echocardiographic analysis indicates defect in G2 hearts.

    Representative movies from 32-week-old animals show increased LV size and impairment in ventricular function in G2 hearts.

  2. 2.

    Cardiac defect in G2 mice that received Angiotensin II.

    Representative movies 3 weeks after the mini-osmotic pump experiment from 12-week-old mdx/mTRHet (Het) and G2 hearts received either saline or Ang II. Note that the G2 hearts with Ang II show left ventricular dilation, thin myocardial wall and compromised contraction.

About this article

Publication history

Received

Accepted

Published

DOI

https://doi.org/10.1038/ncb2790

Further reading