Cellular Responses

Adaptation, Injury and Cell Death April 2005

Cell Response to Stress and Injury

Normal Cell (homeostasis)
Stress Increased demand

Cell injury

Adaptation

Cell injury Inability to adapt Cell death

Adaptive Responses

Hyperplasia and Hypertrophy

Hyperplasia = Increase in cell number Hypertrophy = Increase in cell size A response to increased demand, trophic stimuli Physiological e.g. hyperplasia in female breast
at pregnancy and puberty; hyperplasia and hypertrophy in pregnant uterus Pathological e.g. endometrial hyperplasia, benign prostatic hyperplasia or myocardial hypertrophy

Examples
See webpath for examples
Normal breast (Breast Pathology, image 1,normal breast) Hyperplasia (Breast Pathology, image 10, florid hyperplasia) Hyperplasia of endometrium (Female genital system, endometrial hyperplasia image number 22 and 24) Prostatic hyperplasia (Cellular injury - image 7 and 8) Left ventricular hypertrophy (Cellular injury image 5)

Mechanisms of Hypertrophy and Hyperplasia

Only labile or stable cells capable of cell division become hyperplastic. Non-dividing cells do not (e.g. myocardium and skeletal
muscle)

Activation of cell signalling pathways induce transcription of genes involved in proliferation (hyperplasia) and/or growthrelated proteins (hypertrophy)

 Other adaptive responses can occur

In myocardial hypertrophy there is a switch from - to -myosin heavy chain and production of ANF by left ventricle

Atrophy
Shrinkage of cell by loss of cell substance Physiological or pathological
Decreased workload Loss of innervation Reduced blood supply Aging

Likely due to an imbalance between protein synthesis and degradation

Examples
See webpath for examples
Cerebral atrophy (cellular injury image 3) Skeletal muscle atrophy (cellular injury image 3)

Metaplasia
Reversible change from one adult cell type to another A response to chronic irritation
Columnar to squamous e.g. respiratory tract in smokers; endocervix in response to chronic irritation; excretory duct blocked by stones Squamous to columnar: Barretts oesophagus Within tumours In scars: bone, cartilage

Examples
See webpath for examples
Barretts oesophagus (Gastrointestinal pathology index, oesophagus, image 9 and 10 and 11)

Mechanisms of Metaplasia
Due to re-programming of stem cells or undifferentiated mesenchymal cells to a different cell type Both extra- and intra-cellular signals induce transcription of genes controlling differentiation along new pathway
TGF-: bone and cartilage

Cell Injury and Cell Death

Causes of Cell Injury

Hypoxia

Physical
Radiation, burns, freezing, mechanical, trauma

Chemical
Drugs (e.g. paracetamol), poisons (e.g. paraquat, cyanide)

Infectious agents
Viruses, bacteria etc

Immune reactions Genetic abnormalities Nutritional imbalances

Mechanism of Cell Injury

Whatever the injurious agent, cell injury results when there is dysfunction of essential cellular systems:
Aerobic respiration Membrane integrity Protein synthesis Cytoskeleton Genetic apparatus

Degree of damage to each of these systems depends on the nature of the injury

Reactive O2 species
Lipid, protein, DNA damage Ca2+/Mg2+ ATPase

ER
Activation of Phospholipases, ATPase, protease, endonucleases

Ox. Phos.

Ca2+ ATP

Cytochrome C,

H+

H20

Na2+

K+
Na+/K+ ATPase

pH
Degradative enzymes
Lysosome Loss of cellular contents

Reversible and Irreversible Cell Injury

Transition from reversible to irreversible injury is unclear Inter-dependence of biochemical systems in the cell makes it difficult to determine the exact sequence of changes Two features are characteristic of irreversibility
Irreversible mitochondrial dysfunction Profound membrane dysfunction

Morphological Changes
Cell injury can be seen morphologically (by light microscopy) as
Hydropic change (Reversible cell injury) Fatty change (Reversible cell injury) and Necrosis (Irreversible cell injury) Apoptosis (Irreversible cell injury)

Morphological Changes contd.

Hydropic change
Difficult to see with LM Tiny vacuoles in cytoplasm

Fatty change
Accumulation of triglycerides in cell Most common in liver (also heart, muscle, kidney) Causes: alcohol, obesity, DM, anoxia, toxins, protein malnutrition

Causes of Fatty Change

fatty acids enter liver (starvation) fatty acid synthesis (alcohol) fatty acid oxidation (anoxia, alcohol) apoprotein synthesis (CCl4, protein malnutrition)

Examples
See webpath for examples
Hepatic pathology index (normal liver image 2, 4) Fatty liver (image 5, 6 and 7)

Necrosis
= Cell death Morphological changes result from the denaturation of proteins and enzymatic digestion of cellular organelles Leakage of proteins/enzymes out of the injured cell can be used clinically as a marker of cell death (e.g. raised serum levels
of cardiac enzymes after an MI)

Necrosis
Time to death with hypoxia:
Brain - < 3 minutes Heart - 1-2 hours Kidney 2-3 hours Skin fibroblasts - < 24 hours

Takes about 12 hours to see morphological changes of necrosis by LM Necrosis results in an inflammatory reaction in adjacent tissue

Morphological Types of Necrosis

Terms used historically to describe patterns of necrosis: Coagulative - when denaturation of proteins predominates leaving the basic cell outline intact (e.g. MI) Liquefactive autolysis predominates and results in liquefied mass e.g. hypoxia in CNS, bacterial infections Gangrenous coagulative with superimposed bacterial infection Caseous cheesy white appearance of necrosis in TB granulomata Fat necrosis of adipocytes induced by pancreatic lipases. Fatty acids + Ca2+ = Ca2+ soaps

Examples
See webpath for examples
Cardiovascular pathology index (normal myocardium, image 5) Necrosis of myocardium (MI) (images 27-32) 7) Infarction of kidney (cellular injury index, image 15 and 16) Liquefactive necrosis in brain (cellular injury index, image 22) Caseus necrosis (TB) (cellular injury index, image 30)

Apoptosis
Programmed cell death Required to ensure that there is a steady turnover of cells in tissues and in response to physiological stimuli
Shedding of menstrual endometrium Involution of breast after weaning Prostatic atrophy after castration Cell turnover in intestinal crypts Death of inflammatory cells after inflammation

 Apoptosis also occurs in pathological situations

as a result of certain types of cell injury/ DNA damage e.g. radiation, chemotherapy, drugs viral infections e.g. viral hepatitis in tumours that regress or involution Others including rejection of transplants

Morphologically
Apoptosis is characterised by death of single cells without an inflammatory reaction, unlike necrosis where there is death of large amounts of the tissue and there is an associated inflammatory reaction

Example
See Webpath cell injury index, image number 14, apotosis in viral hepatitis

Mechanism of Apoptosis
Two main pathways 1. Intrinsic mitochondrial pathway Increased permeability of mitochondrial membrane results in release of proapoptotic factors (cytochrome c and AIF) that activate downstream caspases Release of these factors is regulated by Bcl family on mitochondrial membrane

Bcl Family
Family of proteins reside mainly on mitochondrial membrane Bcl-2, Bcl-x are anti-apoptotic Bax, Bim, Bak are pro-apoptotic In apoptosis, pro-apoptotic proteins accumulate and increase permeability of mitochondrial membrane, release of pro-apoptotic molecules e.g. cytochrome c p53 up-regulates pro-apoptotic Bcl proteins

2. Extrinsic death receptor pathway FAS and TNF1 receptor families with death domain Binding of appropriate signals (FAS e.g. FAS lignad) results in activation of caspases

 Caspases result in degradation of cytoskeleton and activation of endonculeases and degrade DNA Cell breaks down into apoptotic bodies that can be seen by LM and these are mopped up by phagocytes

Other Pathways
Cytotoxic lymphocytes utilise another pathway. Lymphocytes release perforins that punch a hole in the cell membrane of the target cell Then, they release granzyme B into target cell that activates the caspases

Apoptosis in Different Settings

Different stimuli activate different apoptotic patways Mitochondrial pathway activated after deprivation of hormones and growth factors p53 stimulation of intrinsic pathway is common after DNA damage FAS-ligand pathway for elimination of lymphocytes that recognise self antigens T-cell mediated cytotoxicity utilises granzyme-B activation e.g. viral infection All three pathways can interact

Deranged Apoptosis
Increased Apoptosis is seen in Viral Infection Graft rejection Neurodegenerative disorders Decreased Apoptosis is the seen in Neoplasia Autoimmune disorders

Apoptosis in Neoplasia
One of the key regulatory systems that is deranged in most tumours Dysfunction of p53 pathway is a common mechanism by which apoptosis becomes deranged p53 mutations are found in 50% of malignant tumours Germ-line (Li-Fraumeni) and somatic (e.g. colon, breast etc) mutations
Point mutations in DNA binding domain (ex 5-9)

Where tumours have wild-type p53, then down- or upstream effectors of p53 are often dysfunctional (e.g. cyclins, p21 etc)