Abstract
Kallistatin, via its two structural elements – an active site and a heparin-binding domain – displays a double-edged function in angiogenesis, apoptosis and oxidative stress. First, kallistatin has both anti-angiogenic and pro-angiogenic effects. Kallistatin treatment attenuates angiogenesis and tumor growth in cancer-bearing mice. Kallistatin via its heparin-binding site inhibits angiogenesis by blocking vascular endothelial growth factor (VEGF)-induced growth, migration and adhesion of endothelial cells. Conversely, kallistatin via the active site promotes neovascularization by stimulating VEGF levels in endothelial progenitor cells. Second, kallistatin inhibits or induces apoptosis depending on cell types. Kallistatin attenuates organ injury and apoptosis in animal models, and its heparin-binding site is essential for blocking tumor necrosis factor (TNF)-α-induced apoptosis in endothelial cells. However, kallistatin via its active site induces apoptosis in breast cancer cells by up-regulating miR-34a and down-regulating miR-21 and miR-203 synthesis. Third, kallistatin can act as an antioxidant or pro-oxidant. Kallistatin treatment inhibits oxidative stress and tissue damage in animal models and cultured cells. Kallistatin via the heparin-binding domain antagonizes TNF-α-induced oxidative stress, whereas its active site is crucial for stimulating antioxidant enzyme expression. In contrast, kallistatin provokes oxidant formation, leading to blood pressure reduction and bacterial killing. Kallistatin-mediated vasodilation is partly mediated by H2O2, as the effect is abolished by the antioxidant enzyme catalase. Moreover, kallistatin exerts a bactericidal effect by stimulating superoxide production in neutrophils of mice with microbial infection as well as in cultured immune cells. Thus, kallistatin’s dual roles in angiogenesis, apoptosis and oxidative stress contribute to its beneficial effects in various diseases.
Introduction
Kallistatin was first identified in human plasma as a tissue kallikrein-binding protein (KBP), and a unique serine proteinase inhibitor (serpin) (Chao et al., 1986; Zhou et al., 1992; Chai et al., 1993; Chao and Chao, 1995; Chen et al., 2000a,b). Kallistatin has subsequently been observed to exert a wide spectrum of biological activities independent of its interaction with tissue kallikrein (TK) (Chao et al., 1990; Miao et al., 2002, 2003; Wang et al., 2005; Gao et al., 2008; Shen et al., 2008, 2010a,b; Yin et al., 2010). The structural elements of kallistatin – an active site and a heparin-binding domain (Chen et al., 2000a,b, 2001) – regulate differential signaling pathways and biological functions (Xiong et al., 1992; Chen et al., 1995; Shen et al., 2009; Yin et al., 2010; Zhang et al., 2013; Li et al., 2014, 2015, 2016; Guo et al., 2015). Kallistatin’s active site is essential for: (1) inhibiting TK’s enzymatic activity and bioavailability (Xiong et al., 1992; Chen et al., 2000a,b); (2) stimulating endothelial nitric oxide synthase (eNOS) expression and activation in endothelial cells and endothelial progenitor cells (EPCs) (Shen et al., 2009, 2010a,b; Guo et al., 2015); (3) increasing sirtuin 1 (SIRT1) and suppressor of cytokine signaling 3 (SOCS3) expression in endothelial cells and macrophages (Guo et al., 2015; Li et al., 2015); (4) stimulating miR-34a and inhibiting miR-21 and miR-203 synthesis in breast cancer cells (Li et al., 2016); and (5) interacting with cell surface tyrosine kinase (Guo et al., 2015; Li et al., 2015). Kallistatin via its heparin-binding domain binds to cell surface heparan sulfate proteoglycans, thereby antagonizing the biological effects of: (1) vascular endothelial growth factor (VEGF)-mediated angiogenesis and vascular permeability (Miao et al., 2003; Yin et al., 2010); (2) tumor necrosis factor (TNF)-α-induced inflammation, oxidative stress and apoptosis (Shen et al., 2010a,b; Yin et al., 2010; Gao et al., 2014); (3) high mobility group box 1 (HMGB1)-induced inflammation (Li et al., 2014); (4) transforming growth factor (TGF)-β-induced fibrosis and endothelial-mesenchymal transition (EndMT) (Shen et al., 2008; Guo et al., 2015); (5) Wnt-modulated cancer cell proliferation, invasion, and autophagy (Zhang et al., 2013; Li et al., 2016); and (6) epidermal growth factor (EGF)-mediated cancer cell migration and invasion (Chao et al., 2017). Therefore, kallistatin’s pleiotropic activities exert numerous effects in various diseases.
Kallistatin is mainly expressed in the liver, and widely distributed in tissues relevant to cardiovascular function, including the heart, kidney and blood vessels (Chao and Chao, 1995; Chen et al., 1995; Wolf et al., 1999). Circulating kallistatin levels are markedly reduced in hypertension, liver disease, sepsis, cardiac and renal injury, severe pneumonia, obesity and cancer in both patients and animal models (Chao and Chao, 1988; Chao et al., 1990, 1992, 1996a,b, 2016; Hatcher et al., 1997; Stadnicki et al., 2003; Luo et al., 2007; Shen et al., 2008; Lin et al., 2013; Zhu et al., 2013; Cheng et al., 2015). Transgenic mice overexpressing kallistatin have a lower blood pressure compared to control mice, and are also resistant to lipopolysaccharide-induced inflammation and mortality (Chen et al., 1996, 1997a,b). Moreover, kallistatin gene or protein delivery in rodents alleviates the pathological conditions of hypertension, vascular, cardiac and renal injury, tumor growth and metastasis, liver fibrosis, bacterial or virus infection, and septic shock (Chen et al., 1996, 1997a,b; Chao et al., 1997, 2006; Miao et al., 2002; Diao et al., 2007; Lu et al., 2007; Zhu et al., 2007; Gao et al., 2008; Shen et al., 2008; Shiau et al., 2010; Yin et al., 2010; Huang et al., 2014a,b; Li et al., 2014, 2015; Guo et al., 2015; Leu et al., 2015; Lin et al., 2015; Yiu et al., 2016). Importantly, kallistatin’s multi-factorial actions are partly attributed to its double-edged actions in angiogenesis, apoptosis and oxidative stress.
Angiogenesis
Kallistatin’s anti-angiogenic effects
Angiogenesis is an important process in cancer development. Kallistatin administration retards the growth and metastasis of breast, colon, stomach, lung and liver carcinomas by inhibiting tumor-associated angiogenesis in animal models (Miao et al., 2002; Diao et al., 2007; Lu et al., 2007; Zhu et al., 2007; Shiau et al., 2010; Jia et al., 2014). A single intramural injection of the kallistatin gene into pre-established breast cancer xenografts in mice resulted in significant suppression of tumor growth and reduction of micro-vessel density (Miao et al., 2002). Moreover, systemic injection of lentivirus carrying the human kallistatin gene in mice dramatically decreased angiogenesis, inflammation and tumor metastasis into the lung (Shiau et al., 2010). Likewise, kallistatin treatment suppressed tumor growth, angiogenesis and VEGF synthesis in gastric and liver cancer xenografts in mice (Lu et al., 2007; Zhu et al., 2007). VEGF is a key regulator in the development of new blood vessels and tumor growth (O’Byrne et al., 2000; Yeo et al., 2014). Kallistatin via its heparin-binding site antagonized VEGF-induced proliferation, migration and capillary tube formation, as well as vascular permeability of cultured endothelial cells (Miao et al., 2003; Yin et al., 2010). Furthermore, kallistatin prevented elevation of VEGF expression induced by Wnt in cancer cells, and by TNF-α in endothelial cells (Zhang et al., 2013; Huang et al., 2014a,b). Thus, kallistatin through the heparin-binding site inhibits angiogenesis by interfering with VEGF-mediated vascularization inhibiting VEGF expression (Figure 1).

Double-edged role of kallistatin in angiogenesis.
Kallistatin’s pro-angiogenic effects
EPCs are a continuous source of replenishment for damaged blood vessels by enhancing neovascularization in response to endothelial injury (Umemura and Higashi, 2008; Mikirova et al., 2009). Decreased numbers of circulating EPCs have been observed in patients with hypertension, chronic renal failure, coronary artery disease, diabetes, rheumatoid arthritis and sepsis (Choi et al., 2004; Grisar et al., 2005; Umemura and Higashi, 2008; Cribbs et al., 2012). Reduced EPC numbers may be attributed to defective mobility and proliferation, or accelerated apoptosis and senescence. Therefore, augmented mobilization of endogenous EPCs from bone marrow is an alternative and effective means to promote angiogenesis and vascular repair. In deoxycorticosterone acetate-salt hypertensive rats, kallistatin administration increased circulating EPC number and reduced aortic oxidative stress and endothelial loss, whereas kallistatin deficiency further decreased EPC levels and exacerbated vascular oxidative stress and endothelial rarefaction (Liu et al., 2012; Gao et al., 2014). Thus, kallistatin protects against vascular injury by promoting EPC mobility and function in hypertensive rats. Mechanistically, kallistatin’s active site is key for stimulating the proliferation, migration, adhesion and tube formation of EPCs by activating Akt-eNOS signaling, and increasing VEGF levels (Gao et al., 2014, 2015). Moreover, kallistatin via its active site elevated the expression levels of eNOS and SIRT1 in endothelial cells; however, kallistatin’s effect was blocked by genistein, indicating a tyrosine kinase-mediated event (Gao et al., 2014; Guo et al., 2015). Therefore, kallistatin through its active site promotes angiogenesis and vascular repair by stimulating the mobility and function of EPCs (Figure 1).
Apoptosis
Kallistatin’s anti-apoptotic effects
Oxidative stress induces tissue damage, cellular apoptosis and senescence (Finkel and Holbrook, 2000; Chao et al., 2016). Kallistatin gene transfer attenuated oxidative stress, apoptosis and organ damage in association with increased eNOS levels in rats with myocardial ischemia/reperfusion, myocardial infarction and salt-induced hypertension (Chao et al., 2006; Gao et al., 2008; Shen et al., 2008, 2010a,b). In addition, kallistatin treatment decreased apoptosis and inflammation in mice with polymicrobial sepsis (Li et al., 2014, 2015; Lin et al., 2015). Kallistatin via its heparin-binding site blocked TNF-α-induced oxidative stress and apoptosis via activation of the phosphoinositide 3-kinase (PI3K)-Akt-eNOS signaling pathway in endothelial cells and EPCs (Shen et al., 2010a,b; Yin et al., 2010; Gao et al., 2014). Kallistatin also antagonized TNF-α-mediated suppression of eNOS synthesis and NO formation in EPCs (Guo et al., 2017). Furthermore, kallistatin via its active site stimulated eNOS synthesis by interacting with Kruppel-like factor-(KLF)-4, and increased eNOS activity by activating the PI3K-Akt pathway, leading to elevated NO formation (Shen et al., 2009, 2010a,b; Guo et al., 2015). NO, in turn, is capable of inhibiting NAD(P)H oxidase activity and reactive oxygen species (ROS) formation (Fujii et al., 1997). Thus, kallistatin, through its two structural elements, exerts anti-apoptotic effects by inhibiting oxidative stress and increasing NO production (Figure 2).

Double-edged role of kallistatin in apoptosis.
Kallistatin’s pro-apoptotic effects
MicroRNAs are endogenous non-coding RNA molecules that affect a wide variety of biological processes, including apoptosis, proliferation, organ injury and cancer (Ng et al., 2009; Natarajan et al., 2015). Overexpression of miR-34a induced apoptosis and inhibited the proliferation and migration of breast cancer cells (Li et al., 2013; Yang et al., 2013; Deng et al., 2014). Conversely, miR-21 was significantly increased and associated with poor survival of breast cancer patients (Yan et al., 2008). miR-203 is overexpressed in human breast cancer, while knockdown of miR-203 sensitized cisplatin-mediated apoptotic cell death (Ru et al., 2011). Kallistatin incubation induced apoptosis and autophagy in MDA-MB-231 cancer cells (Li et al., 2016). Kallistatin’s active site is essential for stimulating miR-34a and suppressing miR-21 and miR-203 synthesis in breast cancer cells (Li et al., 2016). Moreover, kallistatin via its heparin-binding site increased peroxisome proliferator-activated receptor γ (PPARγ) synthesis by inhibiting Wnt signaling in cancer cells (Li et al., 2016). In cultured colorectal cancer cells, kallistatin (SERPINA3K) induced apoptosis by activating the PPARγ-Fas-FasL signaling pathway (Yao et al., 2013). Therefore, kallistatin inhibits tumor progression, in part, by inducing cancer cell death through up-regulation of miR-34a and down-regulation of miR-21 and miR-203 synthesis, as well as preventing Wnt-mediated suppression of PPARγ signaling (Figure 2).
Oxidative stress
Kallistatin’s antioxidative effects
ROS stimulate inflammatory pathways and induce cellular apoptosis and senescence (Finkel and Holbrook, 2000; Chao et al., 2016). Reduced kallistatin levels are correlated with increased oxidative organ damage in animal models of hypertension, cardiovascular and renal damage (Shen et al., 2008, 2010a,b; Chao et al., 2016). Kallistatin administration attenuated superoxide formation, inflammation and organ damage associated with increased eNOS and NO levels in animal models of acute and chronic myocardial damage, and salt-induced hypertension (Gao et al., 2008; Shen et al., 2008, 2010a,b). Conversely, depletion of endogenous kallistatin by neutralizing antibody injection augmented cardiovascular and renal damage, increased oxidative stress, inflammation, endothelial cell loss and fibrosis in hypertensive rats (Liu et al., 2012). Kallistatin’s heparin-binding site is necessary for blocking TNF-α-induced NADPH oxidase activity and expression, and its active site is key for stimulating the expression levels of the antioxidant enzymes eNOS, SIRT1 and catalase in endothelial cells and EPCs (Shen et al., 2010a,b; Gao et al., 2014; Guo et al., 2015). Kallistatin, via NO formation, inhibited superoxide production and NAD(P)H oxidase activity induced by TNF-α, TGF-β, H2O2, or angiotensin II in cultured renal epithelial tubular and mesangial cells, cardiomyocytes, myofibroblasts, endothelial cells, and EPCs (Chao et al., 2006; Gao et al., 2008, 2014; Shen et al., 2008, 2009, 2010a,b; Yin et al., 2010; Zhou et al., 2012; Huang et al., 2014a,b; Guo et al., 2015). Likewise, kallistatin (SERPINA3K) exhibited antioxidant activity in cultured pterygium epithelial cells through inhibition of ROS formation (Zhu et al., 2014). Moreover, kallistatin inhibited liver fibrosis via antioxidative stress (Huang et al., 2014a,b). Collectively, kallistatin, via its two functional, elements protects against multi-organ damage through its antioxidative actions (Figure 3).

Double-edged role of kallistatin in oxidative stress.
Kallistatin’s pro-oxidative effects
Kallistatin induces vasodilation by H2O2 formation
Oxidative stress has both deleterious and beneficial actions. Besides its detrimental effects, ROS also function as a second messenger in intracellular signaling mechanisms that control cell function (Burgoyne et al., 2007). Indeed, H2O2 has been identified as an endothelium-derived hyperpolarizing factor in animals and humans (Matoba et al., 2000; Shimokawa and Morikawa, 2005). H2O2 promotes vasorelaxation by stimulating the dimerization of the redox sensing cGMP-dependent protein kinase (protein kinase G, PKG) isoform PKGIα (Hofmann et al., 2006; Burgoyne et al., 2007). NO, generated by eNOS, diffuses from endothelium to vascular smooth muscle to activate cytosolic guanylate cyclase and trigger cGMP production and PKGIα activation (Hofmann et al., 2006; Burgoyne et al., 2007; Hartzell, 2007). NO has also been shown to be involved in the endothelium-dependent relaxation induced by H2O2 (Zembowicz et al., 1993), and H2O2 up-regulates eNOS transcription and eNOS mRNA half-life (Drummond et al., 2000). Thus, H2O2-induced relaxation in the aorta has both endothelium-dependent and -independent components. Therefore, both H2O2 and NO induce vasodilation through activation of PKGIα.
Kallistatin is a potent vasodilator independent of the tissue kallikrein-kinin system (Chao et al., 1997). An intravenous bolus injection of purified kallistatin caused a rapid and transient reduction of blood pressure in both normotensive and hypertensive rats (Chao et al., 1997, 2016). Kallistatin’s active site is essential for its blood pressure-lowering effect, as wild-type kallistatin and heparin-binding site mutant kallistatin, but not active site mutant kallistatin, induced vasodilation (Chao et al., 2016). Moreover, administration of a NOS inhibitor (Nω-nitro-L-arginine methylester, L-NAME) blocked kallistatin-induced vasodilating activity, indicating an NO-mediated event (Chao et al., 2016). Indeed, kallistatin via its active site activates Akt-eNOS signaling, and thus NO formation, in endothelial cells and EPCs (Shen et al., 2010a,b; Gao et al., 2014; Guo et al., 2015). In addition, kallistatin-induced vasodilation is mediated by H2O2, as kallistatin’s blood pressure-lowering effect was abolished by the antioxidant enzyme catalase (Figure 4A). Furthermore, kallistatin time-dependently induced H2O2 formation in cultured endothelial and vascular smooth muscle cells (Figure 4B, C). Likewise, in isolated aortic segments, kallistatin increased H2O2 formation and PKGIα dimerization under non-reducing conditions (Figure 4D, E). Therefore, kallistatin via its active site induces vasodilation by generation of H2O2 and NO, and thus PKGIα activation in blood vessels (Figure 3). Kallistatin-induced oxidant formation is partly mediated by protein kinase C (PKC) activation, as time-dependent stimulation of H2O2 production by kallistatin in endothelial cells and vascular smooth muscle cells is blocked by chelerythrine, a PKC inhibitor (unpublished results). The signaling mechanisms of kallistatin’s pro-oxidative effect remain to be further elucidated.

Kallistatin induces vasodilation by H2O2 formation.
Kallistatin’s vasodilatory effect is partly mediated by H2O2 formation, as the effect is blocked by catalase (A). Kallistatin stimulates endogenous H2O2 formation in endothelial cells (B), and vascular smooth muscle cells (C). In isolated aorta, kallistatin induces H2O2 formation (D) and PKGIα dimerization (E). *p<0.05 compared to the control group.
Kallistatin induces bacterial killing by stimulating ROS formation
Oxidative stress has been shown to have beneficial effects with bacterial killing activity in inflammatory disorders (Babior, 2000; Splettstoesser and Schuff-Werner, 2002). Kallistatin treatment exhibited a marked bacterial killing effect and significantly promoted the survival of mice with streptococcal infection and polymicrobial sepsis (Lu et al., 2013; Li et al., 2014). The bactericidal activity of kallistatin is most likely attributed to elevated ROS formation in peritoneal neutrophils (Lu et al., 2013). Moreover, kallistatin significantly enhanced clearance of E. coli in conjunction with increased NADPH oxidase expression and activity in neutrophil-like HL-60 cells (Figure 5A–C). Thus, it is likely that kallistatin exerts bactericidal activity by stimulating ROS formation in the immune cells of mice with bacterial infection (Figure 3).

Kallistatin treatment reduces bacterial number, and increases NADPH oxidase expression and activity in neutrophil-like HL-60 cells.
*p<0.05 compared to the control group.
Conclusions
Kallistatin is an endogenous protein with dual roles in angiogenesis, apoptosis and oxidative stress. Kallistatin inhibits angiogenesis and tumor growth in animal models. Kallistatin, via its heparin-binding domain, inhibits angiogenesis by blocking VEGF-induced effects and TNF-α-induced VEGF synthesis, while its active site is crucial for stimulating neovascularization by increasing eNOS and VEGF levels. Moreover, kallistatin attenuates apoptosis and tissue injury in animal models with hypertension and cardiac dysfunction. Kallistatin, via its heparin-binding domain, antagonizes TNF-α-induced apoptosis in endothelial and renal cells, while its active site is crucial for inducing cancer cell apoptosis by stimulating miR-34a and inhibiting miR-21 and miR-203 synthesis. Furthermore, kallistatin attenuates oxidative stress and multi-organ injury in animal models. Kallistatin, via its heparin-binding site, antagonizes cytokine-induced superoxide formation, and its active site is responsible for the stimulation of antioxidant gene expression. In contrast, kallistatin stimulates vascular ROS formation, leading to vasodilation as well as marked bacterial killing activity in immune cells of septic mice. Kallistatin, with its double-edged actions in angiogenesis, apoptosis and oxidative stress, protects against the pathogenesis of hypertension, organ injury, septic syndrome and tumor progression. It has yet to be determined which biological function of kallistatin plays the dominant role in the pathogenesis of diseases. Although the beneficial properties of kallistatin therapy under pathological conditions have been demonstrated in various animal models, future studies are needed to confirm kallistatin’s salutary effects in humans. Collectively, these findings implicate kallistatin as an important player in keeping the balance of biological functions in the normal physiological setting.
Acknowledgements
Our work was supported by the National Institutes of Health grants HL118516 and HL44083.
Conflict of interest statement: The authors declare that they have no conflict of interest.
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©2017 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Reviews
- Regulation of protein function by S-nitrosation and S-glutathionylation: processes and targets in cardiovascular pathophysiology
- Cystine knot growth factors and their functionally versatile proregions
- Kallistatin: double-edged role in angiogenesis, apoptosis and oxidative stress
- Minireview
- The sphingomyelin synthase family: proteins, diseases, and inhibitors
- Research Articles/Short Communications
- Genes and Nucleic Acids
- Comparison of cytochrome P450 expression in four different human osteoblast models
- Cell Biology and Signaling
- The molecular mechanisms involved in lectin-induced human platelet aggregation
- HDAC1 triggers the proliferation and migration of breast cancer cells via upregulation of interleukin-8
- Heat shock protein 47 effects on hepatic stellate cell-associated receptors in hepatic fibrosis of Schistosoma japonicum-infected mice
Articles in the same Issue
- Frontmatter
- Reviews
- Regulation of protein function by S-nitrosation and S-glutathionylation: processes and targets in cardiovascular pathophysiology
- Cystine knot growth factors and their functionally versatile proregions
- Kallistatin: double-edged role in angiogenesis, apoptosis and oxidative stress
- Minireview
- The sphingomyelin synthase family: proteins, diseases, and inhibitors
- Research Articles/Short Communications
- Genes and Nucleic Acids
- Comparison of cytochrome P450 expression in four different human osteoblast models
- Cell Biology and Signaling
- The molecular mechanisms involved in lectin-induced human platelet aggregation
- HDAC1 triggers the proliferation and migration of breast cancer cells via upregulation of interleukin-8
- Heat shock protein 47 effects on hepatic stellate cell-associated receptors in hepatic fibrosis of Schistosoma japonicum-infected mice