Endothelin B receptor inhibition rescues aging-dependent neuronal regenerative decline

Reviewer #1 (Public Review):

The manuscript by Feng et al. reported that the Endothelin B receptor (ETBR) expressed by the satellite glial cells (SGCs) in the dorsal root ganglions (DRG) acted to inhibit sensory axon regeneration in both adult and aged mice. Thus, pharmacological inhibition of ETBR with specific inhibitors resulted in enhanced sensory axon regeneration in vitro and in vivo. In addition, sensory axon regeneration significantly reduces in aged mice and inhibition of ETBR could restore such defect in aged mice. Moreover, the study provided some evidence that the reduced level of gap junction protein connexin 43 might act downstream of ETBR to suppress axon regeneration in aged mice. Overall, the study revealed an interesting SGC-derived signal in the DRG microenvironment to regulate sensory axon regeneration. It provided additional evidence that non-neuronal cell types in the microenvironment function to regulate axon regeneration via cell-cell interaction.

However, the molecular mechanisms by which ETBR regulates axon regeneration are unclear, and the manuscript's structure is not well organized, especially in the last section. Some discussion and explanation about the data interpretation are needed to improve the manuscript.

(1) The result showed that the level of ETBR did not change after the peripheral nerve injury. Does this mean that its endogenous function is to limit spontaneous sensory axon regeneration? In other words, the results suggest that SGCs expressing ETBR or vascular endothelial cells expressing its ligand ET-1 act to suppress sensory axon regeneration. Some explanation or discussion about this is necessary. Moreover, does the protein level of ETBR or its ligand change during aging?

(2) In ex vivo experiments, NGF was added to the culture medium. Previous studies have shown that adult sensory neurons could initiate fast axon growth in response to NGF within 24 hours. In addition, dissociated sensory neurons could also initiate spontaneous regenerative axon growth without NGF after 48 hours. Some discussion or rationale is needed to explain the difference between NGF-induced or spontaneous axon growth of culture adult sensory neurons and the roles of ETBR and SGCs.

(3) In cultured dissociated sensory neurons, inhibiting ETBR also enhanced axon growth, which meant the presence of SGCs surrounding the sensory neurons. Some direct evidence is needed to show the cellular relationship between them in culture.

(4) In Figure 3, the in vivo regeneration experiments first showed enhanced axon regeneration either 1 day or 3 days after the nerve injury. The study then showed that inhibiting ETBR could enhance sensory axon growth in vitro from uninjured naïve neurons or conditioning lesioned neurons. To my knowledge, in vivo sensory axon regeneration is relatively slow during the first 2 days after the nerve injury and then enters the fast regeneration mode on the 3rd day, representing the conditioning lesion effect in vivo. Some discussion is needed to compare the in vitro and the in vivo model of axon regeneration.

(5) In Figure 5, the study showed that the level of connexin 43 increased after ETBR inhibition in either adult or aged mice, proposing an important role of connexin 43 in mediating the enhancing effect of ETBR inhibition on axon regeneration. However, in the study, there was no direct evidence supporting that ETBR directly regulates connexin 43 expression in SGCs. Moreover, there was no functional evidence that connexin 43 acted downstream of ETBR to regulate axon regeneration.

Reviewer #2 (Public Review):

Summary:

In this interesting and original study, Feng and colleagues set out to address the effect of manipulating endothelin signaling on nerve regeneration, focusing on the crosstalk between endothelial cells (ECs) in dorsal root ganglia (DRG), which secrete ET-1 and satellite glial cells (SGCs) expressing ETBR receptor. The main finding is that ETBR signaling is a default brake on axon growth, and inhibiting this pathway promotes axon regeneration after nerve injury and counters the decline in regenerative capacity that occurs during aging. ET-1 and ETBR are mapped in ECs and SGCs, respectively, using scRNA-seq of DRGs from adult or aged mice. Although their expression does not change upon injury, it is modulated during aging, with a reported increase in plasma levels of ET-1 (a potent vasoconstrictive signal). Using in vitro explant assays coupled with pharmacological inhibition in mouse models of nerve injury, the authors demonstrate that ET-1/ETBR curbs axonal growth, and the ETAR/ETBR antagonist Bosentan boosts regrowth during the early phase of repair. In addition, Bosentan restores the ability of aged DRG neurons to regrow after nerve lesions. Despite Bosentan inhibiting both endothelin receptors A and B, comparison with an ETAR-specific antagonist indicates that the effects can be attributed to the ET-1/ETBR pathway. In the DRGs, ETBR is mostly expressed by SGCs (and a subset of Schwann cells) a cell type that previous studies, including work from this group, have implicated in nerve regeneration. SGCs ensheath and couple with DRG neurons through gap junctions formed by Cx43. Based on their own findings and evidence from the literature, the pro-regenerative effects of ETBR inhibition are in part attributed to an increase in Cx43 levels, which are expected to enhance neuron-SGC coupling. Finally, gene expression analysis in adult vs aged DRGs predicts a decrease in fatty acid and cholesterol metabolism, for which previous work by the authors has shown a requirement in SGCs to promote axon regeneration.

Strengths:

The study is well-executed and the main conclusion that "ETBR signaling inhibits axon regeneration after nerve injury and plays a role in age-related decline in regenerative capacity" (line 77) is supported by the data. Given that Bosentan is an FDA-approved drug, the findings may have therapeutic value in clinical settings where peripheral nerve regeneration is suboptimal or largely impaired, as it often happens in aged individuals. In addition, the study highlights the importance of vascular signals in nerve regeneration, a topic that has gained traction in recent years. Importantly, these results further emphasize the contribution of long-neglected SGCs to nerve tissue homeostasis and repair. Although the study does not reach a complete mechanistic understanding, the results are robust and are expected to attract the interest of a broader readership.

Weaknesses:

Despite these positive comments provided above, the following points should be considered:

(1) This study examines the contribution of the ET-1 pathway in the ganglia, and in vitro assays are consistent with the idea that important signaling events take place there. Nevertheless, it remains to be determined whether the accelerated axon regrowth observed in vivo depends also on cellular crosstalk mediated by ET-1 at the lesion site. Are ECs along the nerve secreting ET-1? What cells are present in the nerve stroma that could respond and participate in the repair process? Would these interactions be sensitive to Bosentan? It may be difficult to dissect this contribution, but it should at least be discussed.

(2) It is suggested that the permeability of DRG vessels may facilitate the release of "vascular-derived signals" (lines 82-84). Is it possible that the ET-1/ETBR pathway modulates vascular permeability, and that this, in turn, contributes to the observed effects on regeneration?

(3) Is the affinity of ET-3 for ETBR similar to that of ET-1? Can it be excluded that ET-3 expressed by fibroblasts is relevant for controlling SGC responses upon injury/aging?

(4) ETBR inhibition in dissociated (mixed) cultures uncovers the restraining activity of endothelin signaling on axon growth (Figure 2C). Since neurons do not express ET-1 receptors, based on scRNA-seq analysis, these results are interpreted as an indication that basal ETBR signaling in SGC curbs the axon growth potential of sensory neurons. For this to occur in dissociated cultures, however, one should assume that SGC-neuron association is present, similar to in vivo, or to whole DRG cultures (Figure 2C). Has this been tested? In both in vitro experimental settings (dissociated and whole DRG cultures) how is ETBR stimulated over up to 7 days of culture? In other words, where does endothelin come from in these cultures (which are unlikely to support EC/blood vessel growth)? Is it possible that the relevant ligand here derives from fibroblasts (see point #6)? Or does it suggest that ETBR can be constitutively active (i.e., endothelin-independent signaling)? Is there any chance that endothelin is present in the culture media or Matrigel?

(5) The discovery that ET-1/ETBR signaling in SGC curtails the growth capacity of axons at baseline raises questions about the physiological role of this pathway. What happens when ETBR signaling is prevented over a longer period of time? This could be addressed with pharmacological inhibitors, or better, with cell-specific knock-out mice. The experiments would certainly be of general interest, although not within the scope of this story. Nevertheless, it could be worth discussing the possibilities.

(6) Assessing Cx43 levels by measuring the immunofluorescence signal (Figure 5E-F) is acceptable, particularly when the aim is to restrict the analysis to SGCs. The modulation of Cx43 expression by ET-1/ETBR plays an important part in the proposed model. Therefore, a complementary analysis of Cx43 expression by quantitative RT-PCR on sorted SGCs would be a valuable addition to the immunofluorescence data. Is this attainable?

(7) The conclusions "We thus hypothesize that ETBR inhibition in SGCs contributes to axonal regeneration by increasing Cx43 levels, gap junction coupling or hemichannels and facilitating SGC-neuron communication" (lines 303-305) are consistent with the findings but seem in contrast with the effect of aging on gap junction coupling reported by others and cited in line 210: "the number of gap junctions and the dye coupling between these cells increases (Huang et al., 2006)". I am confused by what distinguishes a potential, and supposedly beneficial, increase in coupling after ETBR inhibition, from what is observed in aging.

(8) I find it difficult to reconcile the results in Figure 5F with the proposed model since (1) injury increases Cx43 levels in both adult and aged mice, (2) the injured aged/vehicle group has a similar level to the uninjured adult group, (3) upon injury, aged+Bosentan is much lower than adult+Bosentan (significance not tested). It seems hard to explain the effect of Bosentan only through the modulation of Cx43 levels. Whether the increase in Cx43 levels following ETBR inhibition actually results in higher SGC-neuron coupling has not been assessed experimentally.

Reviewer #3 (Public Review):

Summary:

This manuscript suggests that inhibiting ETBR via the FDA-approved compound Bosentan can disrupt ET-1-ETBR signalling that they found detrimental to nerve regeneration, thus promoting repair after nerve injury in adult and aged mice.

Strengths:

(1) The clinical need to identify molecular and cellular mechanisms that can be targeted to improve repair after nerve injury.

(2) The proposed mechanism is interesting.

(3) The methodology is sound.

Weaknesses:

(1) The data appear preliminary and the story appears incomplete.

(2) Lack of causality and clear cellular and molecular mechanism. There are also some loose ends such as the role of connexin 43 in SGCs: how is it related to ET-1- ETBR signalling?