ROCK and Rho

Idiopathic pulmonary fibrosis (IPF) is a progressive and usually fatal fibrotic disease of the distal lung alveolar gas exchange units.1King Jr., T.E. Pardo A. Selman M. Idiopathic pulmonary fibrosis.Lancet. 2011; 378: 1949-1961Abstract Full Text Full Text PDF PubMed Scopus (1376) Google Scholar IPF is typically diagnosed in older individuals, after the disease is well established. IPF patients experience progressive shortness of breath, reduced quality of life, and a median survival of only 2 to 3 years after diagnosis.2King Jr., T.E. Tooze J.A. Schwarz M.I. Brown K.R. Cherniack R.M. Predicting survival in idiopathic pulmonary fibrosis: scoring system and survival model.Am J Respir Crit Care Med. 2001; 164: 1171-1181Crossref PubMed Scopus (749) Google Scholar The disease burden is significant considering that the prevalence of disease in the United States is estimated to be between 14 and 42.7 cases per 100,000 individuals3Raghu G. Weycker D. Edelsberg J. Bradford W.Z. Oster G. Incidence and prevalence of idiopathic pulmonary fibrosis.Am J Respir Crit Care Med. 2006; 174: 810-816Crossref PubMed Scopus (1008) Google Scholar and rising.4Gribbin J. Hubbard R.B. Le Jeune I. Smith C.J. West J. Tata L.J. Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK.Thorax. 2006; 61: 980-985Crossref PubMed Scopus (452) Google Scholar Until the recent US Food and Drug Administration approval of pirfenidone and nintedanib, there were no effective therapies.5Richeldi L. du Bois R.M. Raghu G. Azuma A. Brown K.K. Costabel U. Cottin V. Flaherty K.R. Hansell D.M. Inoue Y. Kim D.S. Kolb M. Nicholson A.G. Noble P.W. Selman M. Taniguchi H. Brun M. Le Maulf F. Girard M. Stowasser S. Schlenker-Herceg R. Disse B. Collard H.R. INPULSIS Trial InvestigatorsEfficacy and safety of nintedanib in idiopathic pulmonary fibrosis.N Engl J Med. 2014; 370: 2071-2082Crossref PubMed Scopus (2824) Google Scholar, 6King Jr., T.E. Bradford W.Z. Castro-Bernardini S. Fagan E.A. Glaspole I. Glassberg M.K. Gorina E. Hopkins P.M. Kardatzke D. Lancaster L. Lederer D.J. Nathan S.D. Pereira C.A. Sahn S.A. Sussman R. Swigris J.J. Noble P.W. ASCEND Study GroupA phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis.N Engl J Med. 2014; 370: 2083-2092Crossref PubMed Scopus (2514) Google Scholar However, despite these recent breakthroughs, the outlook for IPF patients remains bleak, and there continues to be an urgent need for new therapies to impede disease progression and, more desirably, reverse established fibrosis. IPF is thought to develop in response to extensive and repetitive injury to the alveolar epithelial cells, resulting in apoptosis and the development of an abnormal repair response.7Noble P.W. Idiopathic pulmonary fibrosis: natural history and prognosis.Clin Chest Med. 2006; 27: S11-S16Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar As is typical of wound repair in other sites, such as the skin, resident fibroblasts and myofibroblast progenitors proliferate and migrate to the injured lung parenchyma. In the transforming growth factor (TGF)-β–rich profibrotic microenvironment of the alveoli and interstitium, fibroblasts and myofibroblast progenitors express contractile proteins, such as α smooth muscle actin (α-SMA), ramp up production of extracellular matrix (ECM) proteins,8Kuhn 3rd, C. Boldt J. King Jr., T.E. Crouch E. Vartio T. McDonald J.A. An immunohistochemical study of architectural remodeling and connective tissue synthesis in pulmonary fibrosis.Am Rev Respir Dis. 1989; 140: 1693-1703Crossref PubMed Scopus (378) Google Scholar, 9Hoyles R.K. Derrett-Smith E.C. Khan K. Shiwen X. Howat S.L. Wells A.U. Abraham D.J. Denton C.P. An essential role for resident fibroblasts in experimental lung fibrosis is defined by lineage-specific deletion of high-affinity type II transforming growth factor beta receptor.Am J Respir Crit Care Med. 2011; 183: 249-261Crossref PubMed Scopus (93) Google Scholar and acquire a canonical myofibroblast phenotype. However, unlike normal resolving wound repair, in which myofibroblasts contract the newly synthesized provisional matrix, undergo apoptosis, and are cleared from the wound once repair is complete, lung myofibroblasts develop resistance to apoptosis induction, continue to produce excessive amounts of fibrotic ECM, and maintain their contractile properties in the lungs of IPF patients.10Gabbiani G. The myofibroblast in wound healing and fibrocontractive diseases.J Pathol. 2003; 200: 500-503Crossref PubMed Scopus (1270) Google Scholar Thus, a full understanding of the molecular mechanisms that control fibroblast–myofibroblast differentiation and their acquired resistance to apoptosis is essential to develop therapeutic approaches to reduce lung myofibroblast numbers, excessive ECM production, and tissue contraction in IPF patients. Studies reported by Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar in this issue of The American Journal of Pathology expand current insights into the mechanisms that control fibroblast–myofibroblast differentiation and their resistance to apoptosis induction in IPF. As illustrated in Figure 1, fibroblast–myofibroblast differentiation can be initiated by a cadre of quintessential profibrotic molecules, including TGF-β, lysophosphatidic acid, thrombin, plasminogen activator inhibitor-1, and mechanotransductive sensing of the increasing stiffness of fibrotic ECM.12Scotton C.J. Chambers R.C. Molecular targets in pulmonary fibrosis: the myofibroblast in focus.Chest. 2007; 132: 1311-1321Abstract Full Text Full Text PDF PubMed Scopus (444) Google Scholar, 13Liu F. Mih J.D. Shea B.S. Kho A.T. Sharif A.S. Tager A.M. Tschumperlin D.J. Feedback amplification of fibrosis through matrix stiffening and COX-2 suppression.J Cell Biol. 2010; 190: 693-706Crossref PubMed Scopus (522) Google Scholar Many of these molecules initiate fibroblast–myofibroblast differentiation by stimulating GTP loading of Rho family GTPases, especially RhoA, which activates the downstream Rho-associated coiled-coil-containing protein kinases (ROCK)-1 and -2.14Schofield A.V. Bernard O. Rho-associated coiled-coil kinase (ROCK) signaling and disease.Crit Rev Biochem Mol Biol. 2013; 48: 301-316Crossref PubMed Scopus (146) Google Scholar These homologous serine/threonine kinases phosphorylate multiple downstream substrates, including myosin light-chain phosphatase, that permit myosin light-chain phosphorylation, facilitating the polymerization of globular G-actin into filamentous F-actin and initiating the assembly of the actomyosin contractile machinery. Myocardin-related transcription factors (MRTFs) A and B (alias megakaryoblastic leukemia factors 1 and 2) are transcriptional coactivators that, when constitutively bound to G-actin, remain sequestered in the cytoplasm and transcriptionally inactive. During ROCK-1/2–dependent F-actin assembly, MRTFs dissociate from G-actin, translocate to the nucleus, and coactivate serum response factor–mediated transcription of fibronectin, procollagen 1, and other ECM genes.15Luchsinger L.L. Patenaude C.A. Smith B.D. Layne M.D. Myocardin-related transcription factor-A complexes activate type I collagen expression in lung fibroblasts.J Biol Chem. 2011; 286: 44116-44125Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar Nuclear translocation of MRTF-A also promotes the expression of α-SMA and antiapoptotic proteins B cell lymphoma 2 (Bcl-2) and X-linked inhibitor of apotosis (XIAP), thereby enhancing contractile potential and promoting myofibroblast resistance to apoptosis.16Zhou Y. Huang X. Hecker L. Kurundkar D. Kurundkar A. Liu H. Jin T.H. Desai L. Bernard K. Thannickal V.J. Inhibition of mechanosensitive signaling in myofibroblasts ameliorates experimental pulmonary fibrosis.J Clin Invest. 2013; 123: 1096-1108Crossref PubMed Scopus (318) Google Scholar In vivo studies in a mouse model of pulmonary fibrosis have validated the importance of these collective findings by showing that the development of pulmonary fibrosis is impaired in mice that have been prophylactically treated with the ROCK inhibitors Y27632 or fasudil before bleomycin instillation.16Zhou Y. Huang X. Hecker L. Kurundkar D. Kurundkar A. Liu H. Jin T.H. Desai L. Bernard K. Thannickal V.J. Inhibition of mechanosensitive signaling in myofibroblasts ameliorates experimental pulmonary fibrosis.J Clin Invest. 2013; 123: 1096-1108Crossref PubMed Scopus (318) Google Scholar, 17Jiang C. Huang H. Liu J. Wang Y. Lu Z. Xu Z. Fasudil, a rho-kinase inhibitor, attenuates bleomycin-induced pulmonary fibrosis in mice.Int J Mol Sci. 2012; 13: 8293-8307Crossref PubMed Scopus (74) Google Scholar, 18Shimizu Y. Dobashi K. Iizuka K. Horie T. Suzuki K. Tukagoshi H. Nakazawa T. Nakazato Y. Mori M. Contribution of small GTPase Rho and its target protein rock in a murine model of lung fibrosis.Am J Respir Crit Care Med. 2001; 163: 210-217Crossref PubMed Scopus (100) Google Scholar The development of pulmonary fibrosis is also impaired in MRTF-deficient mice.16Zhou Y. Huang X. Hecker L. Kurundkar D. Kurundkar A. Liu H. Jin T.H. Desai L. Bernard K. Thannickal V.J. Inhibition of mechanosensitive signaling in myofibroblasts ameliorates experimental pulmonary fibrosis.J Clin Invest. 2013; 123: 1096-1108Crossref PubMed Scopus (318) Google Scholar Thus, components of the Rho-ROCK-MRTF signaling pathway are legitimate therapeutic targets that, when blocked, inhibit the development of pulmonary fibrosis and accelerate its resolution. Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar build on the concept of therapeutically targeting the Rho-ROCK-MRTF signaling pathway to treat fibrotic lung disease. After its release from G-actin during ROCK-1/2–dependent F-actin assembly, MRTF-A is translocated from the cytoplasm into the nucleus through the activity of the importin nuclear translocator.19Pawłowski R. Rajakylä E.K. Vartiainen M.K. Treisman R. An actin-regulated importin alpha/beta-dependent extended bipartite NLS directs nuclear import of MRTF-A.EMBO J. 2010; 29: 3448-3458Crossref PubMed Scopus (95) Google Scholar Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar hypothesized that reducing nuclear import of MRTF-A would impair the expression of several profibrotic and antiapoptotic genes that are involved in the development and maintenance of fibrosis. Using a high-throughput screen to discover candidate small molecule inhibitors of serum response factor/MRTF transcriptional activity, they identified CCG-203971. Their initial studies showed that CCG-203971 reduced TGF-β–induced MRTF-A nuclear translocation and suppressed TGF-β–induced expression of α-SMA and fibronectin in human fibroblast cell lines. These findings provided impetus to determine the effect of CCG-203971 in experimental models of pulmonary fibrosis in mice. Intratracheal instillation of bleomycin has been widely used to study the mechanisms involved in the development of pulmonary fibrosis. The bleomycin model is characterized by an initial inflammatory acute lung injury peaking at day 7 and associated with extensive alveolar epithelial cell apoptosis. This phase is then replaced by a postinflammatory fibrotic phase, peaking at 14 to 21 days, and associated with fibroblast–myofibroblast differentiation and the expression of increased profibrotic gene signatures. Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar investigated the effect of CCG-203971 on the fibrotic phase by initiating treatment with CCG-203971 at day 11. The treatment with CCG-203971 reduced the amount of lung fibrosis at day 21 and resulted in an improvement in lung architecture, indicating resolution of pre-existing fibrosis. They also tested CCG-203971 in a second fibrotic model involving targeted induction of apoptosis in alveolar type II cells that results in mild fibrosis lacking the characteristic inflammatory response of the bleomycin model. CCG-203971 reduced the fibrotic response in this alternative model as well, suggesting that the initial findings in bleomycin-instilled mice were not model specific. To gain further mechanistic insight into the antifibrotic action of CCG-203971, the number of apoptotic myofibroblasts were quantified by evaluating terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)/α-SMA double-positive cells in the bleomycin-induced fibrotic lesions. Consistent with the literature, the fibrotic lungs of bleomycin-instilled mice contained predictably few apoptotic myofibroblasts. However, inhibition of MRTF-A nuclear translocation in CCG-203971–treated fibrotic mice resulted in increased numbers of TUNEL/α-SMA–positive myofibroblasts, suggesting that the compound may also be promoting myofibroblast apoptosis. This result is similar to observations made after ROCK inhibition with fasudil,16Zhou Y. Huang X. Hecker L. Kurundkar D. Kurundkar A. Liu H. Jin T.H. Desai L. Bernard K. Thannickal V.J. Inhibition of mechanosensitive signaling in myofibroblasts ameliorates experimental pulmonary fibrosis.J Clin Invest. 2013; 123: 1096-1108Crossref PubMed Scopus (318) Google Scholar suggesting a similar mechanism of action in vivo after the upstream blockade of the Rho-ROCK-MRTF pathway. Taken together, the in vivo studies reported by Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar suggest that inhibition of the nuclear import of the MRTF-A by CCG-203971 promotes the resolution of established pulmonary fibrosis, at least in part, by reducing the profibrotic phenotype of myofibroblasts and by promoting their apoptosis. Although little is known about the receptors, ligands, and other processes that promote fibroblast apoptosis during the resolution of wound repair in vivo, there are strong implications that the death receptor Fas may be involved. Mice with inactivating mutations in FasL have been observed to develop a mild fibroproliferative interstitial pneumonia that is similar to some forms of rheumatoid arthritis–associated interstitial lung disease.20Sunderrajan E.V. McKenzie W.N. Lieske T.R. Kavanaugh J.L. Braun S.R. Walker S.E. Pulmonary inflammation in autoimmune MRL/Mp-lpr/lpr mice. Histopathology and bronchoalveolar lavage evaluation.Am J Pathol. 1986; 124: 353-362PubMed Google Scholar Furthermore, lung fibroblasts isolated from the fibrotic lungs of bleomycin-induced wild-type mice and primary cultures of lung fibroblasts from IPF patients have uniformly been found to be resistant to Fas-induced apoptosis.21Frankel S.K. Cosgrove G.P. Cha S.I. Cool C.D. Wynes M.W. Edelman B.L. Brown K.K. Riches D.W. TNF-alpha sensitizes normal and fibrotic human lung fibroblasts to Fas-induced apoptosis.Am J Respir Cell Mol Biol. 2006; 34: 293-304Crossref PubMed Scopus (62) Google Scholar, 22Golan-Gerstl R. Wallach-Dayan S.B. Zisman P. Cardoso W.V. Goldstein R.H. Breuer R. Cellular FLICE-like inhibitory protein deviates myofibroblast fas-induced apoptosis toward proliferation during lung fibrosis.Am J Respir Cell Mol Biol. 2012; 47: 271-279Crossref PubMed Scopus (37) Google Scholar With these findings in mind, Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar next investigated the effect of CCG-203971 on Fas-induced lung fibroblast apoptosis. The authors had previously shown that fibroblasts incubated in the presence of TGF-β were protected from Fas-induced apoptosis through a mechanism that involved increased expression of the broad-acting caspase-inhibitor protein, XIAP.23Ajayi I.O. Sisson T.H. Higgins P.D. Booth A.J. Sagana R.L. Huang S.K. White E.S. King J.E. Moore B.B. Horowitz J.C. X-linked inhibitor of apoptosis regulates lung fibroblast resistance to Fas-mediated apoptosis.Am J Respir Cell Mol Biol. 2013; 49: 86-95Crossref PubMed Scopus (52) Google Scholar In their current studies, Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar found that while treatment with CCG-203971 alone had no effect on lung fibroblast apoptosis, it sensitized the cells to Fas-induced apoptosis even in the presence of TGF-β. The ability of CCG-203971 to sensitize fibroblasts to Fas-induced apoptosis was similar in normal fibroblasts and IPF myofibroblasts. Thus, these in vitro studies identify a potential mechanism to account for the increased number of apoptotic myofibroblasts in the previously fibrotic lungs of CCG-203971–treated mice. In the setting of IPF, the data reported by Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar reveal important new insights into the mechanisms controlling lung myofibroblast and to apoptosis. they also Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar found that nuclear translocation with CCG-203971 sensitized myofibroblasts to apoptosis by reducing of the inhibitor, In Zhou et Y. Huang X. Hecker L. Kurundkar D. Kurundkar A. Liu H. Jin T.H. Desai L. Bernard K. Thannickal V.J. Inhibition of mechanosensitive signaling in myofibroblasts ameliorates experimental pulmonary fibrosis.J Clin Invest. 2013; 123: 1096-1108Crossref PubMed Scopus (318) Google Scholar found that the mechanism of apoptosis by the ROCK inhibitor fasudil involved of the antiapoptotic protein in a et R. Wallach-Dayan S.B. Zisman P. Cardoso W.V. Goldstein R.H. Breuer R. Cellular FLICE-like inhibitory protein deviates myofibroblast fas-induced apoptosis toward proliferation during lung fibrosis.Am J Respir Cell Mol Biol. 2012; 47: 271-279Crossref PubMed Scopus (37) Google Scholar that lung myofibroblast resistance to apoptosis is by an antiapoptotic mechanism involving increased Although it is that multiple antiapoptotic mechanisms may to the resistance of fibrotic lung myofibroblast to apoptosis, a of these mechanisms remains to be An issue that is the role of the death receptor Fas in myofibroblast apoptosis. In vitro studies, including the study by Sisson et T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar have shown that Fas an important role in promoting the apoptosis of sensitized primary lung myofibroblasts. However, little is known about the mechanisms that promote myofibroblast apoptosis in vivo or the role of Fas Fas in this understanding of the mechanisms involved in myofibroblast and in IPF has the remains to be about these cells and are in repair processes and in the setting of fibrotic of the lung and other In the findings reported in this issue of the by Sisson et al11Sisson T.H. Ajayi I.O. Subbotina N. Dodi A.E. Rodansky E.S. Chibucos L.N. Kim K.K. Keshamouni V.G. White E.S. Zhou Y. Higgins P.D.R. Larsen S.D. Neubig R.R. Horowitz J.C. Inhibition of MRTF/SRF signaling decreases lung fibrosis and promotes mesenchymal cell apoptosis.Am J Pathol. 2015; 185: 969-986Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar the importance of the Rho-ROCK-MRTF signaling pathway in myofibroblast in the setting of fibrotic lung disease. they identify CCG-203971, a small molecule therapeutic inhibitor of MRTF-A nuclear and that it sensitizes myofibroblasts to apoptosis, and the resolution of pulmonary fibrosis in an and to therapeutically target Rho-ROCK-MRTF signaling in IPF. and of their findings may be of to the control of fibrosis in other MRTF-A has also been in the development of and X. X. Y. X. Z. Wang F. L. J. of fibrotic in mice Rho-associated coiled-coil protein kinase J. 2012; PubMed Scopus Google Scholar, H. X. H. J. L. M. Xu Y. Myocardin-related transcription factor A regulates fibrosis in 2014; of Scholar Inhibition of and Cell American Journal of are to the of tissue fibrosis. Their of results in the release of transcription factor a transcriptional of serum response factor MRTF-A mice are protected from lung fibrosis. hypothesized that the pathway inhibitor CCG-203971 would myofibroblast in vitro and lung fibrosis in and idiopathic pulmonary fibrosis lung fibroblasts were treated CCG-203971 in the of transforming growth factor and apoptosis was PDF