Under normoxic conditions, inhibition of the asparagine hydroxylase factor hypoxia-1 transactivates the HIF-α of the conserved asparagine residues hydroxylated and interacts with P300 to ultimately repress HIF-induced transcription. HIF-3 α is thought to work by interacting with HIF-1 α competitive binding to inhibit HIF-1 α and HIF-2 β function
[29][28]. Among these enzymes, PHD2 exerts major physiological functions. HIF-α is ubiquitinated and degraded by the ubiquitin protease tumor suppressor protein, resulting in reduced intracellular HIF levels, and, at the same time, a hypoxic environment can cause HIF-α levels to become elevated and associated with those in the nucleus β subunits undergoing dimerization
[30,31,32][29][30][31]. Thereby,
wresearche
rs can explore therapies for related diseases, such as ischemia, cancer, diabetes, stroke, infection, wound healing, and heart failure, by targeting the oxygen-sensing pathway.
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2.2.2. Effect of Hypoxia on Bone Function
In the past few years, several authors have studied the effect of low oxygen concentrations on cell growth in different cell models, such as rat bone marrow-derived mesenchymal stem cells and mouse fibroblasts, respectively
[33,34][32][33]. D’ippolito et al.
[35][34] demonstrated that low oxygen concentrations (1%, 3%, 5%, and 10% O
2) increase cell proliferation. At 3% O
2, the cells have the most suitable growth environment. In addition, the low partial pressure of oxygen inhibits osteoblast differentiation, indicating that a low partial pressure environment is one of the essential conditions for cell culture, while illustrating that low partial pressure of oxygen is essential for maintaining mesenchymal stem cells in a poorly differentiated state. Moreover, Lennon et al.
[34][33] reported that rat bone marrow stromal cells showed increased extracellular mineralization in cultures maintained at low PO
2 compared to normoxic conditions. In addition, in several in vitro studies, low oxygen concentrations have been found to stimulate the differentiation process, inducing the cells to progress towards osteogenic, adipogenic, or chondrogenic lineages
[36,37][35][36]. From this
wresearche
rs can determine that cell differentiation and survival can be affected by different partial pressures of oxygen.
The effects of hypoxic environments on bone metabolism and development are complex, mainly through HIFs and pathways related to osteoblasts and osteoclasts, and differ with time and oxygen concentration. Hypoxia can promote osteoblast generation and differentiation
[38,39][37][38]. Short-term hypoxia may promote the early proliferation and differentiation of osteoblasts, while long-term hypoxia may inhibit their proliferation and differentiation. Under a hypoxic environment, HIF stimulates osteoclasts mainly through acidification, whereas it increases bone resorption capacity
[15,26,40][13][24][39]. Hypoxia can lead to osteoclast formation and depends on the duration of hypoxia. Increased anaerobic metabolism and accumulation of acidic metabolites in hypoxia can cause mild acidification of the local microenvironment, and osteoclast activation is precisely dependent on extracellular acidification. Osteoclasts increase in number, volume, and bone resorption capacity, with the greatest effect occurring at 2% O
2 [41,42][40][41].
Hypoxia simultaneously controls many activities of osteogenesis, including angiogenesis, bone repair, osteoblast function, metabolism, and the size and activity of osteoclasts. In particular, the HIF signaling pathway plays an important role in bone formation during fracture repair. Conditional deletion of HIF-1 or HIF-2 in osteoblasts results in a significant reduction in bone volume, whereas HIF-1 and HIF-2 are over-stabilized by the loss of VHL, leading to increased bone mass and thus changes in bone volume
[43,44,45][42][43][44].
In addition to regulating organogenesis and development, hypoxia also plays an important role in maintaining tissue homeostasis. In mature bone tissue, the HIF signaling pathway is involved in the stabilization of the intraosseous environment. This pathway regulates osteoblast-to-osteoclast crosstalk and becomes an important mechanism in medical or pathological bone remodeling processes, such as odontoplasty and osteoporosis. In odontoplasty, driven by forces, mature bone undergoes coordinated tissue resorption and formation. HIF signaling is involved in the coordinated differentiation of osteoblasts and osteoclasts
[46,47,48][45][46][47]. During orthodontic loading, pressure-induced local hypoxia contributes to the stabilization of HIF-1, up-regulates the expression of vascular endothelial growth factor and RANKL in osteoblasts, and promotes osteoclast differentiation
[11,29,49][28][48][49]. RANKL from osteoblasts interacts with the osteoclast precursor RANK, promoting osteoclast activation, whereas OPG (osteoclast inhibitory factor or osteoprotegerin) inhibits osteoclast differentiation. HIF promotes osteoblast-mediated osteoclastogenesis in bone homeostasis by inducing OPG expression, which prevents the resorptive activity of osteoclasts
[50,51,52][50][51][52].
In a hypoxic environment, the pathway involved in bone metabolism changes, affecting the maturation and differentiation of osteoblasts/osteoclasts. For osteoblasts, hypoxia mainly occurs at the early stage of their differentiation. Hypoxia promotes the early differentiation of osteoblasts and generates corresponding signals to stimulate the maturation and mineralization of the matrix
[3,15,53,54][3][13][53][54]. Short-term hypoxia through up-regulation of HIF-1 α promotes matrix mineralization, promotes osteoblast differentiation and maturation, and accelerates osteogenesis. For osteoclasts, hypoxia can increase the production of osteoclasts, which has nothing to do with the differentiation stage of hypoxia, but the duration and severity of hypoxia may affect the differentiation of osteoclasts. During hypoxia, the anaerobic metabolism dominates and acid metabolites accumulate, leading to local mild acidosis. Existing studies have found that the severity and duration of tissue exposure to hypoxia and the stage of osteoblast differentiation in which hypoxia occurs may affect the growth and reconstruction of bone
[5,55,56,57][5][55][56][57].
The HIF signaling pathway enhances bone formation and bone immunity by regulating immune cell activity, important pathways, and important secretory molecules. Bone immunology includes the molecular and cellular interactions between osteoblasts, osteoclasts, lymphocytes, and hematopoietic cells
[58,59,60][58][59][60].
In 2012, Dandajena et al. demonstrated that peripheral blood mononuclear cells co-cultured with osteoblasts can obtain functional osteoclasts by triggering HIF-mediated differentiation. In the pathogenesis of bone- or cartilage-erosive diseases, such as periodontitis and rheumatoid arthritis, HIF-1α plays an important role in synovitis and osteoclast formation of macrophages or monocytes. The formation of osteoclasts may be related to the stimulation of RANKL. Inhibition of HIF-1 α reduces osteoclast production by down-regulating the RANK/RANKL/OPG signaling pathway. The RANK/RANKL/OPG signaling pathway is one of the most classical signal pathways in bone immunology, and it plays an important role in immune organs and bone development
[14,15,31,61][12][13][30][61].
The HIF-1 signaling pathway is closely related to the RANK/RANKL/OPG signaling pathway because it activates HIF-1 α and up-regulates the expression of RANK and RANKL. In addition, the involvement of the HIF-1 signaling pathway in bone immunology is believed to lead to B lymphocytes, IL-1 β, and S1P-S1PR1 signal pathway regulation
[29,62,63][28][62][63].
2.2.3. Hypoxia and Bone-Related Diseases
The reason for hypoxia caused by solid tumors is blood flow obstruction
[10,29,64][10][28][64]. Increasing amounts of evidence show that hypoxia enhances the malignant phenotype of cancer cells by promoting angiogenesis, epithelial–mesenchymal transition (EMT), invasion, tumor stem-cell-like phenotype, tumor cell dormancy, and release of extracellular vesicles (EV). Most of them are HIF-dependent. HIF also plays a major regulatory role in angiogenesis, which is important in tumor metastasis
[11,29,65][28][48][65].
Bone defect refers to the damage to the integrity of bone structure caused by local bone deficiency due to congenital malformation, trauma, inflammation, tumor, and iatrogenic surgical treatment. Generally speaking, defects of limited scale can repair themselves by osteogenesis. HIFs play a key role in promoting acquired pathological ectopic osteogenesis; there may be similar oxygen sensing and action mechanisms that affect the final osteogenic effect by affecting the key cell activity and cytokine secretion.
Additionally, hypoxia is an indispensable factor in inducing angiogenesis. At the cellular level, hypoxia inhibits ATP consumption during metabolism, resulting in abnormal cell behavior. HIFs can regulate the expression of many important genes, which are essential for cell survival, angiogenesis, glycolysis, proliferation, and migration
[31,66][30][66]. HIF is also a key factor to control the function of immune cells and plays an important role in inflammatory reaction.
Osteoporosis occurs when the balance between bone resorption and bone formation is disrupted during bone metabolism, resulting in bone loss and altered bone tissue architecture. In this process, osteoblasts and osteoclasts play a particularly important role. Under the condition of hypoxia, the growth and differentiation of osteoblasts is delayed and the mineralization of the bone matrix is inhibited, thus limiting the overall bone formation. Osteoblasts respond to the hypoxic environment, release adenosine triphosphate (ATP), inhibit bone formation, and stimulate osteoclasts, resulting in an increase in the number and activity of osteoclasts
[23][21].
Hypoxia and hypoxic pathway proteins are influential for stromal cells in the bone/bone marrow environment. They directly regulate bone homeostasis, causing osteolytic damage, leading to the destruction of the normal structure of bone, resorption and loss of bone mass, and ultimately the occurrence of osteoporosis.