The Emerging Roles of Ferroptosis in Pathophysiology and Treatment of Acute Lung Injury

Figures & data

Figure 1 The mechanisms of ferroptosis. Iron accumulation, excessive ROS production and overwhelming lipid peroxidation are hallmarks of ferroptosis. There are three main metabolic pathways that initiate and execute ferroptosis, amino-acid/GSH, lipid, and iron pathways. Moreover, ferroptosis sensitivity is also controlled by additional signaling pathways and regulators. Ferroptosis is illustrated here, demonstrating the key molecules and targets involved in regulating the peroxidation of iron and lipids.

Abbreviations: TF, transferrin; TFR1, transferrin receptor 1; ACSL4, acyl-CoA synthetase long-chain family member 4; LPCAT, lysophosphatidylcholine acyltransferase; FIN 56, Ferroptosis-Inducer-56; DMT1, divalent metal transporter 1; FPN1, ferroportin 1; GSH, glutathione; GSSG, oxidized glutathione; GSS, glutathione synthetase; GCL, glutamate-cysteine ligase; GPX4, glutathione peroxidase 4; HO-1, haem oxygenase 1; HSPB1, heat shock protein beta-1; LOX, lipoxygenase; NCOA4, nuclear receptor coactivator 4; NRF2, nuclear factor E2-related factor 2; PUFA, polyunsaturated fatty acid; PE, phosphatidylethanolamine; ROS, reactive oxygen species; RSL3, Ras-selective lethal 3; STEAP3, six-transmembrane epithelial antigen of prostate 3 metalloreductase; SLC7A11, solute carrier family 7 member 11; SLC3A2, solute carrier family 3 member 2; VDAC2/3, voltage dependent-anion channel 2/3.

Table 1 Common Ferroptosis Agonists, Antagonists and Their Regulatory Mechanisms

	Regulatory Mechanism	Representative Compound
Agonist	Inhibiting Xc-System	Sorafenib;^Citation34 erastin;^Citation35 HO-1;^Citation36 glutamate;^Citation37 deubiquitylase otub1;^Citation38 dihydroorotate dehydrogenase;^Citation39 etc.
	Inhibition/degradation of GPX 4	RSL3;^Citation40 acetaminophen;^Citation41 naringenin;^Citation42 etc.
	Others	FINO (2);^Citation43 statin;^Citation44 ammonium ferric citrate;^Citation45 artesunate;^Citation46 cyst(e)inase;^Citation47 etc.
Antagonists	Inhibits iron accumulation	Ciclopirox olamine;^Citation48 Fty720,^Citation49 dynasore;^Citation50 baicalein;^Citation51 etc.
	Inhibition of lipid peroxidation	Hspb1;^Citation52 Fsp1;^Citation23 Fer-1;^Citation53 cycloheximide;^Citation54 rapamycin;^Citation55 etc.
	Others	Sevoflurane;^Citation56 ginsenoside rd;^Citation56 etc.

Table 2 Biomarkers of Acute (Exudative) and (Fibroproliferative) Phase of ARDS.^4,59

	Marker	Biological Source of Biomarker	Change in ARDS
Alveolar cells type I	sRAGE	Plasma, BALF	↑
Alveolar cells type II	SP-A, SP-B, SP-D	Plasma, BALF	↓ BALF, ↑ plasma
	KL-6	Plasma, BALF	↑
Non-ciliary bronchial cells	CC16	Plasma, BALF	↑
Extracellular matrix	Laminin	Plasma, BALF	↑
	Elastin/Desmosin	Urine	↑
	MMPs	Plasma, BALF	↑
Endothelial cells	Angiopoietin-2	Plasma	↑
	sP-selectin	Plasma	↑
	sICAM- 1	Plasma	↑
	vWF	Plasma	↑
	Thrombomodulin	Plasma	↑
Coagulation	PAI- 1	Plasma	↑
	Protein C	Plasma	↓
	vWF	Plasma	↑
Inflammation	IL- 1β, IL-6, IL-8,	Plasma, BALF	↑
	IL- 10	Plasma, BALF	↑
	TNFα	Plasma, BALF	↑
	CRP	Plasma	↑
	KGF	BALF	↑
Proliferation of epithelium	HGF	BALF	↑
	VEGF	Plasma, BALF	↑ Plasma, ↓ BALF
	Angiopoietin-2	Plasma	↑
Apoptosis of epithelial cells	Fas/FasL	BALF	↑
Proliferation of fibroblasts	N-PCP-III	BALF	↑

Abbreviations: BALF, bronchoalveolar lavage fluid; CC16, Club cell protein; CRP, C-reactive protein; IL, interleukin; KL, Krebs von den Lungen protein; PAI, plasminogen activator inhibitor; sICAM, soluble intercellular adhesion molecule; SP, specific surfactant protein; sRAGE, soluble receptor for advanced glycation end products; vWF, von Willebrand factor; TNF, tumor necrosis factor; MMPs, matrix metalloproteinases; KGF, keratinocyte growth factor; HGF, hepatocyte growth factor; VEGF, vascular endothelial growth factor; N-PCP-III, N-terminal procollagen peptide-III; sP-selectin, soluble P-selectin.

Figure 2 Ferroptosis is associated with ALI caused by ischemia-reperfusion, sepsis, radiation, drowning, and oleic acid.

Table 3 Ferroptosis Antagonists and ALI

Drug	Pathway	ALI Category	Reference
iASPP	Nrf2 / HIF - 1 / TF	Ischemia related ALI	[6]
Rosiglitazone	ACSL4	Ischemia related ALI	[63]
Liproxstatin - 1	Lipid peroxidation	Ischemia related ALI	[11,63]
Ferrostatin - 1	GPX4, SLC7A11	Ischemia related ALI, sepsis related ALI, drowning related ALI	[6,12,53]
GSMTX4	Piezo1	Radiation related ALI	[64]
Sevoflurane	HO - 1	Sepsis related ALI	[65]
Panaxydol	KEAP1 - Nrf2 - HO - 1	Sepsis related ALI	[66]
Mucin 1	GSK3 β/Keap1-Nrf2-GPX4	Sepsis related ALI	[67]
Ferulic acid	Nrf2/HO-1	Sepsis related ALI	[68]

Table 4 Treatment of Ferroptosis Antagonists in Typical ALI Models

ALL Model	Study Type	Cell type	Ferroptosis Antagonist	Target	Signal Pathway	Detected Biomarkers	Results	Reference
IRRALI	In vivo	MLECs (BALF)	iASPP	Nrf2/	Nrf2 / HIF - 1 / TF	IL-1β↓, IL-6↓, and TNF-α↓	Relieved ALI	[6]
RRALI	In vitro and in vivo	HULEC-5a/MLECs (BALF)	GSMTX4	Piezo1/ GPX4	Ca2+/calpain signaling	IL-1β↓, IL-6↓, IL- 10↓, VEGF↓	Relieved ALI	[64]
SRALI	In vitro and in vivo	BEAS-2B cells /MLECs (BALF)	Panaxydol	Nrf2	Keap1-Nrf2/HO-1	TNF-α↓, IL-1β↓, and IL-6↓, SP-A↓, SP-B↓, SP-D↓	Relieved ALI	[66]
DRALI	In vitro	MLECs-12	Ferrostatin-1	Nrf2/ GPX4	Nrf2 pathway	IL- 1β↓, IL-6↓, IL-8↓, IL- 10↓	Relieved ALI	[12]
OARALI	In vivo	MLECs (BALF)	-	-	-	-	-	[13]

Abbreviations: ALI, acute lung injury; MLECs, mice lung epithelia cells; BALF, bronchoalveolar lavage fluid; HULEC, Human pulmonary microvascular endothelial cells; IRRALI, Ischemia-reperfusion related ALI; RRALI, radiation related acute lung injury; SRALI, sepsis related acute lung injury; DRALI, drowning related acute lung injury; OARALI, oleic acid related acute lung injury; IL, interleukin; TNF, tumor necrosis factor; VEGF, vascular endothelial growth factor; SP, specific surfactant protein.

Figure 3 Mechanism of various ALI and treatment of ferroptosis antagonists in typical ALI models.

Abbreviations: ALI, acute lung injury; IRRALI, Ischemia-reperfusion related ALI; RRALI, radiation related acute lung injury; SRALI, sepsis related acute lung injury; DRALI, drowning related acute lung injury; OARALI, oleic acid related acute lung injury. IL, interleukin; TNF, tumor necrosis factor; VEGF, vascular endothelial growth factor; SP, specific surfactant protein.

Table 5 Ferroptosis and ALI

Category of ALI	Main Manifestations	Signaling Pathway
IRRALI and ferroptosis	GPX4 expression and GSH content were decreased, and MDA levels and lipid peroxidation were increased.	iASPP: Nrf2 / HIF - 1 / TF;^Citation6 Nrf2 / HO - 1;^Citation32 Nrf2 / STAT3;^Citation73 Hif-1α-dependent manner;^Citation7 TERT and SLC7A11.^Citation8
RRALI and ferroptosis	Substantial ROS production, disruption of alveolar endothelial function barrier function, and increased Ca2 + influx.	Piezo: Ca2 + / calpain/ VE – Cadherin.^Citation64
SRALI and ferroptosis	SLC7A11 and GPX4 expression was decreased, and MDA and total iron contents were increased.	Nrf2 / ARE;^Citation76 NRF2 and ATF3;^Citation9 GSK3 β/Keap1-Nrf2-GPX4 Pathway;^Citation67 Nrf2/HO-1;^Citation68 KEAP1- Nrf2-HO-1;^Citation66 Nrf2 pathways.^Citation10
DRALI and ferroptosis	GSH expression and SOD activity were decreased, intracellular ROS and MDA levels were increased, and lipid peroxidation was increased.	Nrf2^Citation12
OARALI and ferroptosis	Changes such as lipid peroxidation, iron overload, GSH depletion, and MDA accumulation in lung tissue, and protein expression levels of GPX4 and ferritin were down-regulated in lung tissue.	Ferroptosis.^Citation13

Abbreviations: ALI, acute lung injury; IRRALI, Ischemia-reperfusion related ALI; RRALI, radiation related acute lung injury; SRALI, sepsis related acute lung injury; DRALI, drowning related acute lung injury; OARALI, oleic acid related acute lung injury.

Louandre C, Marcq I, Bouhlal H, et al. The retinoblastoma (Rb) protein regulates ferroptosis induced by sorafenib in human hepatocellular carcinoma cells. Cancer Lett. 2015;356(2 Pt B):971–977. doi:10.1016/j.canlet.2014.11.014

 PubMed Web of Science ®Google Scholar

Li Y, Zeng X, Lu D, Yin M, Shan M, Gao Y. Erastin induces ferroptosis via ferroportin-mediated iron accumulation in endometriosis. Hum Reprod. 2021;36(4):951–964. doi:10.1093/humrep/deaa363

 PubMed Web of Science ®Google Scholar

Tang Z, Ju Y, Dai X, et al. HO-1-mediated ferroptosis as a target for protection against retinal pigment epithelium degeneration. Redox Biol. 2021;43:101971. doi:10.1016/j.redox.2021.101971

 PubMed Web of Science ®Google Scholar

Zhang X, Yu K, Ma L, et al. Endogenous glutamate determines ferroptosis sensitivity via ADCY10-dependent YAP suppression in lung adenocarcinoma. Theranostics. 2021;11(12):5650–5674. doi:10.7150/thno.55482

 PubMed Web of Science ®Google Scholar

Liu T, Jiang L, Tavana O, Gu W. The Deubiquitylase OTUB1 mediates ferroptosis via stabilization of SLC7A11. Cancer Res. 2019;79(8):1913–1924. doi:10.1158/0008-5472.CAN-18-3037

 PubMed Web of Science ®Google Scholar

Mao C, Liu X, Zhang Y, et al. DHODH-mediated ferroptosis defence is a targetable vulnerability in cancer. Nature. 2021;593(7860):586–590. doi:10.1038/s41586-021-03539-7

 PubMed Web of Science ®Google Scholar

Li S, He Y, Chen K, et al. RSL3 drives ferroptosis through NF-κB pathway activation and GPX4 depletion in glioblastoma. Oxid Med Cell Longev. 2021;2021:2915019. doi:10.1155/2021/2915019

 PubMed Web of Science ®Google Scholar

Gai C, Yu M, Li Z, et al. Acetaminophen sensitizing erastin-induced ferroptosis via modulation of Nrf2/heme oxygenase-1 signaling pathway in non-small-cell lung cancer. J Cell Physiol. 2020;235(4):3329–3339. doi:10.1002/jcp.29221

 PubMed Web of Science ®Google Scholar

Xu S, Wu B, Zhong B, et al. Naringenin alleviates myocardial ischemia/reperfusion injury by regulating the nuclear factor-erythroid factor 2-related factor 2 (Nrf2) /System xc-/ glutathione peroxidase 4 (GPX4) axis to inhibit ferroptosis. Bioengineered. 2021;12(2):10924–10934. doi:10.1080/21655979.2021.1995994

 PubMed Web of Science ®Google Scholar

Gaschler MM, Andia AA, Liu H, et al. FINO(2) initiates ferroptosis through GPX4 inactivation and iron oxidation. Nat Chem Biol. 2018;14(5):507–515. doi:10.1038/s41589-018-0031-6

 PubMed Web of Science ®Google Scholar

Shu X, Wu J, Zhang T, et al. Statin-induced geranylgeranyl pyrophosphate depletion promotes ferroptosis-related senescence in adipose tissue. Nutrients. 2022;14:20.

 Web of Science ®Google Scholar

Wu W, Geng Z, Bai H, Liu T, Zhang B. Ammonium ferric citrate induced ferroptosis in non-small-cell lung carcinoma through the inhibition of GPX4-GSS/GSR-GGT axis activity. Int J Med Sci. 2021;18(8):1899–1909. doi:10.7150/ijms.54860

 PubMed Web of Science ®Google Scholar

Eling N, Reuter L, Hazin J, Hamacher-Brady A, Brady NR. Identification of artesunate as a specific activator of ferroptosis in pancreatic cancer cells. Oncoscience. 2015;2(5):517–532. doi:10.18632/oncoscience.160

 PubMedGoogle Scholar

Cramer SL, Saha A, Liu J, et al. Systemic depletion of L-cyst(e)ine with cyst(e)inase increases reactive oxygen species and suppresses tumor growth. Nat Med. 2017;23(1):120–127. doi:10.1038/nm.4232

 PubMed Web of Science ®Google Scholar

Zhou J, Zhang L, Wang M, et al. CPX Targeting DJ-1 Triggers ROS-induced cell death and protective autophagy in colorectal cancer. Theranostics. 2019;9(19):5577–5594. doi:10.7150/thno.34663

 PubMed Web of Science ®Google Scholar

Zhong Y, Tian F, Ma H, et al. FTY720 induces ferroptosis and autophagy via PP2A/AMPK pathway in multiple myeloma cells. Life Sci. 2020;260:118077. doi:10.1016/j.lfs.2020.118077

 PubMed Web of Science ®Google Scholar

Clemente LP, Rabenau M, Tang S, et al. Dynasore blocks ferroptosis through combined modulation of iron uptake and inhibition of mitochondrial respiration. Cells. 2020;9(10):2259. doi:10.3390/cells9102259

 PubMed Web of Science ®Google Scholar

Xie Y, Song X, Sun X, et al. Identification of baicalein as a ferroptosis inhibitor by natural product library screening. Biochem Biophys Res Commun. 2016;473(4):775–780. doi:10.1016/j.bbrc.2016.03.052

 PubMed Web of Science ®Google Scholar

Sun X, Ou Z, Xie M, et al. HSPB1 as a novel regulator of ferroptotic cancer cell death. Oncogene. 2015;34(45):5617–5625. doi:10.1038/onc.2015.32

 PubMed Web of Science ®Google Scholar

Doll S, Freitas FP, Shah R, et al. FSP1 is a glutathione-independent ferroptosis suppressor. Nature. 2019;575(7784):693–698. doi:10.1038/s41586-019-1707-0

 PubMed Web of Science ®Google Scholar

Liu P, Feng Y, Li H, et al. Ferrostatin-1 alleviates lipopolysaccharide-induced acute lung injury via inhibiting ferroptosis. Cell Mol Biol Lett. 2020;25:10. doi:10.1186/s11658-020-00205-0

 PubMed Web of Science ®Google Scholar

Rikhvanov EG, Fedoseeva IV, Varakina NN, Rusaleva TM, Fedyaeva AV. Mechanism of Saccharomyces cerevisiae yeast cell death induced by heat shock. Effect of cycloheximide on thermotolerance. Biochemistry. 2014;79(1):16–24. doi:10.1134/S0006297914010039

 PubMed Web of Science ®Google Scholar

Baba Y, Higa JK, Shimada BK, et al. Protective effects of the mechanistic target of rapamycin against excess iron and ferroptosis in cardiomyocytes. Am J Physiol Heart Circ Physiol. 2018;314(3):H659–h668. doi:10.1152/ajpheart.00452.2017

 PubMed Web of Science ®Google Scholar

Li Y, Yu P, Fu W, et al. Ginsenoside Rd inhibited ferroptosis to alleviate CCl(4)-induced acute liver injury in mice via cGAS/STING pathway. Am J Chin Med. 2023;51(1):91–105. doi:10.1142/S0192415X23500064

 PubMedGoogle Scholar

Mokrá D. Acute lung injury - from pathophysiology to treatment. Physiol Res. 2020;69(Suppl 3):S353–s366. doi:10.33549/physiolres.934602

 PubMedGoogle Scholar

Bhargava M, Wendt CH. Biomarkers in acute lung injury. Transl Res. 2012;159(4):205–217. doi:10.1016/j.trsl.2012.01.007

 PubMed Web of Science ®Google Scholar

Li Y, Cao Y, Xiao J, et al. Inhibitor of apoptosis-stimulating protein of p53 inhibits ferroptosis and alleviates intestinal ischemia/reperfusion-induced acute lung injury. Cell Death Differ. 2020;27(9):2635–2650. doi:10.1038/s41418-020-0528-x

 PubMed Web of Science ®Google Scholar

Xu Y, Li X, Cheng Y, Yang M, Wang R. Inhibition of ACSL4 attenuates ferroptotic damage after pulmonary ischemia-reperfusion. FASEB j. 2020;34(12):16262–16275. doi:10.1096/fj.202001758R

 PubMed Web of Science ®Google Scholar

Li X, Zhuang X, Qiao T. Role of ferroptosis in the process of acute radiation-induced lung injury in mice. Biochem Biophys Res Commun. 2019;519(2):240–245. doi:10.1016/j.bbrc.2019.08.165

 PubMed Web of Science ®Google Scholar

Qiu YB, Wan BB, Liu G, et al. Nrf2 protects against seawater drowning-induced acute lung injury via inhibiting ferroptosis. Respir Res. 2020;21(1):232. doi:10.1186/s12931-020-01500-2

 PubMed Web of Science ®Google Scholar

Guo XW, Zhang H, Huang JQ, et al. PIEZO1 ion channel mediates ionizing radiation-induced pulmonary endothelial cell ferroptosis via Ca(2+)/Calpain/VE-cadherin signaling. Front Mol Biosci. 2021;8:725274. doi:10.3389/fmolb.2021.725274

 PubMed Web of Science ®Google Scholar

Liu X, Wang L, Xing Q, et al. Sevoflurane inhibits ferroptosis: a new mechanism to explain its protective role against lipopolysaccharide-induced acute lung injury. Life Sci. 2021;275:119391. doi:10.1016/j.lfs.2021.119391

 PubMed Web of Science ®Google Scholar

Li J, Lu K, Sun F, et al. Panaxydol attenuates ferroptosis against LPS-induced acute lung injury in mice by Keap1-Nrf2/HO-1 pathway. J Transl Med. 2021;19(1):96. doi:10.1186/s12967-021-02745-1

 PubMed Web of Science ®Google Scholar

Wang YM, Gong FC, Qi X, et al. Mucin 1 inhibits ferroptosis and sensitizes vitamin E to alleviate sepsis-induced acute lung injury through GSK3β/Keap1-Nrf2-GPX4 pathway. Oxid Med Cell Longev. 2022;2022:2405943. doi:10.1155/2022/2405943

 PubMed Web of Science ®Google Scholar

Tang X, Liu J, Yao S, Zheng J, Gong X, Xiao B. Ferulic acid alleviates alveolar epithelial barrier dysfunction in sepsis-induced acute lung injury by activating the Nrf2/HO-1 pathway and inhibiting ferroptosis. Pharm Biol. 2022;60(1):2286–2294. doi:10.1080/13880209.2022.2147549

 PubMed Web of Science ®Google Scholar

Zhou H, Li F, Niu JY, et al. Ferroptosis was involved in the oleic acid-induced acute lung injury in mice. Sheng Li Xue Bao. 2019;71(5):689–697.

 PubMedGoogle Scholar

Dong H, Qiang Z, Chai D, et al. Nrf2 inhibits ferroptosis and protects against acute lung injury due to intestinal ischemia reperfusion via regulating SLC7A11 and HO-1. Aging. 2020;12(13):12943–12959. doi:10.18632/aging.103378

 PubMedGoogle Scholar

Qiang Z, Dong H, Xia Y, Chai D, Hu R, Jiang H. Nrf2 and STAT3 alleviates ferroptosis-mediated IIR-ALI by Regulating SLC7A11. Oxid Med Cell Longev. 2020;2020:5146982. doi:10.1155/2020/5146982

 PubMed Web of Science ®Google Scholar

Zhongyin Z, Wei W, Juan X, Guohua F. Isoliquiritin apioside relieves intestinal ischemia/reperfusion-induced acute lung injury by blocking Hif-1α-mediated ferroptosis. Int Immunopharmacol. 2022;108:108852. doi:10.1016/j.intimp.2022.108852

 PubMed Web of Science ®Google Scholar

Dong H, Xia Y, Jin S, et al. Nrf2 attenuates ferroptosis-mediated IIR-ALI by modulating TERT and SLC7A11. Cell Death Dis. 2021;12(11):1027. doi:10.1038/s41419-021-04307-1

 PubMed Web of Science ®Google Scholar

Yu JB, Shi J, Gong LR, et al. Role of Nrf2/ARE pathway in protective effect of electroacupuncture against endotoxic shock-induced acute lung injury in rabbits. PLoS One. 2014;9(8):e104924. doi:10.1371/journal.pone.0104924

 PubMed Web of Science ®Google Scholar

Wang Y, Chen D, Xie H, et al. AUF1 protects against ferroptosis to alleviate sepsis-induced acute lung injury by regulating NRF2 and ATF3. Cell Mol Life Sci. 2022;79(5):228. doi:10.1007/s00018-022-04248-8

 PubMed Web of Science ®Google Scholar

He R, Liu B, Xiong R, et al. Itaconate inhibits ferroptosis of macrophage via Nrf2 pathways against sepsis-induced acute lung injury. Cell Death Discov. 2022;8(1):43. doi:10.1038/s41420-021-00807-3

 PubMed Web of Science ®Google Scholar