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2012; 52:167202
Doi:10.1111/j.1600-079X.2011.00937.x
REVIEW ARTICLE
Introduction
Alzheimers disease (AD) is a devastating disorder aecting
around 35 million people worldwide [1]. Ten years ago,
there were 4.5 million persons with AD in the US population alone; the number has increased to 5.3 million people
in 2010, according to the Alzheimers Association [2]. It is
estimated there will be 13.2 million people with this
neurodegenerative disorder by 2050 [3].
Alzheimers disease is a primary, progressive neurological
disease, which is of unknown etiology in more than 90% of
the cases. Some characteristic neuropathological and neurochemical features lead to irreversible loss of neurons.
Owing to the nature of the primarily aected neuronal
circuits, the clinical hallmarks of AD are progressive
impairment in memory, judgment, decision making, orientation to physical surroundings, and distorted language.
This illness is the leading cause of dementia in older people
[2].
Rosales-Corral et al.
Melatonin levels in AD
Cerebral spinal uid (CSF) melatonin levels are reportedly
signicantly decreased in aged individuals with early
neuropathological AD-related changes in the temporal
cortex [22]. In aged patients, melatonin levels in CSF have
been found to be one-half those in young control subjects,
but in patients with AD, the CSF melatonin levels are only
one-fth those in young subjects [23]. In fact, it is possible
to replicate hippocampal CA1 and CA3 pyramidal neuron
loss in rats by merely removing the pineal gland (which
lowers melatonin levels) with this eect being reversed by
melatonin replacement in the drinking water [24]. Also,
constant light exposure, which decreases serum melatonin,
is enough to cause Alzheimer-like damage, such as memory
decits, tau hyperphosphorylation at multiple sites, activation of glycogen synthase kinase-3 and protein kinase A, as
well as suppression of protein phosphatase-1 and prominent oxidative stress [25].
169
Rosales-Corral et al.
(ROS/RNS) [73]. Further AFMK deformylation by the
action of arylamineformamidase or hemoperoxidase enzymes produces N1-acetyl-5-methoxykynuramine (AMK)
[77], which, in addition to its ability to react with various
oxidizing and nitrosating free radical species, particularly
singlet oxygen and nitrogen species, also may destroy
carbonate and peroxyl radicals (reviewed in [78]) and
function as an antioxidant [79]. AFMK and AMK metabolism may lead to other oxidation products, such as 3indolinone, cinnolinone, and quinazoline compounds, for
which no specic functions have been identied to date [78].
Interestingly, the parallel orientation of b-sheets, such as
tau and Ab laments, generates channels extending along
the length of the lament to which aromatic small molecules such as indolinones can bind via pp interactions,
stacked arrangement of aromatic molecules [80]. Using
uorescence spectroscopy, atomic force microscopy, and
electron microscopy to screen 29 indole derivatives, Cohen
et al. [81] identied three potent inhibitors of amyloid bril
formation and cytotoxicity, and the indole-3-carbinol was
among them. The interaction of melatonin with Ab will be
reviewed below. Additionally, the 3-substituted indolinones
have been identied as kinase inhibitors [82], which could
be related to the anti-inammatory actions of melatonin
and its metabolites [83].
Melatonin may also prevent abnormal elevation of
reactive nitrogen species, stimulate other antioxidant systems, and/or inhibit some pro-oxidant enzymes; these
indirect actions of melatonin contribute to its potent
antioxidant activity [8486]. An evaluation in human
Fig. 4. Receptor-mediated or acting directly on its substrates, melatonin exhibits a broad diversity of eects to reduce neurodegenerative
changes in the central nervous system. It is a pleiotropic indoleamine, actually. All the protagonists in neurodegenerative diseases express
melatonin receptors; when and how cells or their molecular eectors become activated or inhibited according to the expression of their
melatonin receptors remains unclear. The scheme shows some of the published observations to date, all related to central nervous system
and/or neurodegeneration. Thanks to its ability to transfer electrons, melatonin may repair damaged biomolecules derived from DNA
oxidation, such as guanosine. LTP, long-term potentiation; MT, melatonin receptor (G-protein-coupled receptors); CaM, calmodulin; CRT,
calreticulin; APP, amyloid b precursor protein; 5-LOX, 5-lipoxygenase; COX-2, cyclooxygenase; iNOS, inducible nitric oxide synthase;
PLA2, phospholipase A2.
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Pathogeny of AD
There is a failure of the intercommunication between
neuronal circuits in Alzheimers disease resulting from
synaptic loss and the destruction of neurons. As a consequence, working memory is not transferred through the
hippocampus to long-term memory circuits. The disconnection progresses over time and aects some other
functions in addition to memory, so that behavior, executive functioning, judgment, movement coordination, and
pattern recognition may become eventually aected.
Three major hypotheses have been primarily explored in
an attempt to explain AD: (i) cholinergic hypothesis, (ii)
amyloid cascade hypothesis, and (iii) mitochondrial cascade
hypothesis. Even though the amyloid cascade is the most
extended hypothesis [98], the pathogenic role for Ab is
under debate because of reports showing a poor relationship between Ab accumulation and cell death in the brain,
in addition to other results demonstrating a weak correlation between Ab and cognitive decline [99]. Furthermore,
people with Ab deposits do not necessarily suer AD [100].
Even more importantly, there are some published data
demonstrating that Ab may be protective in brain disease
[101, 102]. Thus, the pathogenic role of Ab in AD deserves
further scrutiny because all of the hypotheses mentioned
include a pathological role of Ab in AD.
Amyloid-b processing
Although far from conclusive, Ab is the most studied factor
related to pathogenic mechanisms of AD. Ab is derived
from the catalytic cleavage of an integral membrane
protein, the APP, a ubiquitously expressed type I transmembrane protein whose primary function is not well
known. This is the rst obstacle in Alzheimers research,
actually. It is known that the lack of APP in hippocampal
neurons enhances neuritic growth, which inuences only
the synapse number at an early age but not in adult animals
[103]. The conserved APP intracellular domain, genetically
uncoupled from APP processing and Ab pathogenesis, has
a key role in survival, proper high-anity choline transporter (ChT) targeting, and neuromuscular synapse development [104]. ChT is responsible for choline uptake from
the synaptic cleft, a rate-limiting step in acetylcholine
synthesis [105]. An extensive review [106] tackles in detail
the possible role of APP in synaptic transmission and
neural plasticity, with its respective implications for learning and memory.
Closely associated with lipid rafts in membranes, composed mostly of sphingolipids and cholesterol, the enzymes
in charge of APP cleavage are proteases generating soluble
isoforms of membrane proteins, a process rst related to
the secretion of angiotensin-converting enzyme in the
kidney [107]. Thus, the APP chain of 695, 751, or 770
Rosales-Corral et al.
Fig. 5. Several routes to prevent the formation of Ab neurotoxic aggregates are used by melatonin. It directly intervenes, aecting the
stability of amyloid b-sheets by disrupting Asp) -His+ salt bridges or aecting the synthesis and maturation of APP, where its ability to
suppress cAMP activity may have a role, because of the cAMP-responsive regions on the APP promoter gene. However, its indirect actions
are signicant as well because melatonin may reduce the activity of GSK3 required for the amyloidogenic APP processing, by activating
and/or enhancing the activity of PKC, or by inducing Akt. Both PKC and Akt may turn o GSK-3 through phosphorylation. COX-2,
related to APP synthesis in astrocytes, is controlled by melatonin and its metabolites. Finally, melatonin has a key role in cholesterol and
fatty acid distribution in membranes, as reviewed later. This is important because, as illustrated, amyloidogenic APP processing seems to be
favored by cholesterol/sphingomyelin-enriched lipid rafts. APP, amyloid precursor protein; bs, b secretase; cs, c-secretase; Ab, amyloid b;
MT, melatonin receptors; PLC, phospholipase C; DAG, diacyl-glycerol; PKC, protein kinase C; PI3K, phosphatidylinositol-3-kinase; Akt,
a serine/threonine protein kinase; PKA, cAMP-dependent protein kinase.
interaction may be a determinant in favor of the amyloidogenic pathway [122] (Fig. 5). Cholesterol decreases the
secretion of soluble amyloid precursor protein (sAPP) by
interfering with APP maturation and inhibiting glycosylation in the protein secretory pathway, in such a manner that
APP cannot be cleaved by a-secretase [132]. Processing APP
at the b-site also requires proper orientation to be accessed
by BACE-1 [133], which in turn localizes largely within
cholesterol-rich lipid rafts [117, 134]. It is proposed that
APP is actually a cholesterol sensor [117]. The AD brain
shows signicant cholesterol retention and high b- and csecretase activities as compared to age-matched nondemented controls, while cholesterol depletion may be associated with reduced cellular cholesterol, b-secretase activity,
and Ab secretion [116].
Another factor inuencing the access to APP in cell
membranes seems to be insulin, a signicant association
that links AD to diabetes mellitus. Insulin accelerates APP
tracking from the trans-Golgi network to the plasma
membrane [135], while the insulin-degrading enzyme (IDE)
degrades not only insulin but also Ab and the intracellular
domain of APP [135, 136]. Thus, insulin reduces intracellular levels of amyloid and increases amyloid secretion in a
process that probably involves the activation of the MAPK
cascade [137], although it might also use the phosphatidyl
inositol 3 kinase (PI3K)-pathway to release sAPP, the
172
nonamyloidogenic secreted form of APP [138]. Importantly, this insulinPI3K pathway locates and halts glycogen synthase kinase-3 (GSK-3) to promote glucose storage
as glycogen, as part of intermediary metabolism. However,
GSK-3 plays another role. Its a-isoform may interact
directly with presenilins within the c-secretase complex, and
it is required for the amyloidogenic APP processing. This is
the reason why GSK-3 has become a target for the
treatment for AD [139]. Insulin deciency in brain leads
to enhancement of GSK3a/b activation, increases cerebral
amyloidosis, and exacerbates behavioral decits, as demonstrated in APP/PS1 transgenic mouse model of AD by
impairing insulin downstream GSK3 and JNK pathways
[140].
Not only brillar Ab but a variety of Ab oligomers may
cause cellular damage. Soluble oligomers, referred to as
amorphous aggregates, micelles, protobrils, prebrillar
aggregates, amyloid b-derived diusible legends (ADDLs),
Ab*56, globulomers, amylospheroids, toxic soluble Ab,
paranuclei, and annular protobrils [141], appear within
neuronal processes and synapses rather than within the
extracellular space. They are neurotoxic rather than amyloid brils found in amyloid plaques [142] and may inhibit
critical neuronal functions including long-term potentiation
[143], a classic experimental paradigm for memory and
synaptic plasticity [143, 144]. Even more, as a consequence
Rosales-Corral et al.
HIF-1, which in turn mediates a neuroprotective response,
presumably by regulating glucose metabolism [170]. HIF-1
has a half-life of approximately 5 min in normoxic conditions and less than a minute under hypoxic conditions.
Thus, the role of melatonin in these HIF-1 dependent
mechanisms is currently only a matter of speculation.
Conformational changes in Ab occur in minutes after
addition of melatonin. In fact, the ability of melatonin to
induce conformational changes in Ab has been used to
investigate the conformation and topology of Ab peptides
interacting with peptide-tethered planar lipid bilayers [171,
172]. Similarly, it has been also demonstrated that lipid
composition of membrane bilayers plays a dominant role in
mediating conformational changes and in AD pathogeny,
as reviewed below.
Levels of Ab aggregates in the brain were reduced by
melatonin in aging mice [173], and in 8-month-old APP 695
transgenic [174] mice or in APP + PS1 double-transgenic
mice. The latter were supplemented with melatonin from 2
to 2.5 months to age 7.5 months [20]. However, in old,
amyloid plaquebearing Tg2576 mice, which started melatonin treatment as late as 14 months of age (5 months
later from the onset of the pathology [175]), melatonin
failed to reproduce its antiamyloid eects (it seems to even
fail to prevent oxidative stress [176]).
The melatonin/Ab interaction could be an inconvenience
according to the bioocculant hypothesis. Even though
the investigation related to inhibitors of Ab aggregation as
a real promise for many investigators [177], blocking or
inhibiting Ab could be a mistake owing to the soluble forms
of this peptide, according to this hypothesis. This is because
Ab could have a primordial function: binding to unwanted
solutes in the extracellular uid, which then precipitates to
build deposits or aggregates. Thus, Ab plaques would be an
ecient means of presenting neurotoxins to phagocytes
[178].
Extracellular Ab may suppress synaptic plasticity or
inhibit long-term potentiation (LTP) [179]. There is, in fact,
an odds ratio homocysteine/AD of 4.5 for histopathologically conrmed AD in a casecontrol study [180], which
also demonstrated that patients with AD and high homocysteine levels showed a more rapid progression over the
following 3 yr. Even more so, high homocysteine levels,
considered a risk factor for dementia and AD [29], are
related to apoptosis [181]. This methionine derivative has
the ability to induce proapoptotic caspases (caspase 3 and
caspase 9), DNA fragmentation, and the Bcl-2associated
X protein (Bax) while reducing the antiapoptotic Bcl-2
protein; these eects may be inhibited in the presence of
melatonin [182].
Cholinergic hypothesis
The cholinergic hypothesis asserts that degeneration of
cholinergic neurons in the basal forebrain and the associated loss of cholinergic neurotransmission in the cerebral
cortex cause deterioration in cognitive function as seen in
patients with AD [183, 184]. This theory was introduced in
1971 when it was demonstrated that cholinergic synapses
were modied as a result of learning and that loss of
sensitivity to acetylcholine was related to forgetfulness
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Rosales-Corral et al.
cytosolic factors p47phox and p67phox to the microglial
membrane in brains of patients with AD, and this is
correlated with proinammatory events, such as TNF-a
and IL-1b overproduction [221, 222]. The synergy between
oxidative and nitrosative stress plus neuroinammation
may increase the overproduction of OONO) by a
1,000,000-fold [223]. PHOX is a multicomponent enzyme
system composed of two integral membrane proteins,
p22phox and gp91phox, integrated as cytochrome b558,
three essential cytosolic components, p47phox, p67phox,
p40phox, and the above-mentioned GTPase Rac1, of the
Rho family of small G proteins. In general terms, the
complex begins its integration when the cytosolic p47phox
subunit becomes phosphorylated and transports the total
cytosolic components to the docking site where they
assemble to the avocytochrome b558 (reviewed in [224]).
GTP-bound Rac coordinates the translocation of the
p47phox/p67phox/p40phox complex and its dissociation
from GTP permits the subsequent inactivation of the
Fig. 7. Ab plaques and oligomers are in the middle of a complex set of interactions among astrocytes, microglia, and neurons originating a
neuroinammatory response. This is linked to reactive oxygen species (ROS) and NOS overproduction (gray clouds) culminating in
oxidative stress, which in turn feeds back on neuroinammation. Organelle dysfunction, particularly mitochondria, adds more free radicals
and aggravates the situation. Even worse, oxidative stress and Ab are interdependent phenomena; thus, the more the oxidation, the
more the amyloid accumulation. Newly formed Ab contributes to more neuroinammation and oxidative stress, closing the vicious cycle. In
fact, Ab can be an oxidant by itself, as shown. During inammatory and oxidative stress, communication between cellular protagonists is
importantly mediated by calcium waves (blue waves) apart from cytokines. Melatonin (green) and its major metabolites AFMK and
AMK play key roles by scavenging free radicals directly, while they enhance endogenous antioxidant systems, as shown in Fig. 3. AMK is
relevant particularly in mitochondria, where it takes ETC components as electron donors or acceptors. Going further, melatonin and its
metabolites have a role in neuroinammation by regulating both proinammatory signals and oxidative stress mediators, such as COX2
and iNOS by avoiding NF-jB full integration. ctk, cytokines; Ab, amyloid-beta; AFMK, N1-acetyl-N2-formyl-5-methoxykynuramine;
AMK, N1-acetyl-5-methoxykynuramine; 3-OHM, cyclic 3-hydroxymelatonin; ETC, electron transport chain; NF-jB, nuclear factor kappa
B; COX-2, cyclooxygenase 2; iNOS, inducible nitric oxide synthase; PGE2, prostaglandin E2.
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DAMPS, to the noncanonical pathway where CD40 and
lymphotoxin receptors activate a p52/relB complex. Moreover, there are other atypical pathways, where genotoxic
stress, hypoxia, UV light, H2O2, or the epidermal growth
factor receptor 2, among others, may intervene (reviewed in
[263]). The link between NF-jB and neurodegenerative
disorders, particularly AD, is an old one [264, 265].
In rat primary cultures of microglial cells and human
neutrophils and monocytes, Ab activates PHOX, and this
eect may be potentiated by the proinammatory stimulus,
such as interferon-gamma or TNF-a, but blocked by
tyrosine kinase inhibitors [266]. Mediated by PHOX,
oligomeric Ab may induce ROS production, possibly
through N-methyl-D-aspartate receptors (NMDAR), and
these PHOX-related ROS, in turn, release the prostanoid
precursor arachidonic acid through the activation of ERKs,
which phosphorylate cytosolic phospholipase A2a [219].
The rate-limiting enzyme, COX-2, can be induced by
multiple cellular factors such as growth factors or the
proinammatory cytokines IL-1b and TNF-a in neurons,
astrocytes, and microglia. COX-2 in turn regulates PGE2
signaling in neurons [267] and can activate APP transcription in astrocytes [156], as well as glutamate release from
astrocytes, which is responsible for excitotoxic damage in
AD [193, 268, 269]. PGE2 and COX-2 feedback each other
and modulate neuroinammation, regulating the production of multiple inammatory molecules.
It seems that melatonin may thus regulate neuroinammation through free radical control and modulation of
important proinammatory transcription factors and their
signaling pathways while reducing glutamate excitotoxicity,
whether it be by inhibiting glutamate-induced ion currents
or by controlling the glutamate delivery. On the other hand,
even though functional cytoplasmic membrane melatonin
receptors have been described in astrocytes derived from
chick brain [301], which could suggest a role for melatonin
as a metabolism regulator in astrocytes, these receptors
have not been corroborated in human glia.
The nuclear hormone retinoid z receptor/retinoid orphan
receptor (RZR/ROR), from the retinoid-related orphan
receptors family, are likely associated with melatonin
signaling and have been identied in the promoter region
of 5-lipoxygenase (5-LOX), a key protagonist in neuroinammation. By repressing the expression of 5-LOX mRNA
in human B lymphocytes, melatonin may reduce the
proinammatory response via nuclear receptor RZR/
RORa [302]. Furthermore, the transcriptional activation
of RZR/RORa by melatonin is possible even in the
nanomolar range [303, 304]. There are no reports conrming this eect of melatonin in the CNS, but 5-LOX is widely
expressed in the brain [305] where it has neuromodulatory
and neuroendocrine functions and plays an important role
in aging and AD, as we will review later. It is worth
mentioning that, in addition to AA-derived leukotrienes,
5-LOX also modulates the c-secretase activity in membranes, favoring Ab formation [306].
Although there is an isolated report indicating that
melatonin is not an important modulator of macrophage
and microglia function [307], melatonins role controlling
the
primarily
microglia-guided
neuroinammatory
response is demonstrated in multiple reports. This is a
consequence of its regulation of the NF-jB overexpression
[308], the amount of LPS-induced proinammatory cytokines [192], or prevention of GSK-3b activation and
neuroinammation in response to Ab, as observed in
astrocytes and microglial cells [166]. Meanwhile, a cumulative dose of 10 mg/kg melatonin may attenuate kainic
acid-induced neuronal death, lipid peroxidation, and microglial activation, reducing the number of DNA breaks in
vivo, as demonstrated in adult male SpragueDawley rats
[309].
The antioxidant and immunomodulatory eects have
inserted melatonin into the two-hit hypothesis [310], which
states that although either oxidative stress or abnormalities
in mitotic signaling can, independently, serve as initiators in
AD, both processes are necessary to propagate the pathological features of the disease.
Rosales-Corral et al.
evidence linking AD to mitochondrial damage in brain
cells had been reported many years earlier. For example,
in 1980, by investigating the mechanism for the production
of acetyl-CoA used in acetylcholine synthesis, a small, but
signicant, reduction in the activity of the pyruvate
dehydrogenase (besides ATP-citrate lyase and acetoacetyl-CoA thiolase) was found in postmortem brain tissue
from cases of AD [312]. In 1985, the activity of the
pyruvate dehydrogenase complex was reported to be
reduced to about 30% of control values in histologically
unaected occipital cortex as well as in histologically
aected frontal cortex of the brains of patients with AD
[313]. Likewise, AD as a primary defect in cytochrome
oxidase was proposed years later [314]. However, it
currently is debatable whether Ab is a downstream
product of the mitochondrial functional decline or whether
Ab-induced mitochondrial damage is an extension of the
amyloid cascade hypothesis. The amyloid cascade, proposed 20 yr ago, suggested that faulty metabolism of APP
was the initiating event in AD pathogenesis, leading
subsequently to the aggregation of Ab, specically Ab1
42 [315, 316]. However, long before the appearance of
extracellular Ab deposits, they are detectable within
mitochondria [317].
Beyond hypotheses, some other important features have
been found since those early years. It has been demonstrated that Ab142 uncouple the mitochondrial respiratory
chain, and this event plays a key role in pathology of AD
[311]. Structurally, Ab induces swelling of isolated mitochondria [318, 319] and, functionally, decreases ATP
synthesis and the activity of various mitochondrial enzymes, as demonstrated in vivo [320] and in vitro in
cultured neuronal cells or in Ab-exposed astrocytes [319
321]. Later, dierent neurotoxic mechanisms for Ab were
proposed, including disruption of mitochondrial function
via binding of the Ab-binding alcohol dehydrogenase
(ABAD) protein [322]or the formation of ion channels
allowing calcium uptake, which induces neuritic abnormality in a dose- and time-dependent manner [323], or the
opening of the mitochondrial permeability transition pore
coupled to inhibition of respiratory complexes [324, 325].
We have found (Rosales-Corral et al., unpublished data)
that following the intracerebral injection of brillar Ab, the
peptide is revealed both intracellularly and intramitochondrially, deep in the cristae, coinciding with other reports
which demonstrate that Ab progressively accumulates in
mitochondria where it is associated with diminished enzymatic activity of the respiratory chain complexes III and IV
[317]. Presence of Ab in mitochondria is related to a
reduction in the rate of oxygen consumption by the electron
transport chain [317]. The enzymes in charge of importing
Ab to mitochondria have been identied as a complex of
translocases, i.e., translocases of the outer membrane
(TOM) and the translocase of the inner membrane (TIM)
[326] (Fig. 8).
In addition to direct eects caused by Ab in mitochondria, there are severe changes attributed to the Ab-induced
oxidative stress. A disturbance of mitochondrial dynamics,
a term that includes ssion, fusion, movement, and
mitochondrial architecture, seems to be implicated in
AD pathogeny. It has been demonstrated in human brains
180
Fig. 8. Both Ab and abnormal phosphorylated tau play key roles in mitochondrial dysfunction long before amyloid plaques appear.
Hyperphosphorylated tau may cause ETC dysfunction by impairing complex I activity, although its major capacity for damaging may come
from its ability to interact with ANT from MtPTP, which leads to swelling, mitochondrial dysfunction, and cell death, ultimately. Amyloidb, whose mitochondrial receptors (ABAD and Hsp) have been identied, causes ETC dysfunction by interrupting the activity of complex III
and complex IV, and possibly it may disrupt ion-motive ATPase. Moreover, Ab impairs energy metabolism by inhibiting directly the activity
of the a-ketoglutarate enzyme during the tricarboxylic acid cycle and the pyruvate dehydrogenase before the cycle. Ab also disrupts Ca2+
homeostasis, which overloads mitochondrial matrix and may lead to complex II deciency, membrane potential loss, ATP reduction, and
ROS overproduction in addition to MtPTP disturbance. Ab-induced oxidative stress has been related to membrane dysfunction, oxidation
of ETC components, free radical leak, and MtDNA damage because MtDNA is particularly vulnerable to these events. The way CytC
escapes from mitochondria is not completely clear, but once released, it initiates a chain of events leading to apoptosis. Melatonin
(represented as red crosses) tends to accumulate inside mitochondria, where (1) it may reduce oxidative stress and its deleterious consequences on MtDNA, proteins, and membrane lipids, such as cardiolipin; (2) it strongly inhibits MtPTP currents and prevents cytochrome c
release in a dose-dependent manner; (3) it may recycle electron carriers, such as NADH; (4) it may prevent apoptosis by impairing Cytc
release from mitochondria; (5) Ca2+ regulation by melatonin may protect mitochondrial functioning. ROS/RNS, reactive oxygen/nitrogen
species; Ub, ubiquitin; ABAD, amyloid-b binding alcohol dehydrogenase; Hsp, heat-shock protein; Cytc, cytochrome c; ETC, electron
transport chain; MtPTP, mitochondrial permeability transition pore; MtDNA, mitochondrial DNA; APAF-1, apoptosis-activating factor 1.
Rosales-Corral et al.
probable mechanisms of mitochondrial protection by
melatonin relates to the prevention of cardiolipin oxidation,
avoiding MtPTP opening and restoring Ca2+ balance (as
reviewed in [353]). However, it is also possible that
melatonin directly inhibits MtPTP at single-channel and
cellular levels, as demonstrated in patch-clamp recordings
on the inner mitochondrial membrane [350].
Three other important proapoptotic factors related to
mitochondrial functioning and signaling have been demonstrated to be modulated by melatonin in brain. The
executory caspase-3, which is known to be directly linked to
cyt c release and widely linked to cell death in AD [99, 320,
354], can be downregulated by melatonin [92]. On the
contrary, melatonin may enhance bcl-2 expression as
demonstrated in AD transgenic mice [92] and in ischemic
brain [355]. Bcl-2 is recognized as an antiapoptotic protective factor, and its relation to Ab is also widely known,
because Ab may deplete bcl-2 as demonstrated in human
primary neuron cultures [356], in microglia [357], or in
human neurons from patients with AD [358]. Furthermore,
the proapoptotic bcl-2associated X protein (Bax), which
moves from the cytosol to the mitochondria, binds to bcl-2,
and promotes cyt c release, is increased in the presence of
Ab in human neurons [356]. However, under a variety of
experimental conditions, melatonin has demonstrated its
utility in diminishing bax [174, 359361]. Thus, melatonin
modulates mitochondrial pathways to apoptosis.
Mitochondrial damage is linked not only to energy
dysmetabolism and leakage of free radicals, which in turn
feeds back to induce oxidative stress, but also to increased
leakage of Ca2+ currents, besides the above-mentioned
apoptosis-inducing factors.
Calcium hypothesis
Other hypotheses have been proposed, complementing the
amyloid cascade theory. For example, it has been proposed
that a calcium-signaling decit causes accumulation of APP
because APP a-processing is a Ca2+-dependent process,
and this phenomenon provides excessive substrate for
b- and c-secretases, the enzymes responsible for APP
processing and Ab overproduction (Fig. 1) [362]. That Ab
increases calcium uptake has been demonstrated in PC12
cells [363], in human cortical neurons linked to glutamate
excitotoxicity [364], in AD brain frontal cortex, and in
plasma membrane vesicles from both rat and human brain
[365]. This occurs via stimulation of L voltage-sensitive
calcium channels, as demonstrated in cultured neurons
[366], but Ab also may increase calcium uptake via
potassium channels, the NMDA receptor, the nicotinic
receptor, or even by its own calcium-conducting pores
(reviewed in [367]). Conversely, calcium accelerates Ab
aggregation, even at physiological concentrations [368], and
it is exacerbated by synthetic calcium ionophores [369]. At
the same time, Ab-induced calcium waves feed the neuroinammatory response, and this increases Ab aggregation
and calcium waves, as mentioned previously [277279].
During the events leading to oxidative stress and neuroinammation in AD pathogeny, the glutamate-override of
the glutamate/cystine-antiporter system, which controls the
levels of glutamate by exchanging cystine in cells for the
182
Fig. 9. Some of the most relevant issues in the calcium hypothesis are related to the following: (1) its functional association with c-and bsecretase activity; thus, APP amyloidogenic processing seems to be a Ca2+-dependent process; (2) Ab, in turn, facilitates Ca2+ uptake using
a variety of calcium channels; (3) Ca2+ accelerates Ab aggregation, which in turn causes neuroinammation, oxidative stress, and glutamate
release; (4) calcium massive entrance causes excessive accumulation of Ca2+ within ER and mitochondria, one dysfunctional and apoptosisrelated phenomenon; (5) dysregulated intracellular Ca2+ activates a number of enzymes including CaM, which in turn activates CaMdependent kinases responsible for tau phosphorylation; (6) cytosolic PLA2 is also a Ca-dependent enzyme and, when activated, causes
arachidonic acid release and the subsequent activation of the neuroinammatory pathway via COX-2. Reports on melatonin (red crosses)
reveal a role for it: (1) as a free radical scavenger and antioxidant, (2) as an antiamyloidogenic, (3) as an inhibitor of Ca2+ inux, (4) as a
CaM antagonist, and melatonin also may impair Ca2+ leaking from ER, and (5) by regulating calreticulin, it is tempting to speculate that
melatonin may delay ER stress. APP, amyloid precursor protein; ROS/RNS, reactive oxygen and reactive nitrogen species; bs, beta
secretase; cs, gamma secretase; NMDA-R, n-methyl-daspartate receptor; L-Type R, voltage dependent L-type calcium receptor; AC,
adenylyl cyclase; cPLA2, cytoplasmic phospholipase A2; AA, arachidonic acid; ER, endoplasmic reticulum; UPR, unfolded protein response; MIT, mitochondria; CaM, calmodulin.
ER stress, so it is tempting to speculate that ER stressinduced CRT augments the folding capacity of the ER. By
regulating calcium inux and release within the cytoplasm,
melatonin regulates not only cellular homeostasis but
apoptosis as well (Fig. 9).
It is obvious that in addition to the inhibition of ER and
mitochondrial-related mechanisms of apoptosis, melatonin
may also prevent spontaneous neuronal apoptosis by acting
on downstream signal targets of the protein kinase B or
Akt: the forkhead box protein O1 (FOXO-1) and the GSK3b [392]. Akt is linked to the PI3-K/Akt survival pathway
and is required for the expression of long-term potentiation
in learning and memory. It is also linked to the insulin
receptor substrate (IRS) for the purpose of regulating
glucose uptake through a series of phosphorylation events.
Moreover, PI3K is phosphorylated upon NMDA receptordependent CamKII activity [393], which is also a melatonin
target, as mentioned above [386388]. According to Tajes
et al. [392], melatonin increases the activation of prosurvival PI3K/Akt, whereas it inhibits GSK-3b and causes an
183
Rosales-Corral et al.
increase in FOXO-1 phosphorylation. This is a proapoptotic transcription factor involved in insulin activity and in
the cellular response to oxidative stress. Finally, GSK-3b,
primarily linked to the inactivation of the glycogen
synthase, has been also associated with AD and frontotemporal dementia [394] where it is related to microtubule
stability because it phosphorylates the microtubule-associated protein tau [395] whose hyperphosphorylation is an
early event preceding the appearance of neurobrillary
tangles (NFT) in AD (Fig. 10).
184
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tion [442, 443] and, reciprocally, Ab aggregates preferentially bind cholesterol within the lipidic rafts [444]. Thus, a
drastic reduction in membrane cholesterol may result in
decreased amyloid production [442, 443]. On the contrary,
it has also been shown that neuronal membrane cholesterol
loss may enhance amyloid peptide generation [445], which
calls into question the population-based studies which have
demonstrated that cholesterol is an early risk factor for the
development of amyloid pathology [446].
Sphingomyelin (SM), another particularly signicant
lipid in signal transduction, when it accumulates, provides
a favorable milieu for GM1 ganglioside-induced assembly
of Ab-protein [447]. According to Grimm et al. [438], while
the control of cholesterol and SM metabolism involves APP
processing via regulation of the activity of the c-secretase
enzyme, Ab directly activates neutral sphingomyelinase, the
enzyme responsible for metabolizing SM to phosphocholine
and ceramide and downregulates SM levels or reduces de
novo cholesterol synthesis by inhibiting the hydroxymethylglutaryl-CoA reductase (HMGR) activity. Thus, Ab
becomes a cholesterol and sphingomyelin regulator, while
cholesterol and glycosphingolipids may elevate Ab production and SM may reduce Ab production by inhibition of
c-secretase [438]. This is particularly true in individuals
carrying the ApoE4 genotype, because this isoform binds
more avidly to Ab [448] (Fig. 11).
Fig. 11. Cholesterol may interfere with a-secretase activity or may enhance c-secretase (cs) activity, favoring the amyloidogenic pathway;
also, it is possible that cholesterol contributes by relocalizing APP near to the b-secretase (bs) inuence. Ab, correspondingly, aects
cholesterol inux and eux because of its ability to bind cholesterol transporters, while it inhibits cholesterol esterication. Sphingomyelin,
which makes up about 10% of the lipids of brain, has been related to c-secretase (cs) activity and the amyloidogenic pathway. Ab for its part
may induce apoptosis by activating the cPLA2-dependent sphingomyelinaseceramide pathway, which is a phenomenon related to caspase 3
activation, PI3K/Akt inhibition, and arachidonic acid release. Melatonins role (red crosses) in this hypothesis is related to the following: (1)
functional stability of the membrane by avoiding the lipid peroxidation cascade, (2) interfering with lipid-derived proinammatory signals,
(3) it is also possible that melatonin may interfere with PLA2 activity, (4) melatonin reduces cholesterol absorption or augments endogenous
cholesterol clearance mechanisms, and (5) melatonin may interfere with cholesterol transport as well or directly interact with cholesterol;
even though the eects derived from this possible interaction remain to be claried, it has been demonstrated that melatonin may favor the
displacement of cholesterol from the phospholipid bilayer. Reciprocally, cholesterol might inuence melatonins antioxidant capacity.
186
Concluding remarks
Is it just a coincidence that while melatonin declines with
age, the probability of experiencing AD grows? New
ndings on CSF ow, possibly moving from the choroid
ssure into the ventricular system, could help to explain
why melatonin is found in higher concentration in the CSF
than in simultaneously sampled blood. Thus, neural tissue
in contact with the ventricular system via hypothetical
choroid plexus portals would have high levels of cellular
melatonin [477]. A CSF deciency of melatonin has been
demonstrated to precede clinical symptoms of AD [22, 265]
and, the loss of this lipophilic antioxidant normally
concentrated in the ventricular CSF exposes highly active
and vulnerable brain tissue to self-generated oxygen radicals.
Melatonins more common indication in patients with
AD is sleep regulation because sleep disruptions, nightly
restlessness, and sundowning are frequently observed in
elderly and particularly in patients with AD [44]. This is
related to decreased levels of both melatonin [415] and
melatonin receptors in the SCN [478]. It has also a potential
to treat mood disorders [30, 43], commonly associated with
AD [28, 30].
By taking into account the most compelling hypotheses
trying to explain the cellular and biomolecular alterations
in Alzheimers disease, however, a growing body of
evidence supports the protective role of melatonin, exceed187
Rosales-Corral et al.
ing the above-mentioned conventional uses. Thus, melatonin has a role in each of the dierent reviewed hypotheses:
(i) it prevents amyloid overproduction, (ii) it reduces
hyperphosphorylation of tau [15, 166], (iii) it is an antioxidant and free radical scavenger, (iv) it modulates proinammatory processes, (v) it works well as an
anticholinesterase agent, (vi) it prevents mitochondrial
damage and the apoptotic phenomena related with AD,
(vii) it may impair calcium-dependent toxicity, (viii) it
reduces insulin resistance as well as glucose transport, and
nally (ix) it is able to maintain the integrity and functionality of cellular membranes, thanks to its ability to interact
with lipids or against their neuroinammatory or proapoptotic signals when the lipid balance becomes aected.
The functional translation of these biomolecular eects
has been also well documented. MT2 receptor-decient
mice undergo impairment of synaptic plasticity and learning-dependent behavior, suggesting that MT2 receptors
participate in hippocampal synaptic plasticity and in
memory processes [299]. Also relevant are the protective
eects of melatonin on cognition in a variety of tasks of
working memory, spatial reference learning/memory, and
basic mnemonic function, as observed in a transgenic model
of AD [20]. It is worth remembering the increased melatonin 1a-receptor immunoreactivity in the hippocampus of
patients with AD, which may be a compensatory response
to impaired melatonin levels [417].
It is also true that in transgenic animals, additionally
exposed to aluminum for months (aluminum has been
circumstantially linked to AD [16, 479, 480]), melatonin did
not ameliorate the behavioral eects [21] even though they
did respond well to the antioxidant actions of [92]. Limited
or even null results in memory performance or other high
mental functions using melatonin have been observed in
some clinical trials [11]. However, these changes are
associated with the loss of brain cells. The greater the loss
of brain cells, the more severe the deterioration in high
mental functions, and no drug exists that is capable of
regenerating lost neurons. Once the brain tissue has
degenerated, there is just a little chance of recovering [176].
There are several concerns about melatonin. From a
cellular, basic perspective, we nd a single report where
melatonin reportedly worsens the neurodegenerative
pathology. It is a rotenone-induced Parkinsons diseasespecic model, where melatonin not only failed to impair
neuronal degeneration but potentiated neurodegeneration
[19]. However, synergistic eects of melatonin against
MPTP-induced mitochondrial damage and dopamine
depletion have been also reported [481]. Otherwise, the
evidence indicating the protective role of melatonin on
mitochondria within CNS is vast [239, 342346, 348350,
352, 353, 355, 359].
On the other hand, there are several clinical concerns.
One refers to dose and side eects. In a few isolated studies,
melatonin has been related to sleepiness, dizziness, headaches, nightmares, confusion, sleepwalking, daytime sleepiness, and abdominal discomfort, even though some results
deserve a re-analysis. For example, using a high dose of
melatonin (20 mg/kg) in mice undergoing electroconvulsive
stimulation, a strong long-term memory decit was attributed to melatonin [482]. However, it was not clear what
188
Acknowledgements
A. Coto-Montes is an associate professor at Universidad de
Oviedo (Spain). Jose A. Boga is a researcher of HUCA/
FICYT (Oviedo, Spain). His stay at UTHSCSA has been
subsidized by Instituto de Salud Carlos III (Madrid, Spain).
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