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Cell death is a fundamental cellular response that has X protein (BAX) and BCL2-antagonist/killer-1 (BAK)
a crucial role in shaping our bodies during develop- double mutant mice) results in significant abnormalities4–6.
ment and in regulating tissue homeostasis by elimi- Apoptosis also functions to maintain homeostasis,
nating unwanted cells. The first form of regulated or especially in the immune system, because it eliminates
programmed cell death (PCD) to be characterized was unwanted cells. Dysregulation of apoptosis leads to vari-
apoptosis, which was described in Caenorhabitis elegans ous human diseases, such as cancer and autoimmunity.
in the early 1990s1. Subsequent genetic analysis of mam- Inappropriate activation of cell death is also the leading
malian apoptosis presented a more complex picture, in cause of tissue injury and functional decline in a large
which individual apoptosis genes from C. elegans have number of acute diseases (such as stroke, myocardial
expanded into large multi-protein families (FIG. 1). These infarction and brain trauma) and chronic diseases (such
findings suggest that redundancy, functional special as diabetes and neurodegeneration). However, effective
ization and compensatory regulation of mammalian cytoprotective therapies for these diseases remain a major
apoptotic signalling and execution might be important unmet medical need.
features of mammalian apoptosis. To a significant extent, the limited success of cyto
Because of its conserved and uniform nature, apop protective drug development can be traced to the simpli-
tosis is frequently defined mechanistically as a pathway fied view that cell death is either intrinsically regulated
of regulated cell death that involves the sequential activa- by apoptosis or that it is unregulated, caused by over-
tion of caspases, a family of Cys proteases, and that is whelming stress (so-called necrosis). Necrosis possesses
controlled both positively and negatively by B-cell lym- characteristic features, such as organelle swelling, mito-
phoma protein-2 (BCL2) family members. Assays have chondrial dysfunction, massive oxidative stress and rapid
*Tufts University,
now been developed for multiple steps of the pathway, plasma-membrane permeabilization, that are thought to
School of Medicine, allowing the characterization of apoptotic death in vitro be indicative of the catastrophic nature of cell death, rather
Department of Biochemistry, and in vivo. Apoptotic cell death is characterized by than a result of cellular regulation. The general view of
136 Harrison Ave., Boston, distinctive morphological features, including nuclear the relationship between apoptosis and necrosis is that
Massachusetts 02111, USA.
fragmentation, membrane blebbing and the formation milder insults to the cell cause apoptosis, whereas more
‡
Harvard Medical School,
Department of Cell Biology, of apoptotic bodies (see Ref. 2 for further details), that intense insults induce uncontrollable necrosis7. It is thought
200 Longwood Ave., Boston, can be used to identify apoptotic cell death events. that such an apparently unregulated — and hence untarg-
Massachusetts 02115, USA. Genetic studies have shown that apoptosis has a sig- etable — process accounts for the bulk of cell death events in
Correspondence to J.Y. nificant role during normal mammalian development3, acute pathologies. However, in the past few years, evidence
e‑mail:
jyuan@hms.harvard.edu
especially in the central nervous system where genetic has emerged for a number of regulated non-apoptotic
doi:10.1038/nrm2393 deficiency of apoptotic genes (such as caspase‑9, apoptotic cell death pathways, including some with morphological
Published online 16 April 2008 protease-activating factor-1 (APAF1), or BCL2-associated features that were previously attributed to necrosis8.
worms. Cytochrome c, which is released from damaged in turn cleave downstream caspases, such as caspase‑3 and
mitochondria, promotes the formation of a heptameric caspase‑7, to execute cell death; alternatively, caspase‑8
‘apoptosome’ megacomplex of APAF1 and caspase‑9 (a can cleave the BH3-only pro-apoptotic protein BID,
member of the CED‑3-like Cys protease family). This which in turn amplifies the cell death signal by causing
leads to the conformational change and activation of mitochondrial damage and cell death24. The development
caspase‑9 (FIG. 1). Activated caspase‑9 in turn cleaves of cytokine-mediated apoptosis programmes in higher
and activates downstream caspases, including caspase‑3, multicellular organisms provides a crucial way to coordin
caspase‑6 and caspase‑7, that carry out the execution ate the regulation of cell numbers at the organismal
phase of apoptosis21. level in response to the environmental stimuli.
In addition to the intrinsic apoptosis pathway, which
resembles PCD in C. elegans, mammalian cells also pos- Evolutionary expansion of apoptosis
sess an extrinsic apoptosis pathway, which is induced by Although the core regulators of PCD in C. elegans consist
pro-apoptotic and pro-inflammatory cytokines (such as of only 4 genes — egl‑1, ced‑3, ced‑4 and ced‑9 — each
FAS ligand (FASL) and tumour-necrosis factor‑α (TNFα), has multiple mammalian homologues. On the basis of
which are ligands for the death-receptor family)22. By bind- close homology in the key regions, the mammalian ced-
ing to death-domain receptors, FASL and TNFα induce like genes probably arose through gene duplication and
the formation of specific intracellular death-induced might have evolved and been selected during evolution
signalling complexes (DISCs23), which activate upstream to meet the challenges that highly complex multicellular
caspases such as caspase‑8. The activation of caspase‑8 can organisms face.
Multiple genes enable functional specialization. One cells is shown by the compensatory upregulation
direct consequence of this gene duplication is specifica- of caspases in different caspase mutant mice — the loss of
tion — different apoptosis regulators respond to different one caspase can be compensated by the upregulation
pro-apoptotic signals. The mammalian caspase family of another caspase37,38. Although the specification of
provides an excellent example of specification. Different different apoptotic regulators in a signal and/or subcellu-
caspase family members possess distinct functions in lar compartmentalization manner provides a mechanism
mammalian cells that are predominantly based on their to fine-tune cellular responses, danger might arise if a
subcellular localization and protein–protein interactions specified response is lost because of a genetic mutation.
rather than on their substrate specificities25. Mammalian In this case, it appears that upregulation of an alternative
caspases were initially assigned to three major classes: caspase, or of its regulators, can compensate for the loss
apical or activator caspases, such as caspase-2, -4, ‑8, -9, of a specific caspase.
‑10 and ‑12, which initiate the caspase cascade in apop- Although different caspases exhibit specificity towards
tosis; executioner caspases, such as caspase‑3, ‑6 and ‑7, certain cleavage sites39, such specificity is relative. When
which act in the downstream execution steps of the proc- present in a sufficient concentration and given sufficient
ess; and inflammatory caspases, such as caspase‑1, -5 incubation time, most caspases can cleave most, if not
and ‑11, which mediate cell death and inflammatory all, of the caspase substrates that have been identified to
responses. Further analyses suggest that there might be date. The preferential cleavage of a selective subgroup
additional important distinctions between family mem- of caspase substrates in the early phase of apoptosis
bers in the same class. Activator caspases have distinct may only reflect the proximity of the substrates to the
roles that depend on the activating complexes that they activated caspases at that specific time or they may serve
are recruited to. For example, caspase‑8 specifically to modulate the kinetics of the process. The ability of
contributes to death-receptor signalling26 and normal multiple caspases to cleave common substrates might
proliferation of lymphocytes27; caspase‑2 mediates serve to insure the execution of apoptosis even when
genotoxic stress-mediated death28; mouse caspase‑12 one caspase is lost. Furthermore, although upstream
and human caspase‑4 mediate endoplasmic reticulum caspases can be activated preferentially during the early
(ER)‑stress-mediated death29,30; and caspase‑9 is activ stages of apoptosis (such as caspase-8 and ‑10, which are
ated by the apoptosome downstream of cytochrome c preferentially activated in response to a FASL or TNFα
release31. Such division of labour might provide a sensi- signal26), all caspases are cleaved and activated during
tive mechanism to allow complex multicellular organ- the later stages of apoptosis. Therefore, all of the caspases
isms to detect and differentially respond to distinct may contribute to the execution of apoptosis21. Apoptosis
environmental stimuli. in mammalian cells is genetically programmed to maxi-
A similar division of labour has been observed for mize the ability to kill the cells once an appropriate order
the members of the BCL2 family. BCL2 family members is received.
can be subdivided into three major classes on the basis of
structural and functional differences17 (BOX 1). However, Expansion or reduction. Although the findings dis-
recent studies suggest that subtle but important differ- cussed above lead us to suggest that apoptotic pathways
ences exist in each sub-class. In particular, although all expanded during evolution, another view is also poss
BH3-only factors possess a similar EGL‑1-like mode ible. C. elegans, along with its evolutionary relatives,
of action, they can be activated non-redundantly by might have experienced a reduction in the complexity
particular types of apoptotic signals. For example, BID of the apoptotic machinery from primordial ancestors
mediates signalling by the TNF-family and by genotoxic with apoptotic machinery that might have been closer
stress16,32; BIM plays a key part in inducing death in lym- to that of humans. However, we find this scenario less
phoid and myeloid cells following cytokine withdrawal33; likely, because no such developed apoptotic machinery,
NOXA and PUMA signal downstream of p53 (Ref. 34); resembling that of mammals, has been identified in more
and BMF has a key role in anoikis35. The specificities of primitive organisms, such as plants, fungi and bacteria.
BH3-only factors not only result from their interactions
with upstream regulators, they also result from their Non-apoptotic mechanisms of cell death
distinct binding preferences for different multidomain Emerging evidence suggests that apoptosis is not the
Anoikis BCL2 family members. For example, the BH3 domain of only mechanism of cellular suicide, but rather that cells
Cell death caused by cell
detachment from the matrix.
BAD binds BCL2 and BCL-XL, whereas the BH3 domain might choose one of many mechanisms to die when
of NOXA displays selectivity towards MCL1 and the they are ready, with apoptosis often representing the
Linker cell BCL2-related protein A1 (Ref. 36). Such selectivity in top choice. In C. elegans, most developmental cell death
A cell in a C.elegans embryo the interactions of different members of the BCL2 family events occur through the apoptotic mechanism and only
that is positioned between the
provides an important mechanistic basis for activating rare events, such as the developmental death of a linker
gonad and the cloacal tube.
distinct apoptosis signalling pathways in response to cell, are non-apoptotic40. Type I cell death, which displays
Type I cell death different pro-apoptotic stimuli. the characteristic morphology of apoptosis as discussed
A term introduced as part of a above, is also the most frequently observed form of
morphological classification of The benefits of redundancy. An additional and non- death during normal mouse development2. Although
developmental cell death.
Type I death shows the
conflicting significance of the multiplication of apoptosis induction of morphologically non-apoptotic develop-
morphological features of regulators is the benefit that is provided by redundancy. mental cell death becomes prominent in mice in vivo
apoptosis. The redundancy of apoptosis programmes in mammalian when apoptotic machinery is genetically disrupted
Box 3 | The contribution of non-apoptotic cell death to pathological injury Although the fine details of PARP1-dependent cell death
remain to be sorted, it is clear that PARP1-mediated cell
Recent studies have shown that non-apoptotic cell death is not just a nuisance of death is an important subject for investigation because
in vitro experimentation — it makes important contributions to pathological of its role in various human pathologies (BOX 3).
regulation in vivo.
Autophagy has been prominently observed in various disease models and its
inhibition can provide therapeutic benefit. For example, recent studies suggest that
The roots of regulated cell death
Beclin-1-dependent autophagy promotes injury in mouse models of heart ischaemia– Curiously, although the phenomenon of apoptosis was
reperfusion injury and heart failure125,126. In addition, autophagy suppresses apoptosis first described in the context of developmental regulation,
in MYC-dependent lymphomas, promoting tumour growth127. Conversely, genetic the function of apoptosis in development is not clear-
analysis has clearly established that Beclin-1 functions as a tumour suppressor128. cut; C. elegans ced‑3 (loss-of-function) or ced‑4 (loss-of-
Autophagy promotes the survival of cancer cells that express apoptosis-inhibiting function) mutants are developmentally normal81. If PCD
BCL2 family members under the conditions of hypoxia129. However, inhibiting does not provide a developmental advantage for nema-
autophagy under such conditions unleashes necrosis, which might promote todes that have it compared with ancient variants that
inflammation and, ultimately, tumorigenesis. These data suggest a complex role of lacked it, what factors might have led to the selection and
autophagy in tumour formation.
evolution of PCD mechanisms? Interestingly, ced‑3 and
As the morphology of necroptotic cell death is similar to that of necrosis, it has been
ced‑4 mutants were found to be significantly more sensi-
investigated whether pathological necrosis might actually represent, if only in part,
regulated necroptosis. Indeed, administration of necroptosis inhibitor necrostastin‑1 tive to death caused by Salmonella typhimurium infection
(Nec‑1) provides significant tissue protection and functional improvements in a range compared with wild-type worms82, raising the possibility
of acute tissue injuries in vivo in mouse models (brain and heart ischaemia–reperfusion) that the host defence response, rather than develop
by mechanisms that are clearly distinct from the inhibition of pathological mental cell death, might be the primordial function
apoptosis63,72,130. In particular, in a mouse model of stroke, the effect of Nec‑1 was both of apoptosis.
temporally and mechanistically (measured through caspase‑3 activation) distinct from The host defence function of apoptosis has been
that of apoptosis inhibitors. Furthermore, the protective effect of Nec‑1 did not require expanded in mammalian cells. A large family of mamma-
co-administration of caspase inhibitors, although the pan-caspase inhibitor zVAD.fmk lian NLR (NOD-like receptor) proteins, homologous to
and Nec‑1 did have an additive effect (FIG. 3).
C. elegans CED‑4 and mammalian APAF1, function
Poly(ADP–ribose) polymerase‑1 (PARP1) inhibitors provide significant protective
to regulate the activation of caspases in response to
effects in mouse brain and heart ischaemia–reperfusion injury, mouse models of
colitis and other inflammatory diseases, neurodegeneration and diabetes mellitus intracellular pathogens83. NLRs contain three distinct
(reviewed in Refs 131–133). PARP1 inhibitors have also emerged as promising domains: an N‑terminal caspase-recruitment domain
anti-cancer agents, increasing the sensitivity of resistant cancer cells to various (CARD) or pyrin effector domain (with the exception
DNA-damaging agents and also selectively killing some tumour cells134. of neuronal apoptosis-inhibitory protein (NAIP) and,
possibly, NOD5 (also known as NLRX1)); a nucleotide-
binding and oligomerization domain (the so-called
Rapidly proliferating glycolytic cells might pose a sig- NACHT domain); and a variable number of C‑terminal
nificant danger for the organism if they accumulate Leu-rich repeats (LRRs) (BOX 1). The 22 identified NLRs
DNA damage and, hence, have to be efficiently elimi- can be divided into two large sub-classes — the NODs
nated; by contrast, vegetative cells can be allowed (NOD1–5), which activate the RIP2–NF-κB pathway,
more time to complete DNA repair. Along these lines, and the NLRs, consisting of NALP1–14 (NALP is named
PARP1 activation also leads to the specific release of the after NACHT‑, LRR- and pyrin domain (PYD)-containing
inflammatory cytokine high mobility group protein‑B1 proteins), IPAF (also known as NLRC4) and NAIP,
(HMGB1), which can alert immune cells to the presence which promote caspase‑1 activation84. In addition, the
of dangerous cells with damaged DNA77. PARP1 also NLR protein CIITA (major histocompatibility complex
mediates cell death that is induced by secondary DNA (MHC) class II trans-activator) serves the function of
damage associated with acute neuronal injury. In this master regulator of MHC class II transcription85. At least
case, excitatory neuronal cell death leads to the trans- some of the NALPs function by recruiting the adaptor
location of the poly(ADP–ribose)-polymer into the protein ASC through a homotypic PYD–PYD inter-
cytosol, triggering translocation of protein apoptosis- action, and ASC in turn recruits caspase‑1 through a
inducing factor (AIF) from the mitochondria to the CARD–CARD interaction86. Oligomerization of NALPs
nuclei, where it mediates cell death78,79. Interestingly, brings the inflammatory caspases, such as caspase‑1 and
DNA-damage-induced PARP1-mediated cell death caspase‑5, into close proximity to promote their activa-
involves TNF receptor-associated factor-2 (TRAF2)– tion. This NALP protein complex is called the inflam-
RIP1-dependent activation of c-Jun N‑terminal masome87. The activation of caspase‑1 in turn leads to
kinase‑1 (JNK1, also known as MAPK8), which con- the processing and release of interleukin‑1β (IL-1β) and
tributes to mitochondrial dysfunction and necrotic IL‑18, which serve important pro-inflammatory func-
death80. However, the relationship between this process tions. The NALP1-mediated caspase‑1 activation is also
and necroptosis remains unclear. regulated by anti-apoptotic proteins of the BCL2 family88,
Currently, it is difficult to make definitive conclu- providing a possible role for BCL2 family proteins in
sions regarding the relationship of the two pathways regulating the host defence response.
NLR of PARP1-induced cell death. However, it appears pos- Interestingly, the origins of the NLR family can be
A mammalian protein that is
characterized by the presence
sible that NAD+ depletion and AIF activity act in the traced to non-apoptotic regulators in simple organisms,
of NACHT and Leu-rich repeat same pathway and that their relative contributions to potentially providing an exciting insight into the evo
(LRR) domains. cell demise might depend on the specific cell milieu. lutionary origins of mammalian apoptosis. Mammalian
a Predominantly necroptosis b Predominantly apoptosis One could speculate that autophagic cell death might have
arisen from the need to ensure the survival of the whole
organism through sacrificing infected cells. Both type I and
II interferons (IFNs) modulate macroautophagy as a part
of the antiviral response98. In this regard, it is interesting
that treatment of human HeLa cells with IFNγ leads to
the induction of autophagy through the activation of
death-associated protein (DAP) kinases104, and overactiv
ation of DAP kinases can lead to autophagic cell death.
Thus, autophagic cell death might be part of the antiviral
No cytoprotection Maximal Maximal No cytoprotection response that is activated by IFNs.
cytoprotection cytoprotection The functional significance of necroptosis in the host
defence response is less clear. However, RIP1, a kinase
c Mixed model d Synergistic model
that is crucially involved in the activation of necroptosis,
has an important role mediating the activation of NF‑κB
and IFN genes in the context of the innate immune
system105, although apparently in a kinase-independent
manner. RIP1 signalling can be triggered by extracellular
pathogen-sensing Toll-like receptors106,107, components
of invading pathogens108 and inflammatory cytokines,
such as TNFα. The closest D. melanogaster homologue
of RIP1, IMD, is also a key mediator of the innate immune
response to Gram-negative bacteria, acting upstream of
Partial cytoprotection Partial cytoprotection No cytoprotection No cytoprotection a number of factors that are also linked to RIP1 signal-
ling in mammalian cells, including the D. melanogaster
homologues of FADD, caspase‑8, IKK (inhibitor of
nuclear factor (NF)-κB (IκB) kinase) complex and
NF‑κB109. Furthermore, IMD can also mediate caspase-
dependent apoptosis109, similar to the recently discovered
RIP1-dependent, caspase‑8-mediated apoptosis cascade
Maximal Maximal
cytoprotection cytoprotection in mammalian cells110.
Curiously, IMD lacks a kinase domain, so kinase-
zVAD.fmk Apoptotic cell Healthy cell dependent induction of necroptosis might be an evo-
Nec-1 Necroptotic cell lutionarily novel addition to the repertoire of RIP1
functions. Therefore, RIP1 might promote both the
Figure 3 | Plasticity of cell death activation in vivo. The existence of multiple cell
death mechanisms suggests that careful consideration should be given to determine induction of specific inflammatory signalling (by NF-κB
Nature Reviews | Molecular Cell Biology
which mechanism (or mechanisms) is primarily activated in any particular injury and IFN upregulation) and the elimination of infected
paradigm if therapeutic approaches are to prove useful. As an example, multiple cells through a pro-inflammatory process (necrosis). The
outcomes of anti-apoptotic or anti-necroptotic therapies can be anticipated depending promotion of necrosis can by itself serve to potentiate
on the specific injury paradigm. a | Predominant necrotic death might occur when the the antibacterial response by causing a leakage of cellular
endogenous conditions prohibit apoptosis. Use of necrostatin‑1 (Nec-1), which inhibits contents and the specific release of pro-inflammatory
RIP1-dependent necroptosis, might provide maximal cytoprotective benefit as a single mediators, such as IL-6 (Ref. 111). Recently discovered
agent under these circumstances. b | Alternatively, apoptotic cell death might be cell-death-independent activation of autophagy by
predominant in cell populations that are not subjected to excessive external stress, or TLR4–RIP1 as a potential mechanism for bacterial clear-
that are intrinsically deficient in necroptosis activation58,63. zVAD.fmk prevents apoptosis
ance also fits well with this notion103. These data suggest
by inhibiting caspases. c | A mixture of apoptotic and necroptotic cell death might occur,
leading to a significant, but partial, cytoprotective effect of each treatment and an that the evolution of the innate immune response might
additive effect of combination therapy. d | Apoptosis might be the predominant ‘primary’ have led to the acquisition of the RIP1-kinase-mediated
form of cell death. However, inhibition of apoptosis might result in the activation of necroptotic response by the IMD pathway.
necroptosis. In this scenario, neither apoptosis nor necroptosis inhibitors might work as
single agents, and combined treatment could provide maximal cytoprotective benefit. Opportunities for cytoprotective therapy
Catastrophic cell death is the main underlying cause of
death and lifelong disabilities in a broad range of human
Autophagy has a well-established role in defending diseases, from acute disorders (such as stroke, myocardial
against viral and bacterial invasion (reviewed in Ref. 98). infarction, brain and spinal cord trauma and septic shock)
Sindbis virus, a single-stranded RNA virus of the Togavirus to chronic neurodegenerative conditions. Cell death is
Macroautophagy family, causes encephalitis, which can be ameliorated by also an important compounding factor as a side effect
The sequestration of cytosolic overexpression of Beclin-1 in transgenic mice99. Bacteria of chemotherapy, many inflammatory diseases, diabetes
components in that escape into the cytosol from the endosomes can be and other conditions. Therefore, the development of effi-
autophagosomes and their
subsequent degradation when
engulfed by macroautophagy100,101. Furthermore, autophagic cient strategies to inhibit pathological cell death remains
autophagosomes fuse with machinery promotes the clearance of extracellular a key challenge of cell death research and a crucial unmet
lysosomes. bacteria that are recognized by the TLR4 receptor102,103. medical need.
TRAF2
TRAF2
membrane
Necroptosis complex
RIP1
RIP1
RIP1
RIP1
RIP1
RIP1
TRADD
TRADD
TRADD
Ub ? Ub ? Ub ?
Complex I
Ub Ub Ub
Ub Ub Ub
Rac1
Rac1
Rac1
Ub ? Ub ? Ub ?
DISC
NIK
NIK
IKK
IKK
IKK
NIK
TRADD
The discovery of apoptosis and the development of It is important to keep in mind that although apopto-
specific genetic and small molecule methods to inhibit sis may be the preferred type of physiological cell death,
pathological apoptosis in vivo have shown that pathological the option to die by apoptosis might not always be avail-
cell death can, indeed, be targeted for therapeutic benefit. able under in vivo conditions. Situations that involve an
However, the success of anti-apoptotic therapies has been imbalance of ROS-generation and ROS-detoxification,
limited, perhaps because of our lack of understanding of limited energy metabolism or a lack of proper protein
the complexity of cell death regulation in mammalian synthesis might restrict the ability of cells to activate
cells. The appreciation of such complexity leads us to sug- apoptotic cell death. Under such circumstances, cells
gest that when considering the possibility of inhibiting a might choose to die through one of the alternative
specific pathological mechanism of cell death, we must cell death pathways. The existence of other cell death
consider several issues. Does one particular form of cell options suggests that there might be some plasticity in
death have a major role in the injury (FIG. 3)? Alternatively, the choice of cell death programmes, with apoptosis
are several cell death mechanisms operational in the being only one of the spectrum of available regulated cell
injured tissue? If several mechanisms are operational, death options. Furthermore, rather than considering a
then combination therapy might provide maximal benefit. hierarchal regulation of multiple cell death mechanisms,
Whether a combination therapy will be effective depends in which cells first activate apoptosis and only undergo
on the contribution of each form of death, not only to the non-apoptotic cell death if apoptosis is inhibited, we
tissue injury, but also to the functional decline of the tissue propose that commitment to apoptosis might not even
(FIG. 3c). We must also consider whether a possible backup be necessary for the activation of non-apoptotic cell
cell death mechanism that might be activated in the event demise. In other words, non-apoptotic signalling can
of the primary mechanism is being inhibited. Given these be initiated independently through alternative mecha-
Interferon
An inflammatory cytokine that
possibilities, cytoprotective treatment might not only be nisms to carry out the order of cellular execution under
is produced by cells as part of improved by combination treatment, it might require conditions that are ill-suited for apoptosis, but ideal for
the innate immune response. combination treatment (FIG. 3d). non-apoptotic cell death (FIG. 4).
The discovery of the apoptotic programme opened the these features allowed specialized activation of cell death
door for the development of specific cell-death-targeting responses by various upstream stimuli, improved inte-
‘smart’ therapies. Pathological cell death processes might gration of apoptosis with other cellular signalling and
represent a ‘conscious’ decision of the cell in response metabolic pathways, and increased fidelity of apoptosis
to specific pathological signals, which would allow the execution, due to the redundancy in the functions of
development of specific approaches to influence this individual members of apoptosis regulatory families.
‘choice’ by small molecule or protein-based agents that Recent characterization of the inflammasome pathway
could target the apoptotic signalling machinery. This of caspase‑1 activation revealed that the evolution of
has already led to the development of multiple classes mammalian apoptosis probably involved convergence
of agent, such as BCL2 and inhibitor of apoptosis (IAP) of the primitive apoptosis machinery with the innate
proteins, that specifically trigger apoptosis in cancer immune system.
cells112. Although these agents are still in the early stages In the past few years we have also begun to appreciate
of clinical development, preliminary evidence is promis- that apoptosis is not the only form of regulated cell death.
ing. At the same time, therapies to eliminate catastrophic Three of the best-understood examples of non-apoptotic
tissue damage and functional decline, which are asso- cell death are type II cell death, necroptosis and PARP1-
ciated with pathological cell death in various human mediated necrotic death (see above). Although these
pathologies (from stroke to myocardial infarction), are processes can serve functions that are complimentary
still limited. The recent discovery of regulated non- or reinforce apoptosis, it is likely that they have evolved
apoptotic cell death might offer a new hope for treating to serve specific non-redundant functions in responses to
these diseases. Although the study of these forms of cell pathogen infection, nutrient and energy deprivation,
death is still in its infancy, a number of promising results and DNA damage. The changing perception of regu-
have already been generated (BOX 3). lated cell death as an array of diverse responses, rather
than a single apoptotic pathway, implicates complexity
Conclusion and provides novel opportunities for cytoprotective
Less than 2 decades ago, cell death was categorically con- therapies. In particular, the discovery of the specific
sidered to be passive and uninteresting. The discovery regulated, morphologically necrotic, non-apoptotic cell
of mammalian homologues of C. elegans cell death genes death mechanisms suggests that at least a subset of
led to the understanding that cell death, in the form of necrotic pathological cell death might also be regulated
apoptosis, can be a highly regulated cellular mechanism. by cellular mechanisms and, therefore, could be amend-
In-depth characterization of mammalian apoptosis able to therapeutic drug development. Understanding
uncovered both conservation of the basic layout of apop- how cell death operates under the specific conditions of
totic signalling in C. elegans and evolutionary expansion particular human diseases might bring in a new era
of the protein families of apoptotic regulators. Moreover, of cytoprotective drug development.
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