Given the role of the autophagic pathway as a degradation system for clearance of aggregated proteins, it is not surprising that autophagic deregulation observed in various neurodegenerative disorders has attracted mounting interests. For example, accumulation of autophagosomes are evident in the brains of Alzheimer's disease patients [
13]. Indeed, protein aggregates presents one of the common features in a myriad of neurodegenerative diseases, including the β-amyloid plagues in Alzheimer's disease, mutant huntingtin cytoplasmic inclusions in Huntington's disease, and the alpha-synuclein containing Lewy bodies in PD. While the role of these protein aggregates in the pathogenesis of these disorders remain controversial, it is plausible that removal of protein aggregates through activation of the autophagic pathway would interfere with the potential toxicity of these aggregates, thereby alleviating disease progression. Indeed, accumulating evidence supports a protective role of autophagy through clearance of protein aggregates. For example, reduction of huntingtin aggregates in a model of Huntington's disease through activation of macroautophagy limits neuronal loss and behavioral deficits [
16]. Furthermore, knock down of autophagy-related (ATG) genes, molecular players that are pivotal for the induction and execution of macroautophagy, results in neurodegeneration and the presence of cytoplasmic inclusions filled with ubiquitinated proteins [
17,
18]. These observations suggest that basal level of autophagy is important for the clearance of protein aggregates, and the reduction of cytoplasmic inclusions may be protective against neurodegenerative diseases. Nonetheless, excessive activation of the autophagic pathway has also been associated with cell death [
15]. It is therefore pivotal to delineate the precise involvement of autophagy in the pathogenesis of neurodegenerative diseases.
Autophagy as a protective mechanism in PD
One of the first evidence in support of an important role of autophagy in PD came from the demonstration that alpha-synuclein is degraded by macroautophagy and CMA [
19‐
21]. Since alpha-synuclein is the major constituent of Lewy bodies, which is a pathological hallmark in both sporadic and familial cases of PD, it is important to delineate the mechanisms by which alpha-synuclein is degraded. Interestingly, while the ubiquitin-proteasome pathway and macroautophagy are both implicated in the clearance of alpha-synuclein, CMA was found to be essential for the degradation of wildtype alpha-synuclein [
19‐
21]. Furthermore, inhibition of CMA results in the formation of high molecular weight and detergent-insoluble species of alpha-synuclein [
21], revealing that in healthy neurons, clearance of alpha-synuclein by CMA is crucial for limiting the oligomerization of alpha-synuclein. Importantly, A53T and A30P mutants of alpha-synuclein, which cause familial PD, were found to inhibit CMA through exhibiting a higher affinity for LAMP2A [
20]. Nonetheless, alpha-synuclein mutants are poorly internalized into lysosomes, and are degraded by macroautophagy instead of CMA. Accompanying the inhibition of CMA by alpha-synuclein mutants is a compensatory activation of macroautophagy, although the physiological significance of this event is incompletely understood. Nonetheless, these observations suggest that A53T and A30P alpha-synuclein mutants may induce alpha-synuclein aggregation through inhibition of CMA, thereby leading to impaired clearance of cellular alpha-synuclein. On the other hand, 193M missense mutation in UCH-L1, which was previously identified in familial cases of PD, is also implicated in the regulation of CMA [
22]. They found that mutant UCH-L1 exhibits an abnormally high affinity towards key players in the CMA pathway, such as LAMP2A and Hsc70. More importantly, overexpression of UCH-L1 mutant increases alpha-synuclein level [
22], suggesting that UCH-L1 mutation may also contribute to PD pathology through regulating alpha-synuclein levels. These findings reveal that inhibition of CMA-mediated degradation of alpha-synuclein may constitute an important pathogenic mechanism for PD.
Interestingly, it was recently demonstrated that alpha-synuclein may also contribute to neuronal death in PD through inhibiting CMA-mediated degradation of survival factor MEF2D [
23]. Both wildtype and A53T mutant of alpha-synuclein interfere with the binding of MEF2D to CMA machinery Hsc70. Consistent with this observation, MEF2D level is elevated in A53T alpha-synuclein transgenic mice, and also in PD patients. Furthermore, overexpression of both wildtype and A53T mutant of alpha-synuclein inhibit MEF2 activity, and result in neuronal death [
23]. These observations reveal that in addition to alpha-synuclein, impaired CMA may also trigger neuronal death through inefficient degradation of other proteins. These findings collectively raise the interesting possibility that preservation of CMA functions may serve as an effective treatment against PD.
Aside from the degradation of alpha-synuclein, the autophagic pathway is also involved in the turnover of mitochondria. Mitochondrial dysfunction presents one of the pathogenic mechanisms in PD. In particular, deficits in the mitochondrial complex I is observed in PD patients. Furthermore, MPTP, the neurotoxin that generates PD symptoms in human through selective degeneration of dopaminergic neurons in the substantia nigra, functions as a complex I inhibitor after it is converted into MPP
+ [
3]. More importantly, mutations identified from cases of familial PD have been mapped to Parkin and PINK1, two proteins that are implicated in the control of mitochondrial morphology and function [
11,
12]. Mutation in these two proteins presumably leads to loss of function, thus resulting in mitochondrial abnormality. Recently, Parkin was found to facilitate macroautophagy of impaired mitochondria, a process that is also known as mitophagy [
24]. Parkin is selectively targeted to mitochondria that are impaired, characterized by a low mitochondrial transmembrane potential, which are then eliminated by macroautophagy [
24]. In support of a role of autophagy in the clearance of defective mitochondria in PD, knock down of PINK1 expression induces mitochondrial fragmentation, followed by activation of autophagy/mitophagy [
25]. These observations suggest that the autophagic pathway is essential for the turnover of dysfunctional mitochondria in PD. Failure to activate efficient mitophagy may serve as a pathogenic mechanism of PD.
Could excessive activation of the autophagic pathway lead to cell loss?
Despite mounting observations that are in support of a protective role of autophagy in various models of PD, one essential question remains unanswered. While it is perceivable that insufficient autophagy activation would impair clearance of protein aggregates and dysfunctional mitochondria, whether excessive activation of autophagy happens in PD, and whether it plays a role in PD pathology remains unknown. This question is particularly important since excessive activation of autophagy is associated with neuronal loss [
15]. Indeed, abnormal presence of autophagic vacuoles is evident in the brains of PD patients, in contrast to the rare detection of autophagosomes in normal brain, due to the rapid clearance of these vesicles in the central nervous system [
26,
27]. The presence of autophagosomes in PD brains could represent aberrant activation of macroautophagy, although defective clearance of the autophagic vacuoles could also account for this observation. While there is little evidence to delineate the two possibilities,
in vitro findings reveal that macroautophagy can be induced by players associated with PD pathology. For example, as mentioned previously, overexpression of alpha-synuclein mutants results in activation of macroautophagy [
20,
21]. Aside from alpha-synuclein, GPR37, another protein that is present in Lewy bodies, is also recently demonstrated to induce macroautophagy [
28]. Furthermore, treatment with MPP
+ has also been observed to increase autophagic vacuole contents [
29]. Clearly, a question that urgently needs to be addressed is whether the induction of macroautophagy results in cell death. Several studies provided evidence that overexpression of A53T mutant of alpha-synuclein in PC12 cells, cultured neurons and the nigrostriatal systems results in autophagic cell death [
23,
30‐
32]. These studies indicate that while activation of macroautophagy may serve as a protective machinery, excessive activation could result in neuronal death and hence also contribute to cell loss in PD.