Hyaluronan 35 prevents endotoxin-mediated dysregulated skeletal muscle proteostasis during ethanol exposure

Authors: WELCH, NICOLE - Cleveland Clinic; PUGAZHENDHI, KANNAS - Cleveland Clinic; Davuluri, Gangarao; BELLAR, ANNETTE - Cleveland Clinic; ATTAWAY, AMY - Cleveland Clinic; MISHRA, SAURABH - Cleveland Clinic; CUNNINGHAM, JASMIN - Cleveland Clinic; KUMAR, AVINASH - Cleveland Clinic; MUSICH, RYAN - Cleveland Clinic; ERTUGAL, ELIF - Cleveland Clinic; AGRAWAL, VANDANA - Cleveland Clinic; HSU, ISAAC - Cleveland Clinic; HARFORD, TERRI - Cleveland Clinic; WEISLEDER, NOAH - Cleveland Clinic; KOTHAPALLI, CHANDRASEKHAR - Cleveland State University; DE LA MOTTE, CAROL - Cleveland Clinic; NAGY, LAURA - Cleveland Clinic; DASARATHY, SRINIVASAN - Cleveland Clinic

Submitted to: American Journal of Physiology - Endocrinology and Metabolism
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 1/6/2026
Publication Date: 1/7/2026
Citation: Welch, N., Pugazhendhi, K., Davuluri, G., Bellar, A., Attaway, A., Mishra, S., Cunningham, J., Kumar, A., Musich, R., Ertugal, E., Agrawal, V., Hsu, I., Harford, T., Weisleder, N., Kothapalli, C., De La Motte, C., Nagy, L., Dasarathy, S. 2026. Hyaluronan 35 prevents endotoxin-mediated dysregulated skeletal muscle proteostasis during ethanol exposure. American Journal of Physiology - Endocrinology and Metabolism. 330:E212-E232. https://doi.org/10.1152/ajpendo.00283.2025.
DOI: https://doi.org/10.1152/ajpendo.00283.2025

Interpretive Summary: The studies evaluated the protective effects of Hyaluronic Acid (HA35) on skeletal muscle outcomes in models of alcohol-associated liver disease (ALD) and sepsis. Sarcopenia (muscle loss) in alcohol related liver disease (ALD) is frequent and contributes to adverse clinical outcomes with limited treatment options. Hyaluronans of specific fragment sizes (30-40 KDa) have anti-inflammatory and tissue protective properties. In an array of preclinical models of ALD, the investigators demonstrate that HA35 reverses ALD associated signaling, mitochondrial oxidative dysfunction, and phenotypic perturbations associated with sarcopenia in ALD. These effects are mediated without restoring the low muscle tissue concentrations of HA in ALD. Using combination of in vivo and in vitro analyses to studies explore the HA35-CD44 signaling axis, highlighting potential therapeutic mechanisms.

Technical Abstract: Sarcopenia in alcohol-related liver disease (ALD) is of high clinical significance but there are no effective treatments. Hyaluronan 35kDa (HA35), a glycosaminoglycan polymer, modulates responses to TLR4, a lipopolysaccharide receptor, to improve hepatic and macrophage function in ALD. We evaluated skeletal muscle responses to HA35 in preclinical models of ALD. Methods. Responses to ethanol, LPS, and HA35 were studied in differentiated murine C2C12/human-induced pluripotent stem cell (hiPSC)-derived myotubes, and wild-type/HA receptor CD44 knockout (CD44-/-) mouse models of ALD (mALD). Signaling molecules and measures of protein homeostasis (proteostasis) were quantified by immunoblots, mitochondrial oxidative function was determined by high-sensitivity respirofluorometry, membrane elasticity by atomic force microscopy, and muscle contractile responses to electrical stimulation ex-vivo were quantified. Multiomics, weighted gene co-expression network, and image analyses, were also performed. Results. Ethanol caused a sarcopenic phenotype in myotubes and mALD (lower myotube/muscle fiber diameter, muscle mass), less protein synthesis, impaired mTORC1 signaling, and higher autophagy markers and unaltered membrane elasticity. Expressions of LPS (TLR2, TLR4) and HA (CD44) receptors were upregulated by ethanol. In myotubes, LPS treatment caused a sarcopenic phenotype at lower concentrations in ethanol-treated myotubes. HA35 reversed ethanol/LPS-induced lower protein synthesis, impaired mTORC1 signaling, and mitochondrial complex I function in myotubes/muscle tissue. Muscle concentrations of HA fragments were lower in mALD, but beneficial responses to HA35 occurred without restoring HA concentrations, and HA35 was not beneficial in CD44-/- mALD. Conclusions. Sarcopenia, signaling perturbations, and mitochondrial oxidative dysfunction in mALD are reversed by HA35, allowing for rapid clinical translation.