Aop: 173


Each AOP should be given a descriptive title that takes the form “MIE leading to AO”. For example, “Aromatase inhibition [MIE] leading to reproductive dysfunction [AO]” or “Thyroperoxidase inhibition [MIE] leading to decreased cognitive function [AO]”. In cases where the MIE is unknown or undefined, the earliest known KE in the chain (i.e., furthest upstream) should be used in lieu of the MIE and it should be made clear that the stated event is a KE and not the MIE. More help

Substance interaction with the lung resident cell membrane components leading to lung fibrosis

Short name
A short name should also be provided that succinctly summarises the information from the title. This name should not exceed 90 characters. More help
Substance interaction with the lung cell membrane leading to lung fibrosis

Graphical Representation

A graphical summary of the AOP listing all the KEs in sequence, including the MIE (if known) and AO, and the pair-wise relationships (links or KERs) between those KEs should be provided. This is easily achieved using the standard box and arrow AOP diagram (see this page for example). The graphical summary is prepared and uploaded by the user (templates are available) and is often included as part of the proposal when AOP development projects are submitted to the OECD AOP Development Workplan. The graphical representation or AOP diagram provides a useful and concise overview of the KEs that are included in the AOP, and the sequence in which they are linked together. This can aid both the process of development, as well as review and use of the AOP (for more information please see page 19 of the Users' Handbook).If you already have a graphical representation of your AOP in electronic format, simple save it in a standard image format (e.g. jpeg, png) then click ‘Choose File’ under the “Graphical Representation” heading, which is part of the Summary of the AOP section, to select the file that you have just edited. Files must be in jpeg, jpg, gif, png, or bmp format. Click ‘Upload’ to upload the file. You should see the AOP page with the image displayed under the “Graphical Representation” heading. To remove a graphical representation file, click 'Remove' and then click 'OK.'  Your graphic should no longer be displayed on the AOP page. If you do not have a graphical representation of your AOP in electronic format, a template is available to assist you.  Under “Summary of the AOP”, under the “Graphical Representation” heading click on the link “Click to download template for graphical representation.” A Powerpoint template file should download via the default download mechanism for your browser. Click to open this file; it contains a Powerpoint template for an AOP diagram and instructions for editing and saving the diagram. Be sure to save the diagram as jpeg, jpg, gif, png, or bmp format. Once the diagram is edited to its final state, upload the image file as described above. More help


List the name and affiliation information of the individual(s)/organisation(s) that created/developed the AOP. In the context of the OECD AOP Development Workplan, this would typically be the individuals and organisation that submitted an AOP development proposal to the EAGMST. Significant contributors to the AOP should also be listed. A corresponding author with contact information may be provided here. This author does not need an account on the AOP-KB and can be distinct from the point of contact below. The list of authors will be included in any snapshot made from an AOP. More help

Sabina Halappanavar 1*, Monita Sharma2, Silvia Solorio-Rodriguez1, Hakan Wallin3, Ulla Vogel3, Kristie Sullivan4, Amy J. Clippinger2

1Environmental Health Science and Research Bureau, Health Canada, Ottawa.

2PETA International Science Consortium Ltd., London, United Kingdom.

3National Research Centre for the Working Environment, Copenhagen, Denmark.

4Physicians Committee for Responsible Medicine, Washington, DC.

*Point of contact

Sabina Halappanavar, PhD

Research Scientist, Genomics and Nanotoxicology Laboratory

Environmental Health Science and Research Bureau, ERHSD, HECSB, Health Canada

Tunney's Pasture Bldg. 8 (P/L 0803A),

50 Colombine Driveway, Ottawa, Ontario, K1A 0K9 Canada.


Point of Contact

Indicate the point of contact for the AOP-KB entry itself. This person is responsible for managing the AOP entry in the AOP-KB and controls write access to the page by defining the contributors as described below. Clicking on the name will allow any wiki user to correspond with the point of contact via the email address associated with their user profile in the AOP-KB. This person can be the same as the corresponding author listed in the authors section but isn’t required to be. In cases where the individuals are different, the corresponding author would be the appropriate person to contact for scientific issues whereas the point of contact would be the appropriate person to contact about technical issues with the AOP-KB entry itself. Corresponding authors and the point of contact are encouraged to monitor comments on their AOPs and develop or coordinate responses as appropriate.  More help
Cataia Ives   (email point of contact)


List user names of all  authors contributing to or revising pages in the AOP-KB that are linked to the AOP description. This information is mainly used to control write access to the AOP page and is controlled by the Point of Contact.  More help
  • Monita Sharma
  • Sabina Halappanavar
  • Cataia Ives


The status section is used to provide AOP-KB users with information concerning how actively the AOP page is being developed, what type of use or input the authors feel comfortable with given the current level of development, and whether it is part of the OECD AOP Development Workplan and has been reviewed and/or endorsed. “Author Status” is an author defined field that is designated by selecting one of several options from a drop-down menu (Table 3). The “Author Status” field should be changed by the point of contact, as appropriate, as AOP development proceeds. See page 22 of the User Handbook for definitions of selection options. More help
Author status OECD status OECD project SAAOP status
Under development: Not open for comment. Do not cite EAGMST Under Review 1.32 Included in OECD Work Plan
This AOP was last modified on May 08, 2022 11:33
The date the AOP was last modified is automatically tracked by the AOP-KB. The date modified field can be used to evaluate how actively the page is under development and how recently the version within the AOP-Wiki has been updated compared to any snapshots that were generated. More help

Revision dates for related pages

Page Revision Date/Time
Substance interaction with the lung resident cell membrane components May 04, 2022 12:11
Increased, secretion of proinflammatory mediators January 25, 2022 15:50
Increased, recruitment of inflammatory cells January 25, 2022 15:52
Loss of alveolar capillary membrane integrity December 15, 2021 10:13
Increased, activation of T (T) helper (h) type 2 cells December 15, 2021 10:16
Increased, fibroblast proliferation and myofibroblast differentiation November 29, 2021 14:37
Increased, extracellular matrix deposition January 25, 2022 16:26
Pulmonary fibrosis December 06, 2021 10:07
Accumulation, Collagen May 04, 2022 12:47
Interaction with the lung cell membrane leads to Increased proinflammatory mediators December 15, 2021 09:26
Increased proinflammatory mediators leads to Recruitment of inflammatory cells December 07, 2021 10:28
Recruitment of inflammatory cells leads to Loss of alveolar capillary membrane integrity December 15, 2021 09:38
Loss of alveolar capillary membrane integrity leads to Activation of Th2 cells December 15, 2021 09:41
Activation of Th2 cells leads to Increased cellular proliferation and differentiation December 15, 2021 09:47
Increased cellular proliferation and differentiation leads to Increased extracellular matrix deposition December 07, 2021 09:39
Increased cellular proliferation and differentiation leads to Accumulation, Collagen May 04, 2022 12:55
Increased extracellular matrix deposition leads to Pulmonary fibrosis December 06, 2021 16:55
Bleomycin October 29, 2019 13:08
Carbon nanotubes, Multi-walled carbon nanotubes, single-walled carbon nanotubes, carbon nanofibres January 01, 2018 17:52


In the abstract section, authors should provide a concise and informative summation of the AOP under development that can stand-alone from the AOP page. Abstracts should typically be 200-400 words in length (similar to an abstract for a journal article). Suggested content for the abstract includes the following: The background/purpose for initiation of the AOP’s development (if there was a specific intent) A brief description of the MIE, AO, and/or major KEs that define the pathway A short summation of the overall WoE supporting the AOP and identification of major knowledge gaps (if any) If a brief statement about how the AOP may be applied (optional). The aim is to capture the highlights of the AOP and its potential scientific and regulatory relevance More help

This AOP describes the qualitative linkages between interactions of substances (e.g. physical, chemical or, receptor-mediated) with the membrane components (e.g. receptors, lipids) of lung cells leading to fibrosis. This AOP represents a pro-fibrotic mechanism that involves a strong inflammatory component. It demonstrates the applicability of the AOP framework for nanotoxicology and describes a mechanism that is common to both chemical and nanomaterial-induced lung fibrosis. Lung fibrosis is a dysregulated or exaggerated tissue repair process. It denotes the presence of scar tissue in the localised alveolar capillary region of the lung where gas exchange occurs; it can be localised or more diffuse involving, bronchi and pleura. It involves the presence of sustained or repeated exposure to a stressor and intricate dynamics between several inflammatory and immune response cells, and the microenvironment of the alveolar-capillary region consisting of both immune and non-immune cells, and the lung interstitium. The interaction between the substance and components of the cellular membrane leading to release of danger signals/alarmins marks the first event, which is a molecular initiating event (MIE; Event 1495) in the process of tissue repair. As a consequence, a myriad of pro-inflammatory mediators are secreted (Key Event (KE) 1; Event 1496) that signal the recruitment of pro-inflammatory cells into the lungs (KE2; Event 1497). The MIE, KE1 and KE2 represent the same functional changes that are collectively known as inflammation. In the presence of continuous stimulus or persistent stressor, non-resolving inflammation and ensuing tissue injury, leads to the alveolar capillary membrane integrity loss (KE3; Event 1498) and activation of adaptive immune response, T Helper type 2 cell signalling (KE4; Event 1499), during which anti-inflammatory and pro-repair/fibrotic molecules are secreted. The repair and healing process stimulates fibroblast proliferation and myofibroblast differentiation (KE5; Event 1500), leading to synthesis and deposition of extracellular matrix or collagen (KE6; Event 1501). Excessive collagen deposition culminates in alveolar septa thickening, decrease in total lung volume, and lung fibrosis (Adverse Outcome (AO); Event 1458).

Lung fibrosis is frequently observed in miners and welders exposed to metal dusts, making this AOP relevant to occupational exposures. Other stressors include pharmacological products, fibres, chemicals, microorganisms or over expression of specific inflammatory mediators. Novel technology-enabled stressors, such as nanomaterials possess properties that promote fibrosis via this mechanism. Lung fibrosis occurs in humans and the key biological events involved are the same as the ones observed in experimental animals. Thus, this AOP is applicable to a broad group of substances of diverse properties and provides a detailed mechanistic account of the process of lung fibrosis across species.

Acknowledgements: The lead author would like to acknolwedge the able assistance of Andrey Boyadhziev of Health Canada, Ottawa, Ontario, Canada, in putting together the response document and preparing some responses to external reviewers' comments and questions.

Background (optional)

This optional subsection should be used to provide background information for AOP reviewers and users that is considered helpful in understanding the biology underlying the AOP and the motivation for its development. The background should NOT provide an overview of the AOP, its KEs or KERs, which are captured in more detail below. Examples of potential uses of the optional background section are listed on pages 24-25 of the User Handbook. More help

There is a high potential for inhalation exposure to toxicants in various occupational settings and polluted environments. Extensive investigation of pulmonary toxicity following inhalation of chemical and particulate stressors have demonstrated that these toxicants mount an exuberant inflammatory response early after exposure that, when unresolved, lays the foundation for later pathologies. Although inflammation is a normal immune reaction of the organism designed to effectively eliminate the invading threat, chronic and unresolved tissue inflammation is detrimental. Unresolved lung inflammation in humans plays a causative role in many debilitating and even lethal adverse health effects, such as decreased lung function, emphysema, fibrosis, and cancer. The various pathways, mechanisms, and biological processes associated with the pulmonary inflammatory process are well characterized in experimental animals and, to a great extent, in humans. Here, a mechanism underlying stressor-induced lung fibrosis that involves a pro-inflammatory component is described.

Pulmonary fibrosis is a chronic lung pathology, which when not treated, results in lethality. It is characterized by the excessive extracellular matrix deposition and restructuring. Numerous respiratory diseases, such as pneumoconiosis, silicosis, asbestosis, bronchiolitis obliterans (‘popcorn lung’), and chronic beryllium disease have pulmonary fibrosis as a main or secondary symptom. In addition, exposure to pharmaceuticals and environmental contaminants such as bleomycin and arsenic via inhalation, oral or intravenous routes also induces the adverse outcome of pulmonary fibrosis. Idiopathic pulmonary fibrosis (IPF) is the most common type of lung fibrosis in humans and involves alveolar regions of the lung consisting of type 2 alveolar epithelial cells (AEC2s), type 1 cells (AEC1s) and mesenchymal cells. AEC1s are responsible for gas exchange and AEC2s synthesise surfactant. The AEC2s are capable of self-renewal and differentiate to AEC1s regularly during normal tissue maintenance (Barkauskas & Noble, 2014). In pro-fibrotic conditions, AEC2s fail to regenerate AEC1s lost by injury and do not respond normally to epithelial injury, undergoing hyperplasia. As a result, human patients suffering from IPF have dysregulated levels of surfactant proteins normally secreted by AEC2s (Barlo et al.,2009; Phelps et al., 2004). Genetic studies have associated mutations in genes encoding surfactant proteins and the development of a familial type of lung fibrosis. Furthermore, immunohistochemical staining of human IPF lung slices shows AEC death as well as proliferation adjacent to fibrotic foci (Uhal et al., 1998). AEC2s are hyperplastic and are located on top of the fibrotic lesions in the lung in human specimens (Katzenstein & Myers, 1998). In animal models of bleomycin-induced lung fibrosis, abnormal AEC2s are incapable of protecting the basement membrane destroyed by cell death, leading to aberrant repair and deposition of ECM, resulting in fibrosis (Rock et al., 2011). Targeted removal of AEC2s in mouse lungs results in full manifestion of the fibrotic disease (Sisson et al., 2010). In certain infectious conditions, epithelial cell stress and dysfunction leading to inefficient repair capacity or transcriptional reprogramming of epithelial cells to secrete pro-fibrotic and pro-inflammatory factors leads to lung fibrosis (Lawson et al., 2008; Lawson et al., 2011). Mesenchymal cells are the other main type of cell, which contribute to fibrosis development. The dysregulated proliferation of fibroblasts and myofibroblast differentiation leading to excessive ECM deposition in the fibrotic scar is the result of disrupted cross talk between epithelial and mesenchymal cells (Barkauskas 2014). Myofibroblasts exhibiting contractile properties of smooth muscle cells and expressing a-SMA and vimentin, are the types of mesenchymal cells that are most commonly associated with excessive collagen secretion in pro-fibrotic phenotypes (Todd et al., 2012). Myofibroblasts can arise mainly from differentiation of tissue resident fibroblasts, translocation of bone marrow derived fibrocytes into the lung, or from epithelial-to-mesenchymal transformation (EMT; a type of trans-differentiation) (Hung, 2020; Todd et al., 2012). These cells are critical to the normal process of wound healing, and are the main cells contributing to collagen deposition in both normal wear-and-tear repair processes and in disease promoting conditions. Following successful wound healing, myofibroblasts de-differentiate and disappear (Friedman, 2012). Myofibroblasts persistence is suggested to play a key role in progressive pulmonary fibrosis in humans. There is evidence for both EMT derived myofibroblasts and bone marrow derived fibrocytes in human pulmonary fibrotic conditions. Air epithelial biopsies from human patients suffering from bronchiolitis obliterans (BO) following lung transplant show significantly increased staining for mesenchymal markers (Vimentin and a-SMA), decreased staining for e-cadherin, and co-localization of epithelial and mesenchymal markers as compared to stable patients (Borthwick et al., 2009). With respect to bone marrow derived fibrocytes, these cells have been proposed as an indicator for poor prognosis in human IPF patients, and research has shown that the amount of fibrocytes in the human IPF lung correlates with the amount of fibroblastic foci (Andersson-Sjöland et al., 2008; Moeller et al., 2009). Additional cell types involved in fibrotic process include endothelial cells and immune cells such as macrophages, neutrophils, and T helper cells. Endothelial cells contribute to the fibrotic process through endothelial-to-mesenchymal transformation, as evidenced in bleomycin model systems in which endothelial cells in fibrotic conditions take on the characteristics of myofibroblasts (Kato et al., 2018). Macrophages present in the alveolar space as well as macrophages recruited to the lung during the fibrotic process also contribute to the inflammatory environment and potentiate the adverse outcome of pulmonary fibrosis. Direct interaction of fibrotic stressors, such as Multi-Walled Carbon Nanotubes (MWCNTs), silica, and asbestos, with the macrophage cell membrane can occur through scavenger receptors as well as through receptors such as MARCO (Li & Cao, 2018; Murphy et al., 2015). This can induce macrophage cell injury through frustrated or incomplete phagocytosis which leads to the production of alarmins such as IL-1b and ROS, and profibrotic mediators such as TNF-a, TGF-b, and PDGF (Dong & Ma, 2016; Li & Cao, 2018). The injured resident macrophages contribute to the initial acute phase inflammatory response leading to recruitment of additional immune cells to the lung. Depending on the fibrotic stressor, different populations of immune cells can be initially recruited to the site of action. The recruitment of neutrophils into the lung space potentiates the inflammatory response and tissue damage. Furthermore, in conditions of acute lung injury, which can precede the development of a fibrotic phenotype, neutrophilic recruitment to the lung through trans-epithelial migration can induce the formation of lesions in the epithelium and contribute to the loss of alveolar capillary membrane integrity (Zemans et al., 2009). Finally, T helper (Th) cells recruited to the lung potentiate the inflammatory environment, and through the induction of a Th2 response, stimulate the proliferation of fibroblasts and differentiation of myofibroblasts driving the development of a fibrotic phenotype (Shao et al., 2008; Wynn, 2004).

Although this AOP is applicable to a broad group of chemicals of diverse properties, the AOP was specifically assembled keeping in mind, a novel class of engineered materials (nanomaterials) exhibiting sophisticated properties that have been shown to induce lung fibrosis via this mechanism. Thus, it demonstrates the applicability of the AOP framework to nanotoxicology.

Given the fundamental role of inflammation in organ homeostasis, well characterized AOPs targeting the pathological outcomes of unregulated inflammatory responses are important and will guide the development of appropriate assays to measure the key events that are predictive of inflammation-mediated chronic health impacts, and aid in screening a large array of inhalation toxicants that are inflammogenic, for their potential to induce lung diseases.

Summary of the AOP

This section is for information that describes the overall AOP. The information described in section 1 is entered on the upper portion of an AOP page within the AOP-Wiki. This is where some background information may be provided, the structure of the AOP is described, and the KEs and KERs are listed. More help


Molecular Initiating Events (MIE)
An MIE is a specialised KE that represents the beginning (point of interaction between a stressor and the biological system) of an AOP. More help
Key Events (KE)
This table summarises all of the KEs of the AOP. This table is populated in the AOP-Wiki as KEs are added to the AOP. Each table entry acts as a link to the individual KE description page.  More help
Adverse Outcomes (AO)
An AO is a specialised KE that represents the end (an adverse outcome of regulatory significance) of an AOP.  More help
Sequence Type Event ID Title Short name
1 MIE 1495 Substance interaction with the lung resident cell membrane components Interaction with the lung cell membrane
2 KE 1496 Increased, secretion of proinflammatory mediators Increased proinflammatory mediators
3 KE 1497 Increased, recruitment of inflammatory cells Recruitment of inflammatory cells
4 KE 1498 Loss of alveolar capillary membrane integrity Loss of alveolar capillary membrane integrity
5 KE 1499 Increased, activation of T (T) helper (h) type 2 cells Activation of Th2 cells
6 KE 1500 Increased, fibroblast proliferation and myofibroblast differentiation Increased cellular proliferation and differentiation
7 KE 1501 Increased, extracellular matrix deposition Increased extracellular matrix deposition
8 KE 68 Accumulation, Collagen Accumulation, Collagen
9 AO 1458 Pulmonary fibrosis Pulmonary fibrosis

Relationships Between Two Key Events (Including MIEs and AOs)

This table summarises all of the KERs of the AOP and is populated in the AOP-Wiki as KERs are added to the AOP. Each table entry acts as a link to the individual KER description page.To add a key event relationship click on either Add relationship: events adjacent in sequence or Add relationship: events non-adjacent in sequence.For example, if the intended sequence of KEs for the AOP is [KE1 > KE2 > KE3 > KE4]; relationships between KE1 and KE2; KE2 and KE3; and KE3 and KE4 would be defined using the add relationship: events adjacent in sequence button.  Relationships between KE1 and KE3; KE2 and KE4; or KE1 and KE4, for example, should be created using the add relationship: events non-adjacent button. This helps to both organize the table with regard to which KERs define the main sequence of KEs and those that provide additional supporting evidence and aids computational analysis of AOP networks, where non-adjacent KERs can result in artifacts (see Villeneuve et al. 2018; DOI: 10.1002/etc.4124).After clicking either option, the user will be brought to a new page entitled ‘Add Relationship to AOP.’ To create a new relationship, select an upstream event and a downstream event from the drop down menus. The KER will automatically be designated as either adjacent or non-adjacent depending on the button selected. The fields “Evidence” and “Quantitative understanding” can be selected from the drop-down options at the time of creation of the relationship, or can be added later. See the Users Handbook, page 52 (Assess Evidence Supporting All KERs for guiding questions, etc.).  Click ‘Create [adjacent/non-adjacent] relationship.’  The new relationship should be listed on the AOP page under the heading “Relationships Between Two Key Events (Including MIEs and AOs)”. To edit a key event relationship, click ‘Edit’ next to the name of the relationship you wish to edit. The user will be directed to an Editing Relationship page where they can edit the Evidence, and Quantitative Understanding fields using the drop down menus. Once finished editing, click ‘Update [adjacent/non-adjacent] relationship’ to update these fields and return to the AOP page.To remove a key event relationship to an AOP page, under Summary of the AOP, next to “Relationships Between Two Key Events (Including MIEs and AOs)” click ‘Remove’ The relationship should no longer be listed on the AOP page under the heading “Relationships Between Two Key Events (Including MIEs and AOs)”. More help

Network View

The AOP-Wiki automatically generates a network view of the AOP. This network graphic is based on the information provided in the MIE, KEs, AO, KERs and WoE summary tables. The width of the edges representing the KERs is determined by its WoE confidence level, with thicker lines representing higher degrees of confidence. This network view also shows which KEs are shared with other AOPs. More help


The stressor field is a structured data field that can be used to annotate an AOP with standardised terms identifying stressors known to trigger the MIE/AOP. Most often these are chemical names selected from established chemical ontologies. However, depending on the information available, this could also refer to chemical categories (i.e., groups of chemicals with defined structural features known to trigger the MIE). It can also include non-chemical stressors such as genetic or environmental factors. Although AOPs themselves are not chemical or stressor-specific, linking to stressor terms known to be relevant to different AOPs can aid users in searching for AOPs that may be relevant to a given stressor. More help

Life Stage Applicability

Identify the life stage for which the KE is known to be applicable. More help
Life stage Evidence
Adult High

Taxonomic Applicability

Latin or common names of a species or broader taxonomic grouping (e.g., class, order, family) can be selected. In many cases, individual species identified in these structured fields will be those for which the strongest evidence used in constructing the AOP was available in relation to this KE. More help
Term Scientific Term Evidence Link
human Homo sapiens High NCBI
mouse Mus musculus High NCBI
rat Rattus norvegicus High NCBI

Sex Applicability

The authors must select from one of the following: Male, female, mixed, asexual, third gender, hermaphrodite, or unspecific. More help
Sex Evidence
Unspecific High

Overall Assessment of the AOP

This section addresses the relevant biological domain of applicability (i.e., in terms of taxa, sex, life stage, etc.) and WoE for the overall AOP as a basis to consider appropriate regulatory application (e.g., priority setting, testing strategies or risk assessment). The goal of the overall assessment is to provide a high level synthesis and overview of the relative confidence in the AOP and where the significant gaps or weaknesses are (if they exist). Users or readers can drill down into the finer details captured in the KE and KER descriptions, and/or associated summary tables, as appropriate to their needs.Assessment of the AOP is organised into a number of steps. Guidance on pages 59-62 of the User Handbook is available to facilitate assignment of categories of high, moderate, or low confidence for each consideration. While it is not necessary to repeat lengthy text that appears elsewhere in the AOP description (or related KE and KER descriptions), a brief explanation or rationale for the selection of high, moderate, or low confidence should be made. More help

Pulmonary fibrosis is the thickening and scarring of lung tissue, caused by excessive deposition of collagen/extracellular matrix. The most common fibrotic disease of the lung in humans is IPF, a complex, progressive disease of unknown etiology with often poor prognosis. Pulmonary fibrosis in humans is also observed following exposure to pharmacological agents such as bleomycin, following inhalation of silica, asbestos, cigarette smoke, coal dust and following exposure to microbials and allergens. Regardless of the etiology, lung fibrosis in humans is characterised by the presence of inflammatory lesions, excessive extracellular matrix deposition, reduced lung volume and function. Mechanistically, using animals, it has been shown that key biological events that play a critical role in the onset and progression of the disease are similar in humans and animals. The main differences are limited to anatomical and physiological aspects of lung and its functions.

Some other considerations of relevance to this AOP:

This AOP represents a fibrotic mechanism that involves a strong inflammatory component. Exposure to pro-fibrotic stressors such as, bleomycin, silica, asbestos, CNTs, radiation or models of cytokine overexpression involve a profound inflammatory response. IPF in humans is more commonly observed in male subjects. A study in mice showed that male mice developed lung fibrosis more readily following exposure to bleomycin compared to female mice and that age is a risk factor, with aged male mice showing exuberant fibrosis (Redente et al., 2011). Scar formation is reduced in fetal wounds (Yates et al., 2012). Asbestosis and silicosis, (two types of fibrotic disease) are clinically manifested in aged humans. Thus, the AOP presented here is applicable to lung fibrosis observed in adults predominantly.

Different animal species have been used to study the pathology of fibrotic disease; with mice being the most common and rats the second most used. Australian sheep, horse, dogs, cats, donkeys, pigs and other animals have been studied to investigate different types of fibrosis. There are some limitations, however, in these animal systems with respect to modelling human pulmonary fibrosis. The most commonly used model, the bleomycin mouse model, presents a rapidly developing fibrotic phenotype which undergoes at least partial resolution following 28 days (Tashiro et al., 2017). Higher order organisms, like dogs, cats, and horses offer a chance to examine naturally occurring pulmonary fibrosis, with closer resemblance to human IPF in animals with a natural cough reflex (Williams & Roman, 2015). However, inherent limitations in these models, such as their outbred nature and lack of systematic characterization (Williams & Roman, 2015) make them poor candidates for routine fibrosis research. Regardless of the species or the type of fibrosis investigated, the key characteristic events that define the disease process are the same with few species-specific anatomical, physiological and histological differences. Thus, cross-species applicability for this AOP is strong.

Domain of Applicability

The relevant biological domain(s) of applicability in terms of sex, life-stage, taxa, and other aspects of biological context are defined in this section. Biological domain of applicability is informed by the “Description” and “Biological Domain of Applicability” sections of each KE and KER description (see sections 2G and 3E for details). In essence the taxa/life-stage/sex applicability is defined based on the groups of organisms for which the measurements represented by the KEs can feasibly be measured and the functional and regulatory relationships represented by the KERs are operative.The relevant biological domain of applicability of the AOP as a whole will nearly always be defined based on the most narrowly restricted of its KEs and KERs. For example, if most of the KEs apply to either sex, but one is relevant to females only, the biological domain of applicability of the AOP as a whole would be limited to females. While much of the detail defining the domain of applicability may be found in the individual KE and KER descriptions, the rationale for defining the relevant biological domain of applicability of the overall AOP should be briefly summarised on the AOP page. More help

Sex/Gender and Age:

IPF in humans is more commonly observed in male subjects. Male mice develop lung fibrosis more readily following exposure to bleomycin compared to female mice and that age is a risk factor, with aged male mice showing exuberant fibrosis (Redente et al., 2011). Scar formation is reduced in fetal wounds (Yates et al., 2012). Asbestosis and silicosis, forms of fibrotic disease are clinically manifested in aged humans. Thus, the AOP presented here is applicable to lung fibrosis observed in adult males predominantly.


Different animal species have been used to study the pathology of fibrotic disease; with mice being the most common and rats the second most used. Australian sheep, horse, dogs, cats, donkeys, pigs and other animals have been studied to investigate different types of fibrosis. There are some limitations, however, in these animal systems with respect to modelling human pulmonary fibrosis. The most commonly used model, the bleomycin mouse model, presents a rapidly developing fibrotic phenotype which undergoes at least partial resolution following 28 days (Tashiro et al., 2017). Higher order organisms, like dogs, cats, and horses offer a chance to examine naturally occurring pulmonary fibrosis, with closer resemblance to human IPF in animals with a natural cough reflex (Williams & Roman, 2015). However, inherent limitations in these models, such as their outbred nature and lack of systematic characterization (Williams & Roman, 2015) make them poor candidates for routine fibrosis research. Regardless of the species or the type of fibrosis investigated, the key characteristic events that define the disease process are the same with few species-specific anatomical, physiological and histological differences. Thus, cross-species applicability for this AOP is strong.

Types of Stressors:

Persistent and soluble stressors can induce fibrotic pathologies in humans (as well as in model animals) in concordance with the AOP presented. Asbestos exposure in humans has long been known to induce pulmonary fibrosis (asbestosis) due to chronic inflammation induced from persistent fibres deposited within the lung (Kamp and Weitzman 1997). Similarly, human exposure to silica leads to the development of silicosis in concordance with the AOP presented (Ding et al., 2002). Furthermore, the soluble chemotherapeutic compound bleomycin has long been known to induce pulmonary fibrosis in humans (in line with this AOP) as a side effect of intravenous administration (Froudarakis et al., 2013). In addition to these model stressors, exposure to various metals including uranium, arsenic, cadmium, and soluble copper can lead to fibrotic outcomes in humans (Assad et al., 2019). Occupational exposure to cobalt can induce interstitial lung disease in humans, which can progress to fibrotic outcomes (Traci et al., 2017). In male mice exposed via inhalation to cadmium oxide nanoparticles, increases in the pro-fibrotic and pro-inflammatory mediators IL-1b, TNF-a, and IFN-g were noted one day post exposure, with accompanying pulmonary inflammation (Blum et al., 2014). In another study , intratracheal instillation of cadmium chloride in mice induced peribronchiolar fibrosis through activation of myofibroblasts via SMAD signalling (Li et al., 2017). As with the aforementioned cadmium nanoparticles, murine animals exhibit pronounced acute inflammation and immune cell infiltration after pulmonary exposure to Copper oxide (CuO) nanoparticles (Gosens et al., 2016), which can progress to a fibrotic phenotype in some model systems after 28 days with marked increases of TGF-b detected in the BALF, activation of myofibroblasts, and pronounced deposition of extracellular matrix (Lai et al., 2018). In mice, intratracheal instillation of cobalt nanoparticles results in pronounced infiltration of neutrophils and macrophages into the alveolar and interstitial space, and increased amounts of CXCL1 in the BALF 1-7 days post exposure; pronounced pulmonary fibrosis was detected at 4 months post-exposure marked by increased collagen deposition and bronchiolization of the alveolar epithelium (Wan et al., 2017).

Essentiality of the Key Events

An important aspect of assessing an AOP is evaluating the essentiality of its KEs. The essentiality of KEs can only be assessed relative to the impact of manipulation of a given KE (e.g., experimentally blocking or exacerbating the event) on the downstream sequence of KEs defined for the AOP. Consequently evidence supporting essentiality is assembled on the AOP page, rather than on the independent KE pages that are meant to stand-alone as modular units without reference to other KEs in the sequence.The nature of experimental evidence that is relevant to assessing essentiality relates to the impact on downstream KEs and the AO if upstream KEs are prevented or modified. This includes: Direct evidence: directly measured experimental support that blocking or preventing a KE prevents or impacts downstream KEs in the pathway in the expected fashion. Indirect evidence: evidence that modulation or attenuation in the magnitude of impact on a specific KE (increased effect or decreased effect) is associated with corresponding changes (increases or decreases) in the magnitude or frequency of one or more downstream KEs.When assembling the support for essentiality of the KEs, authors should organise relevant data in a tabular format. The objective is to summarise briefly the nature and numbers of investigations in which the essentiality of KEs has been experimentally explored either directly or indirectly. See pages 50-51 in the User Handbook for further definitions and clarifications.  More help

The essentiality of the MIE; Event 1495 was rated as moderate, due to the non-specific nature of the event, and the dynamic nature of the membrane interaction, especially with nanomaterials, which may adopt a molecular corona in biological environments that mediates cellular interactions.

The essentiality of KE1; Event 1496 and KE2; Event 1497 was rated as moderate, due to the redundant nature of the inflammatory response and the inherent challenges in abrogating this response without inducing another pathology in the model system.

For KE3; Event 1498, the essentiality was also listed as moderate, due to the fact that attenuation or abrogation of this response isn’t practical, and as such the supporting evidence is indirect.

For KE4; Event 1499 and KE6; Event 1501, the essentiality was rated as high due to the plethora of experimental evidence showing that modulation of these responses modifies the AO and downstream KEs. For additional information, please consult the Evidence Assessment Call Table below.

Evidence Assessment

The biological plausibility, empirical support, and quantitative understanding from each KER in an AOP are assessed together.  Biological plausibility of each of the KERs in the AOP is the most influential consideration in assessing WoE or degree of confidence in an overall hypothesised AOP for potential regulatory application (Meek et al., 2014; 2014a). Empirical support entails consideration of experimental data in terms of the associations between KEs – namely dose-response concordance and temporal relationships between and across multiple KEs. It is examined most often in studies of dose-response/incidence and temporal relationships for stressors that impact the pathway. While less influential than biological plausibility of the KERs and essentiality of the KEs, empirical support can increase confidence in the relationships included in an AOP. For clarification on how to rate the given empirical support for a KER, as well as examples, see pages 53- 55 of the User Handbook.  More help

Concordance of Dose-Response Relationships:

The AOP presented here is qualitative. There is some evidence on dose-response relationships; however, dose-response relationships for each individual KE are not available. In Labib et al., 2016, Benchmark Dose (BMD) analysis of MWCNT-induced gene expression changes in lungs of mice and canonical pathways associated with each of the KEs identified in this AOP was conducted and the resulting BMD values were correlated with BMD values derived for the apical endpoints that measured histologically manifested fibrotic lesions in rodents. The study showed that low doses of MWCNTs induce early KEs of inflammation and immune response at the acute post-exposure timepoints, and histological manifestation of fibrosis required higher MWCNT doses and was only evident at the later timepoints. Similarly, in another study, the meta-analyses of transcriptomics data gathered from mouse lungs (over 2000 microarrays) exposed individually to a variety of pro-fibrotic agents showed that the gene expression profiles from the high dose MWCNT-exposed samples collected at sub-chronic timepoints were strongly associated with the Th2 response signalling observed in mouse fibrotic disease models compared to the low dose early timepoint MWCNT samples (Nikota et al., 2016). These studies showed temporal and dose-response relationships between KEs. 

In another study, pharyngeal aspiration of 10, 20, 40, or 80 µg/mouse MWCNT induced lung fibrosis in a dose-dependent manner, which became apparent as early as 7 days post-exposure at 40 µg/mouse dose and persisted up to 56 days post-exposure (Porter et al., 2010). Pharyngeal aspiration of 10, 20, 40, or 80 µg/mouse MWCNTs induced significant alveolar septa thickness over time (1, 7, 28, and 56 days post-exposure) in 40 and 80 µg dose groups (Mercer et al., 2011). Similarly, inhalation of MWCNTs (10 mg/m3, 5h/day) for 2, 4, 8, or 12 days showed dose-dependent lung inflammation and lung injury with the development of lung fibrosis in mice (Porter et al., 2012). Lung inflammation and fibrosis was observed in mice intratracheally instilled with 162 µg/mouse MWCNTs at 28 days post-exposure (Nikota et al., 2017). The above studies involving CNTs showed elevated levels of pro-inflammatory mediators, pro-inflammatory cells and cytotoxicity in BALF.

Strength, Consistency, and Specificity of Association of Adverse Outcome and Initiating Event:

This AOP describes a non-specific MIE. Typically, in an experimental setting, the MIE itself is not assessed. Rather, the outcomes of MIE engagement or MIE trigger are assessed. Depending on the type of stressor and its physical-chemical property, the type of interactions between the stressor and the lung resident cells differ. High aspect ratio fibres such as asbestos and CNTs induce frustrated phagocytosis, acute cell injury (Boyles et al., 2015; Dörger et al., 2001; Brown et al., 2007; Kim et al., 2010; Poland et al., 2008), leading to inflammation, immune responses and fibrosis. Asbestos and silica crystals engage scavenger receptors present on the macrophages (Murthy et al., 2015), resulting in acute cell injury and inflammatory cascade, leading eventually to the AO. Bleomycin binds high affinity bleomycin binding sites present on rat alveolar macrophage surfaces, leading to macrophage activation (Denholm and Phan, 1990). Asbestos fibres also bind directly to cellular macromolecules including proteins and membrane lipids, which is influenced by their surface properties such as surface charge (reviewed in Agency for Toxic Substances and Disease Registry 2001). These studies demonstrate the types of interactions between cells and the pro-fibrotic stressors, which are often not measured in animal or cell culture experiments. Instead, the consequences or outcomes of triggering the MIE are measured, which are the release of Danger Associated Molecular Signals (DAMPs) or alarmins from cells.

The alarmin HMGB1 is released from damaged or necrotic cells in cell culture models and in animals following exposure to asbestos and is involved in the inflammatory events elicited by asbestos (Yang et al, 2010), which plays a critical role in asbestosis. CNTs interact with HMGB1-RAGE, which is implicated in pro-inflammatory and genotoxic effects of CNTs (Hiraku et al., 2015). Mechanical stress and membrane damage following cellular uptake of long and stiff CNTs by lysosomes results in cell injury and consequent adverse effects (Zhu, et al., 2016). CNT-induced inflammatory response in vitro is mediated by IL-1, absence of which negatively impacts gap junctional intercellular communication (Arnoldussen et al., 2016). The levels of IL-1a are increased in BALF of mice immediately after exposure to MWCNT doses that induce fibrosis (Nikota et al., 2017).

Although there is enough empirical evidence to suggest the occurrence of the MIE; Event 1495 following exposure to pro-fibrogenic substances, there is incongruence in supporting its essentiality to the eventual AO. The inconsistency could be due to the fact that early defence mechanisms involving DAMPs is fundamental for the organism’s survival, which may necessitate multifaceted signalling pathways. As a result, inhibition of a single biological pathway of the innate immune response may not be sufficient to completely abrogate the lung fibrotic response. For example, MWCNTs induce IL-1a secretion in BALF of mice (Nikota et al., 2017) and thus, IL-1a mediated signalling is involved in MWCNT induced lung inflammation and fibrosis (Rydman et al., 2015). Inhibition of IL-1a signalling alone does not alter the MWCNT-induced fibrotic response in mice (Nikota et al., 2017). This study further showed that simultaneous inhibition of both acute inflammatory events (KE1; Event 1496 and KE2; Event 1497) and Th2 –mediated signalling (KE4; Event 1499) is required to suppress lung fibrosis induced by MWCNTs (Nikota et al., 2017). Disengagement between innate immune responses (MIE; Event 1495, KE1; Event 1496 and KE2; Event 1497) and lung fibrosis is shown in mice following exposure to silica (Re et al., 2014). In this study, the role of innate immune responses in lung fibrosis were characterised in 11 separate knockout mouse models lacking individual members of the IL-1 family. The study supported the earlier hypothesis of Nikota et al., 2017 that inhibition of a single pathway may not be sufficient to attenuate the fibrotic response. On the contrary, IL-1a and IL-1R1 mediated signalling are shown to be involved in bleomycin-induced lung inflammation and fibrosis; inhibition of IL1-R1 signalling attenuated the bleomycin pathology (Gasse et al, 2007).

Biological Plausibility, Coherence, and Consistency of the Experimental Evidence:

As described above, there is significant evidence to support the occurrence of the MIE and individual KEs, and thus, evidence supporting the KEs involved in this AOP is strong. However, there is inconsistency in empirical evidence supporting the KERs. Again, this may be due to the redundancy in pathways involved in the early immune responses to injury and repair. Despite the incongruences, AOP presented is coherent and logical.

Alternative Mechanisms:

The AOP as presented is the most agreed upon sequence of biological events occurring in the process of lung fibrosis that involves robust inflammation following exposure to a variety of stressors of different physical-chemical properties. However, in a recent study, using ToxCast data, a different MIE that involves inhibition of PPARg resulting in lung fibrosis was proposed (Jeong et al., 2019). This alternate AOP for fibrosis placed activation of TGF-b1 upstream of inflammatory events (KE2; Event 1497, KE3; Event 1498), which is contrary to its perceived role in downstream events leading to fibroblast proliferation and differentiation, and ECM deposition. The stressors identified in this study were also different, suggesting the PPARg inhibition may be selective to a group of chemicals. The other alternative mechanisms may involve bypassing of the initial inflammatory KEs that directly trigger activation of fibroblast proliferation and differentiation leading to extracellular matrix deposition. For example, overexpression of TGF-b1 can promote excessive ECM deposition and fibrosis in rodents independent of inflammation (Hardie et al., 2004)

Further mechanisms may involve the targeted inhibition of receptor tyrosine kinases by compounds like Gefitinib, Imatinib, and Sorafenib, as well as some monoclonal antibodies which affects receptors for growth factors like PDGF, EGF, and VEGF. This is thought to directly impair the regenerative capacity of lung epithelial cells (MIE; Event 1495 to KE3; Event 1497), resulting in an aberrant wound healing response (Li et al., 2018). Finally, one more alternative mechanism involves pulmonary fibrosis in the context of bronchiolitis obliterans. In this condition, the fibrotic phenotype is brochiolocentric and not alveolocentric – with the main insult involving the bronchiolar epithelium and an inability of the basal cells to replace lost bronchio epithelial cells.  Stressors, such as soluble diacetyl used in popcorn flavouring and e-cigarette vape liquids, can cause bronchiolitis obliterans in humans. A recent human case study of a Canadian youth admitted to hospital with bronchiolitis obliterans following vaping flavoured liquid containing diacetyl, as well as tetrahydrocannabinol, shows septal thickening, type II pneumocyte hyperplasia, immune cell infiltration and myofibroblast proliferation & incorporation into pulmonary septa (Landmann et al., 2019). Pulmonary exposures in murine model systems indicate that diacetyl induces pronounced damage to the airway epithelium, and that repair processes result in a compositionally different epithelium (Reviewed in Brass & Palmer, 2017). In a study using rat models, inhalation of 200 ppm of diacetyl resulted in bronchiolar fibrosis, with chronic inflammation accompanying the fibrotic outcomes (Morgan et al., 2016).

Evidence Assessment Summary:

The MIE; Event 1495 and KE1; Event 1496 – KE2; Event 1497 occur in sequence, however most in vivo and in vitro experiments are not designed to measures these events separately. This is an area of focus for future pulmonary fibrosis research.

Support for Essentiality of KEs

MIE; Event 1495:  Interaction with the lung resident cell membrane components

Persistent fibres like CNTs and asbestos are known to induce frustrated or incomplete phagocytosis in resident lung cells following respiratory exposure. Particles such as silica, as well as asbestos fibres engage scavenger receptors on the surface of macrophages leading to activation and inflammation. The soluble pro-fibrotic compound bleomycin binds to as-of-yet uncharacterised sites on macrophages, leading to similar activation.

Essentiality: Moderate. While the specific receptors involved vary depending on the stressor, and there is evidence of compensation in the context of knockout models, over 20 years of research has shown that interaction between the fibrotic stressor and the resident lung cells is crucial for downstream responses. (Behzadi et al., 2017; Denholm & Phan 1990; Mossman & Churg 1998). 

KE 1; Event 1496:  Increased, secretion of proinflammatory mediators

Injured and activated resident lung cells release pro-inflammatory and fibrotic mediators, such as cytokines, chemokines, growth factors and reactive oxygen species, into the surrounding environment.

Essentiality: Moderate. It is accepted that one of the main mechanisms underlying pulmonary fibrosis involves a profound inflammatory component. This has been shown in animal models exposed to fibrotic stressors such as bleomycin, MWCNT, silica, and asbestos. The exact nature of the secreted mediators, and the essentiality of specific mediators requires further research. (Park & Im, 2019; Rahman et al., 2017; Rabolli et al., 2014).

KE 2; Event 1497:  Increased, recruitment of inflammatory cells

Inflammatory cells migrate into the lung according to the pro-inflammatory stimuli released.

Essentiality: High. The migration of inflammatory immune cells relies upon secretion of chemotactic stimuli in response to a stressor. Knockout models have shown reduced recruitment of immune cells to the lung in response to fibrotic stressors such as bleomycin. However, compensation has been noted due to the redundant nature of these molecules. (Gasse et al., 2007; Girtsman et al., 2014; Rabolli et al., 2014)

KE 3; Event 1498:  Loss of alveolar capillary membrane integrity

Significant alveolar damage from the inflammatory environment (including chronic inflammation and oxidative stress) results in the loss of alveolar capillary membrane (ACM) integrity.

Essentiality: Moderate. While it is generally recognized that damage to the alveolar capillary membrane is integral to the development of fibrosis, there evidence from knock-out models is lacking. Indirect evidence using bleomcyin has shown that animals deficient in Nrf2, and therefore presenting a weakened antioxidant response, have higher levels of ACM injury and more pronounced fibrosis as compared to Nrf2 competent mice. This was assessed by proxy, using LDH release into the BALF and the presence of pulmonary injury markers as a proxy for ACM injury. (Cho et al., 2004; Kikuchi et al., 2010)

KE 4; Event 1499:  Increased, activation of T (T) helper (h) type 2 cells

T helper cells present in, and recruited to the lung environment commit to Th2 differentiation, which then release cytokines like IL-4, IL-5, and IL-13 and potentiate a Th2 driven response.

Essentiality: High. Induction of a Th2 response stimulates fibroblast proliferation & pulmonary fibrogenesis. Over expression of Th2 type cytokine IL-13 stimulates pulmonary fibrosis in the absence of external stressors. IL-13 can directly activate TGF-b1 and initiates fibroblast prolieration and differentiation in pulmonary fibrosis. In mice deficient in STAT6, MWCNT treatment reduced the Th2 response, and downstream fibroblast proliferation, and overall fibrotic response. There is some inconsistency however, as IL4 deficient mice had a lower fibrotic response compared to wild-type after bleomycin treatment, however with higher rate of mortality. This highlights that the timing of the Th2 response is important for the manifestation of fibrosis. (Lee et al., 2001; Huaux et al., 2003; Nikota et al., 2017; Sempowski et al., 1994; Zhu et al., 1999)

KE 5; Event 1500:  Increased, fibroblast proliferation and myofibroblast differentiation

Fibroblasts originally present in the lung, and recruited to the lung, or which transdifferentiate from epithelial and endothelial cells proliferate and undergo differentiation into a collagen secreting myofibroblast phenotype which expresse smooth muscle actin. This is the main effector cell responsible for secretion of extracellular matrix components in pulmonary fibrosis, and represents a nexus KE.

Essentiality: High. The proliferation of fibroblasts and differentiation into myofibroblasts is integral to the development of pulmonary fibrosis. Inhibition or attenuation of fibroblast proliferation and differentiation using TGF-b antagonism attenuates fibrosis in bleomycin mice models. Targeted inhibition of the Wnt/b-catenin pathway inhibited myofibroblasts transition and reduced the overall fibrotic phenotype. (Cao et al., 2018; Chen et al., 2013; Kuhn & McDonald, 1991; Guan et al., 2016)

KE 6; Event 1501:  Increased, extracellular matrix deposition

The balance between extra cellular matrix (ECM) synthesis and destruction is disrupted, with a sustained increase in the deposition of ECM bearing compositional differences as compared to the native matrix.

Essentiality: High. A sustained imbalance between ECM synthesis and destruction is a prerequisite for the development of pulmonary fibrosis, and as such this KE is essential to the AO. (Bateman et al., 1981; McKleroy et al., 2013)

AO; Event 1458:  Pulmonary fibrosis

Destruction of lung architecture and alveolar capillaries due to increased and aberrant deposition of extra cellular matrix in the context of prolonged inflammation results in pulmonary fibrosis.

Essentiality: N/A. This is the adverse outcome of this AOP, and therefore, is essential.

Associative Event 1:  Chronic Inflammation

In the presence of continuous stimulus (e.g., presence of biopersistent toxic fibres such as asbestos, MWCNTs) or following repeated stimulus (e.g., repeated exposure to silica or coal dust), the ensuing cell injury fuels the inflammatory mechanisms leading to accumulation of immune cells, prolonged inflammation and aggravated tissue damage. This sustained and perpetuated immunological response is termed as chronic inflammation. During this phase, active inflammation, tissue injury and destruction, and tissue repair processes proceed in tandem. Thus, the causative substance must contain unique physico-chemical properties that grant the material biopersistance in the pulmonary environment or the pulmonary system has to be repeatedly exposed to the same substance that perpetuates the tissue injury leading to loss of ACM. Although, increases in number of neutrophils are observed during chronic inflammation, mononuclear phagocytes (circulating monocytes, tissue macrophages) and lymphoid cells mark this phase. The macrophages, components of mononuclear phagocyte system, are the predominant cells in chronic inflammation. Activated macrophages release a variety of cytokines, chemokines, growth factors, and reactive oxygen species that, which when uncontrolled, lead to extensive tissue injury. The other types of inflammatory cells involved in chronic inflammation include eosinophils in allergen induced lung fibrosis, lymphocytes and epithelial cells. Chronic inflammation exists to potentiate the KEs associated with inflammation and tissue injury, rather than acting as a separate KE itself.

Essentiality: Moderate. Knockdown and knockout models have shown that attenuation of the inflammatory response, attenuates the downstream fibrotic phenotype. Compensation from other inflammatory pathways makes complete abrogation of this response difficult. Furthermore, the essentiality of this associative event to fibrotic phenotypes like IPF is questionable, as treatment with anti-inflammatory agents like corticosteroids does not have substantial benefits for patients. (Strieter & Mehrad, 2009; Ueha et al., 2012; Wilson & Wynn, 2009)

Associative Event 2:  Oxidative stress

Oxidative stress is defined as an imbalance in the oxidant – antioxidant axis towards oxidants (hydrogen peroxide, superoxide anions, hydroxyl radicals) in a supraphysiological manner. Reactive oxygen species (ROS) serve as part of an important redox signalling system which helps cells adapt to their environment and tackle stress through modulation of transcriptional regulation. In the context of pulmonary fibrosis, oxidative stress potentiates the inflammatory response (KE1-2) and injury to the respiratory epithelium (KE3), and contribute to the differentiation and activation of myofibroblasts (KE5). The exact species of ROS, the specific cell types, and the perturbed oxidative stress related pathways vary depending on the type of pulmonary fibrosis, and even among different human patients suffering from the same fibrosing disease (ex. IPF). Increased levels of ROS have been shown to activate TGF-b, and induce apoptosis of alveolar epithelial cells. Furthermore, oxidative stress induces secretion of pro-inflammatory mediators (mitochondrial DNA, Nalp3 inflammasome related molecules) from the injured epithelium as well as from resident immune cells like macrophages. This potentiates additional recruitment of immune cells to the site of injury, further compounding the inflammatory response, and inducing further production of ROS by effector cells like neutrophils. Clinical studies in IPF patients have consistently found higher levels of ROS biomarkers in the BALF, serum, as well as in exhaled condensate. Furthermore, increases in ROS and oxidative stress are associated with brionchiolitis obliterans, a fibrosing disease of the brionchioles instead of the alveolar tissue. While there is strong evidence for the involvement of ROS in the pathogenesis of pulmonary fibrosis, it acts to potentiate multiple KEs rather than acting as a key event itself. Oxidative stress is both causative and the consequence of observed responses in a feedforward type mechanism.

Essentiality: Moderate. Multiple studies, using knockdown and knockout mammalian models have shown that oxidative stress is involved in the development of pulmonary fibrosis. However, its essentiality in its pathogenesis is not conclusive, as antioxidant treatment offers no significant benefit in patients with IPF, the most common type of pulmonary fibrosis in humans. Furthermore, uncertainties remain concerning the exact molecular mechanisms underlying oxidative stress in the context of pulmonary fibrosis. (Checa & Aran, 2020; Cheresh et al., 2013; Dostert et al., 2008; Madill et al., 2009ab; Veith et al., 2019)

Associative Event 3:  Macrophage polarization

Depending on the lung microenvironment (damaged cells, microbial products, activated lymphocytes), the precursor monocytes differentiate into distinct types of macrophages. Classically activated (M1) macrophages and alternatively activated (M2) macrophages are the important ones to consider in the context of this AOP. The M1 macrophages produce high levels of pro-inflammatory cytokines, mediate resistance to pathogens, induce generation of high levels of reactive oxygen species (ROS) and reactive nitrogen species (RNS), and T helper (Th) 1 type responses. M1 macrophages produce IL-1, IL-12, IL-23 and induce Th1 cell infiltration and activation. The M2 macrophages secrete anti-inflammatory mediators, by which they play a role in regulation of inflammation. The M2 polarisation is mediated by Th2 cytokines such as IL-4 and IL-13, which in turn, promotes M2 activation. M2 macrophages express immunosuppressive molecules such as IL-10, Arginase-1 and -2 (Arg-1, Arg-2), which suppress the induction of Th1 cells that produce the anti-fibrotic cytokine IFNg. The activity of M2 is associated with tissue remodelling, immune regulation, tumour promotion, tissue regeneration and effective phagocytic activity.

Essentiality: High. Inhibition of M2 polarization through genetic depletion of surface receptors such as MARCO, attenuates the fibrotic phenotype. Depletion of interstitial macrophages bearing the M2 phenotype has been shown to block radiation induced lung fibrosis. (He et al., 2013; Meziani et al., 2018; Murthy et al., 2015; Stahl et al., 2013)

Support for Biological Plausibility of KERs

MIE --> KE1; Relationship 1702

Injury and activation resulting from the interaction of pro-fibrotic stressors with the membranes of resident lung cells results in the secretion of pro-inflammatory cytokines, chemokines, growth factors, and reactive oxygen species from the resident epithelial or immune cell.

Biological plausibility: High. There is a mechanistic relationship between the MIE and KE1 which has been evidenced in a number of both in vitro and in vivo model systems in response to stressors such as, asbestos, silica, bleomycin, carbon nanotubes, and metal oxide nanoparticles. (Behzadi et al., 2017; Denholm & Phan 1990; Mossman & Churg 1998)

KE1 --> KE2; Relationship 1703

The secreted pro-inflammatory and pro-fibrotic mediators induce chemotactic recruitment of immune cells to the lung, in a signal specific manner. Increases in the presence of macrophages, neutrophils, and eosinophils within pulmonary air spaces is commonly seen in the process of fibrosis, depending on the fibrotic stressor in question.

Biological plausibility: High. There are very well established functional relationships between the secreted signalling molecules and the chemotactic effects on pro-inflammatory and pro-fibrotic cells. (Harris, 1954; Petri & Sanz, 2018)

KE2 --> KE3; Relationship 1704

Inflammatory cells recruited to the lung potentiate further injury to the alveolar capillary membrane through ROS production and direct damage, persistent inflammation, or an insufficient wound healing response. Type I alveolar cells are lost, type II cells exhibit enhanced proliferation, extracellular matrix changes are notable and alveoli collapse.

Biological plausibility: High. There is a mechanistic relationship between an increase in pro inflammatory cells and mediators, and damage to the ACM. (Bhalla et al., 2009; Ward, 2003; Zemans et al., 2009)

KE3 --> KE4; Relationship 1705

Continued loss of alveolar capillary membrane integrity, together with oxidative stress and chronic inflammation induce a Th2 response in the lung. T helper cells differentiate into Th2 cells in response to stimuli such as IL-6 and IL-4, which increase the secretion of IL-4 and IL-13. Increased Th2 cells in the lung polarize macrophages to the M2 phenotype which further suppresses Th1 cell differentiation.

Biological Plausibility: High. There is a mechanistic relationship between ACM injury (tissue damage), and the induction of a Th2 response (responsible for wound healing). (Gieseck et al., 2018; Wynn, 2004)

KE4 --> KE5; Relationship 1706

The increased population of Th2 cells and M2 polarized macrophages increases secretion of pro-fibrotic mediators, like TGF-b, IL-4, and IL-13 which activate lung resident fibroblasts, as well as fibroblasts and fibrocytes recruited to the lung, and potentiate endo/epithelial to mesenchymal transition. This induces their proliferation and differentiation into a contractile myofibroblast phenotype capable of extra cellular matrix synthesis and deposition.

Biological plausibility: High. There is a widely understood functional relationship between Th2 response related mediators, and their ability to induce proliferation and differentiation of fibroblasts. (Dong & Ma, 2018; Shao et al., 2008; Wynn, 2004; Wynn & Ramalingam, 2012)

KE5 --> KE6; Relationship 1707

Differentiated myofibroblasts represent the main effector cell responsible for the deposition of extracellular matrix during lung fibrosis. In the context of continuous stimuli and elevated levels of TGF-b, myofibroblasts are persistently activated and deposit excessive amounts of collagen in the lung.

Biological plausibility: High. There is an accepted mechanistic relationship between activated myofibroblasts, and the capacity to secrete collagen. (Hinz, 2016ab; Hu & Phan, 2013)

KE6 --> AO; Relationship 1708

Persistent myofibroblast activation and continued deposition of extracellular matrix causes destruction of alveolar structures and normal lung architecture. Reductions in lung function are noted, and pulmonary fibrosis develops.

Biological plausibility: High. By definition, pulmonary fibrosis is characterized by excessive deposition of extracellular matrix and destruction of native lung architecture. Thus, the plausibility of this association is undisputed. (Fukuda et al., 1985; Richeldi et al., 2017; Thannickal et al., 2004)

Empirical Support for KERs

MIE --> KE1; Relationship 1702

Direct interaction with the membrane is not a typically assessed endpoint in fibrosis research, except when dealing with fibrous stressors. Specific receptors involved in the initial immune cell activation are not wholly understood, even for model fibrotic stressors such as bleomycin. Limited in vitro studies have shown toll like receptors are involved in silica and zinc nanoparticle macrophage recognition, which stimulates secretion of inflammatory factors. Similarly, bleomycin has been shown to bind to high affinity sites on the surface of macrophages, which stimulates secretion of growth factors and monocyte chemotactic molecules.

Empirical Support: Moderate. There are limited in vitro studies which show a temporal and dose-dependant relationship between these two events, using the upregulation of specific surface receptors as a proxy for direct membrane interaction. (Chan et al., 2018; Denholm & Phan 1990; Roy et al., 2014)

KE1 --> KE2; Relationship 1703

There are many studies which have shown empirically shown a relationship between secreted mediators and recruitment of immune cells to the lung. A paper by Chen et al., showed that increases in the levels of CXCL1, CXCL2, and CXCL5 in the lung preceded neutrophil recruitment following in vivo treatment with carbon nanoparticles. In an in vitro study, Schremmer et al., exposed rat alveolar macrophages to nano silica and noted increases in CCL4, CXCL1, CXCL3, and TNF-a in the supernatant. This supernatant was able to induce chemotaxis in unexposed macrophages.

Empirical Support: Moderate. There are many studies which show temporal and dose-dependant recruitment of immune cells following increases in pro-inflammatory mediators. However, these mediators exhibit pleiotropy, and knockdown or knockout of a single pathway or mediator can result in compensation and recruitment of immune cells at a later time, as is seen in Nikota et al.,. 2017. (Chen et al., 2016; Nikota et al., 2017; Schremmer et al., 2016)

KE2 --> KE3; Relationship 1704

The chronic inflammatory environment and oxidative stress potentiated by an increase of immune cells in the lung is well known to precede significant alveolar damage. However, the variety of infiltrating leukocytes differs depending on the stressor in question. In a study with crystalline silica, Umbright et al., were able to show that increases in pulmonary leukocytes at 3 weeks, preceded increases in total albumin (loss of ACM integrity) at 6 weeks. In another publication by Zeidler-Erdely et al., mice exposed to stainless steel welding fumes had an increased amount of alveolar macrophages 1 day post exposure, while alveolar damage (as measured by total protein) was not evident until 4 days post exposure.

Empirical Support: Moderate. There is both temporal and dose-response evidence to suggest that an increased amount of pro-inflammatory immune cells potentiates alveolar capillary damage. However, few studies assessing these KEs include multiple concentrations and timepoints, and as such, these KEs are typically reported as occurring together (i.e. damage is detected along with an increase in cell abundance). (Umbright et al., 2017; Zeidler-Erdely et al., 2011)

KE3 --> KE4; Relationship 1705

Few studies have directly assessed the direct of ACM integrity loss on the induction of a Th2 response. In one publication, He et al., showed that ROS induced by a specific superoxide dismutase induces M2 polarization in asbestosis, and inhibition of signalling by Jmjd3 reduces ROS, M2 polarization, and fibrosis. In another study using NRF2 knockout mice, a significant Th2 bias is observed following bleomycin treatment, with enhanced fibrosis noted. Discrepancies are present, for instance where many groups have found that TNF-a receptor 1 (TNF-R1) and TNF-R2 are associated with fibrosis, and even though TNF-a is a therapeutic target for IPF and asbestosis in humans, other groups have reported the opposite and that its exogenous delivery can reduce the fibrotic burden.

Empirical Support: Moderate. There is limited in vitro and in vivo evidence to support a direct relationship between these two KEs, with some inconsistencies with respect to the specific mediators in question. (Ortiz et al., 1998; Piguet, 1989; Redente et al., 2014)

KE4 --> KE5; Relationship 1706

Activation of a Th2 response is known to activate lung fibroblasts. Research by Hashimoto  et al., indicates that the Th2 cytokines IL-4 and IL-13 induces differentiation of human fibroblasts to myofibroblasts. Furthermore, IL-13 has been shown to directly activate TGF-b in vivo, and lead to pulmonary fibrosis.

Empirical Support: High. There is a plethora of dose and time response evidence which shows that Th2 cytokines induce the activation and proliferation of fibroblasts. (Hashimoto et al., 2001; Lee et al., 2001)

KE5 --> KE6; Relationship 1707

While it is difficult to show the accumulation and incorporation of extracellular matrix (ECM) in vitro, the levels of soluble collagen can be assessed. Many publications have reported secretion of soluble matrix components by activated myofibroblasts. For example, research by Li et al., has shown that soluble cadmium can induce fibrosis in mice, and that in vitro treatment of fibroblasts with cadmium induces expression of alpha smooth muscle actin (hallmark of myofibroblasts), as well as soluble collagen.

Empirical Support: High. It is generally accepted knowledge that activated myofibroblasts are collagen secreting cells. (Blaauboer et al., 2014; Hinz, 2016a; Li et al., 2017)

KE6 --> AO; Relationship 1708

Pulmonary fibrosis results from excessive accumulation of collagen and extracellular matrix in the lungs, in the context of prolong inflammation, injury, and an aberrant healing response. Idiopathic pulmonary fibrosis is the most common form in humans, with a poor prognosis overall.

Empirical Support: High. Excessive ECM deposition is the defining characteristic of pulmonary fibrosis, and the evidence to support this relationship is unequivocal. (Meyer, 2017; Thannickal et al., 2004; Williamson et al., 2015; Zisman et al., 2005)

Quantitative Understanding

Some proof of concept examples to address the WoE considerations for AOPs quantitatively have recently been developed, based on the rank ordering of the relevant Bradford Hill considerations (i.e., biological plausibility, essentiality and empirical support) (Becker et al., 2017; Becker et al, 2015; Collier et al., 2016). Suggested quantitation of the various elements is expert derived, without collective consideration currently of appropriate reporting templates or formal expert engagement. Though not essential, developers may wish to assign comparative quantitative values to the extent of the supporting data based on the three critical Bradford Hill considerations for AOPs, as a basis to contribute to collective experience.Specific attention is also given to how precisely and accurately one can potentially predict an impact on KEdownstream based on some measurement of KEupstream. This is captured in the form of quantitative understanding calls for each KER. See pages 55-56 of the User Handbook for a review of quantitative understanding for KER's. More help

The presented AOP is mostly qualitative and additional studies are needed to support the essentiality of the KEs and to build KERs. However, it is important to note that it is difficult to experimentally demonstrate the relevance of earlier KEs to the end outcome of fibrosis because of the redundancy in pathways involved. The mode or type of interactions between the resident cell membrane and a substance is dependent on the specific physical-chemical characteristics of the substance. There has been an attempt to determine quantitatively the dose at which the events in AOP 173 are induced with respect to CNTs (Labib et al., 2016; reproduced below). In this manuscript, researchers applied global transcriptomic analysis and benchmark dose (BMD) modelling to determine the dose at which the MIE, KE1, KE2, KE4, KE5, and KE6 are induced using samples from three separate studies and compared the results to the apical BMD of the AO of pulmonary fibrosis. From the results shown, it can be seen that the BMD intervals of transcriptional pathway induction for each KE largely overlap but are representative of the BMD of AO induction. These results serve to highlight the parallel nature of the KEs in AOP 173, with many of the events occurring concurrently in addition to occurring sequentially.

Quantitative concordance table for AOP 173 KERs. Data is reproduced from Labib et al., 2016 (Figure 4., Additional file 4: Table S3). CNT: carbon nanotube. N/A: Not assessed



Time Point

















Mitsui 7 CNT


24 Hr

4 – 9

3 - 7

9 – 13


5 – 11

10 – 21

9 – 13


Mitsui 7 CNT


3 / 7 day

11 – 22

6 – 22

14 – 24


9 – 16

15 – 26

17 – 34


Mitsui 7 CNT


28 day

No Effect

14 – 26

36 – 51


14 – 26

11 – 20

No Effect


Mitsui 7 CNT


56 day








14 – 27b




24 Hr

No effect

8 – 15

20 – 37


8 – 15

21 – 39

No Effect





3 / 7 day

16 – 28

16 – 27

19 – 33


15 – 24

16 – 26

19 – 36





28 day

No Effect

No Effect

No Effect


12 – 20

No Effect

No Effect





24 Hr

No Effect

3 – 20

8 – 22


8 – 22

13 – 22

18 – 29





3 / 7 day

11 - 17

12 - 19

12 - 20


7 - 20

14 - 22

13 – 21





28 day

20 - 37

17 - 28

No Effect


No Effect

13 - 21

18 – 31


a: Benchmark dose (BMD) (Benchmark dose low (BMDL) à BMD) intervals in µg / lung based on transcriptional pathway induction.

b: BMDL – BMD interval in µg / lung based on alveolar thickness.

The MIE of substance interaction with the lung cell membrane is intentionally kept broad and vague, to reflect the many interactions pro-fibrotic substances can have with the plasma membrane of cells. The presented AOP, while applicable to both soluble and persistent stressors, is specifically applicable to substances which induce fibrosis through immune responses. Nanomaterials are a group of such substances, which interact with organisms and cells via a dynamic biomolecular corona that is dependant on the biological microenvironment. While great strides have been made in recent years to characterize and understand this corona and how it impacts cellular recognition, further research is needed in order to accurately describe the specific interactions necessary for the initiation of fibrosis pathogenesis. Indeed, this is also true for model soluble stressors such as bleomycin, for which cellular binding and uptake is incompletely understood.

The specific mediators involved in the first KE (KE1; Event 1496), and the threshold necessary for progression to subsequent KEs is incompletely understood. Knockout models have shown that ablation of alarmins, such as IL-1, changes the initial trajectory of pulmonary fibrosis, however, compensation from other pathways makes it difficult to determine its essentaility to the end pathogenesis.

The role of reactive oxygen species (ROS) and oxidative stress in potentiating pulmonary fibrosis is also ambiguous. Many pro-fibrotic substances induce the formation of ROS and subsequent oxidative stress, as do many non-fibrotic stressors. While it is hard to deny that ROS and oxidative stress serve an important role in fibrosis (by increasing cellular injury, potentiating an environment of chronic inflammation & damage, and activation of pro-fibrotic factors like TGF-b, a causal relationship between the two has not been established.  Furthermore, anti-oxidant treatment in IPF patients have been largely unsuccessful, indicating a lack of knowledge of the specific redox mechanisms involved. Recent research has indicated a potential role of specific redox mechanisms, such as mitochondrial ROS and NOX derived ROS, however further research is needed to elucidate their role in potentiating pulmonary fibrosis. The development of newer fibrosis model systems which better capitulate the human condition will assist in clarifying this aspect.

Considerations for Potential Applications of the AOP (optional)

At their discretion, the developer may include in this section discussion of the potential applications of an AOP to support regulatory decision-making. This may include, for example, possible utility for test guideline development or refinement, development of integrated testing and assessment approaches, development of (Q)SARs / or chemical profilers to facilitate the grouping of chemicals for subsequent read-across, screening level hazard assessments or even risk assessment. While it is challenging to foresee all potential regulatory application of AOPs and any application will ultimately lie within the purview of regulatory agencies, potential applications may be apparent as the AOP is being developed, particularly if it was initiated with a particular application in mind. This optional section is intended to provide the developer with an opportunity to suggest potential regulatory applications and describe his or her rationale.To edit the “Considerations for Potential Applications of the AOP” section, on an AOP page, in the upper right hand menu, click ‘Edit.’ This brings you to a page entitled, “Editing AOP.” Scroll down to the “Considerations for Potential Applications of the AOP” section, where a text entry box allows you to submit text. In the upper right hand menu, click ‘Update AOP’ to save your changes and return to the AOP page or 'Update and continue' to continue editing AOP text sections.  The new text should appear under the “Considerations for Potential Applications of the AOP” section on the AOP page. More help

This AOP is applicable to occupational exposures as lung fibrosis is frequently observed in miners and welders exposed to metal dusts.

Pulmonary fibrosis is a progressive debilitating disease with no cure. A number of environmental and occupational agents, such as cigarette smoke, agriculture or farming, wood dust, metal dust, stone and sand dust, play a causative role in the development of lung fibrosis. More recently, laboratory experiments in animals have shown that exposure to nanomaterials, novel technology-enabled materials of sophisticated properties induce lung fibrosis. Fibrosis also develops in other organs (skin, liver, kidney, heart and pancreas) and the underlying mechanisms are similar. Thus, this AOP is applicable to screening of a broad group of suspected inhalation toxicants and allows the development of in silico and in vitro testing strategies for chemicals suspected to cause inhalation toxicity. Indeed, recent efforts aimed at collating all AOPs with potential relevance to NM risk assessment has led to the production of an AOP network which identified shared KEs of relevance to multiple AOs (Halappanavar et al., 2020). From this list, KE1 and KE2 from this AOP are among the most commonly shared between the various AOPs in the network. Shared KEs such as these can be prioritized for in vitro bio-assay development and tier-1 testing strategies. In a recent review, AOP 173 was used as a case study to define a testing strategy consisting of a slew of targeted bio assay alternatives that can be used to screen for the in vivo occurrence of a number of the contained KEs (Halappanavar et al., 2021). These recent efforts serve to highlight the utility of AOP 173 in guiding the development of rapid screening strategies as well as research recommendations spanning across multiple AOPs with shared events.

This AOP is also currently being used by the various European Union nano research consortia to inform the design and development of relevant in vitro and in silico models for screening, prioritising, and assessing the potential of nanomaterials to cause inhalation hazard. Specifically, this AOP has recently informed the development of a Nano Quantitative Structure Activity Relationship (NanoQSAR) model of CNT induced pulmonary inflammation, which found that the transcriptional response is associated with the aspect ratio of the nano fibres (Jagiello et al., 2021). Furthermore, this AOP can also inform the creation of biomarkers for fibrosis, such as the preliminary biomarker PFS17, which was produced using global transcriptional datasets from mice exposed to CNTs (Rahman et al., 2020). Although in a preliminary stage, this signature composed of 17 genes can be used to assess the response of the MIE (Event 1495), KE1 (Event 1496), KE2 (Event 1497), KE4 (Event 1499), and KE5 (Event 1500), based on the differential expression of key bioinformatics-informed transcripts.

Given the fact that a number of pharmacological agents and allergens cause fibrosis via a similar mechanism; the mechanistic representation of the lung fibrotic process in an AOP format, clearly identifying the individual KEs potentially involved in the disease process, enables visualisation of the possible avenues for therapeutic interference in humans.

Confidence in the AOP

Mechanistically, there is enough evidence to support the occurrence of each individual KE in the process of lung fibrosis as described. There is also enough evidence to support each KERs. However, as mentioned earlier, the early KEs constitute an organism's defence system and thus exhibit high heterogeneity in the signalling pathways and biological networks involved. Therefore, the results of the essentiality experiments may show incongruence based on the individual protein, gene or a pathway selected for intervention.

How well characterised is the AOP?

The adverse outcome is established and there is some quantitative data for some stressors.

How well are the initiating and other key events causally linked to the outcome?

The occurrence of each individual KE in the process leading to lung fibrosis is well accepted and established. However, individual studies mainly focus on a single KE and its relationship with the end AO. Quantitative data to support individual KERs is scarce.

What are the limitations in the evidence in support of the AOP?

As described earlier, attempts have been made to establish an in vitro model to predict the occurrence of fibrosis. However, the model has not been validated for screening the potential fibrogenic substances; the model has been used to identify drug targets that can effectively inhibit the progression to fibrosis (Chen et al., 2009). This is mainly due to the inability to accurately capture the responses induced by different cell types involved, and the intricate dynamics between the cell types, biological pathways and the biomolecules involved. Studies conducted to date have mainly focussed on the adverse outcome.

Is the AOP specific to certain tissues, life stages/age classes?

Fibrosis is a disease that affects several organ systems in an organism including lung, liver, heart, kidney, skin, and eye. The hallmark events preceding the end AO are similar to the one described here for lung fibrosis and involve similar cell types and biomolecules. Thus, the AOP can be extended to represent fibrosis in other organs. The AOP is mainly applicable to adults as evidence to support applicability to different life stages is lacking. Lung fibrosis is thought to be a disease of male subjects. The early inflammatory KEs represented in this AOP constitute functional changes that describe inflammation in general. Several diseases are known to be mediated by inflammation and thus, early KEs in this AOP can be extended to any study investigating inflammation mediated adverse outcomes.

Are the initiating and key events expected to be conserved across taxa?

The events and pathways captured in this AOP are suggested to be conserved across different species and the process itself is influenced by the physical-chemical properties of the toxic substance.


List the bibliographic references to original papers, books or other documents used to support the AOP. More help
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