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Zonulin
Zonulin
Zonulin
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Alessio Fasano
Alessio Fasano

Zonulin (haptoglobin 2 precursor)[1] is a protein that increases the permeability of tight junctions between cells of the wall of the digestive tract.[2] It was discovered in 2000 by Alessio Fasano and his team at the University of Maryland School of Medicine. As the mammalian analogue of zonula occludens toxin, secreted by cholera pathogen Vibrio cholerae, zonulin has been implicated in the pathogenesis of coeliac disease and diabetes mellitus type 1.[3] Type 2 diabetic patients have shown increased zonulin.[4] However, in recent years, researchers in the field have called into question the existence of zonulin after discovering that the popular ELISA assay used to measure zonulin may have in fact been measuring different proteins across studies. These observations have led some in the field to conclude that zonulin is an ill-defined term encompassing potentially many different proteins and is therefore a poor biomarker of celiac disease.[5]

Gliadin (a glycoprotein present in gluten) activates zonulin signaling irrespective of the genetic expression of autoimmunity, leading to increased intestinal permeability of macromolecules.[3][6]

Zonula occludens toxin is being studied as an adjuvant to improve absorption of drugs and vaccines.[7] In 2014 a zonulin receptor antagonist, larazotide acetate (formerly known as AT-1001), completed a phase 2b clinical trial.[8][9]

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References

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Zonulin

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Zonulin is a 47-kDa protein known as the precursor of haptoglobin-2 (pre-HP2), functioning as the only known physiological modulator of intercellular tight junctions in epithelial and endothelial barriers, particularly in the intestine. It reversibly regulates by promoting the disassembly of tight junctions through activation of proteinase-activated receptor 2 (PAR2) and transactivation of (EGFR), thereby controlling the paracellular trafficking of macromolecules, fluids, and antigens across the gut barrier. Discovered in 2000 by Alessio Fasano and colleagues during studies on the Vibrio cholerae-derived zonula occludens toxin (), zonulin was initially identified in and animal intestinal tissues using anti-Zot antibodies and Ussing chamber assays to measure permeability changes. Its molecular identity as pre-HP2 was confirmed in through proteomic analysis of sera, revealing that the uncleaved form induces permeability, while cleavage into alpha and beta subunits (as in mature ) abolishes this activity. In healthy , zonulin maintains intestinal by facilitating innate immune responses, such as flushing out luminal and antigens during exposure to environmental triggers like or microbial products. Dysregulation of zonulin is implicated in numerous chronic inflammatory and autoimmune conditions, where elevated levels—measured via zonulin-family peptides (ZFP), though assays vary and their validity as biomarkers is debated—lead to increased gut permeability, promoting the passage of pro-inflammatory antigens and contributing to disease pathogenesis. For instance, zonulin is upregulated in , correlating with barrier dysfunction and immune activation; similar associations exist in celiac disease and . Recent research has also linked serum zonulin elevation to the onset of , where it precedes inflammation by facilitating T-cell migration from the gut to synovial tissues. Therapeutically, zonulin antagonists like larazotide acetate have shown promise in restoring barrier integrity and attenuating disease progression in preclinical models of celiac disease; however, Phase III clinical trials for celiac were discontinued in 2022 due to lack of , while as of 2025, it demonstrates and benefits in pediatric post-COVID multisystem inflammatory contexts.

Discovery and History

Initial Identification

Zonulin was first identified in 2000 by Alessio Fasano and colleagues at the University of Maryland Center for Celiac Research as a novel human protein that modulates intestinal permeability. The discovery stemmed from research exploring endogenous regulators of epithelial tight junctions, revealing zonulin as a physiological analogue to the Vibrio cholerae-derived Zonula occludens toxin (Zot), which similarly promotes tight junction disassembly. This protein was isolated from human intestinal tissues using affinity-purified antibodies against Zot, confirming its structural and functional similarities to the bacterial toxin. Initial experiments demonstrated zonulin's capacity to reversibly increase in models of nonhuman intestinal epithelia mounted in Ussing chambers. Upon zonulin exposure, tight junctions disassembled, leading to enhanced paracellular flux, but this effect was transient and reversible upon withdrawal, highlighting its role as a controlled modulator rather than a permanent disruptor. These findings established zonulin as an endogenous signaling protein that could dynamically regulate gut barrier function in response to environmental or physiological cues. An early connection to celiac disease emerged from observations of elevated zonulin expression in duodenal tissues from patients during the acute phase of the condition, which is triggered by exposure. In these individuals, heightened zonulin levels correlated with increased and opened tight junctions, suggesting a mechanistic link between -induced zonulin release and the loss of gut barrier integrity central to celiac pathogenesis. This initial association positioned zonulin as a potential for -related epithelial dysfunction.

Key Milestones in Research

In 2009, researchers identified zonulin as the precursor peptide of 2 (pre-HP2), a 47-kDa protein, through proteomic of human sera, resolving earlier uncertainties about its molecular identity. This finding clarified zonulin's structural relation to the haptoglobin family and its potential as a modulator of tight junctions. Between 2008 and 2011, studies solidified zonulin's status as the sole known physiological regulator of mammalian intestinal tight junctions, emphasizing its reversible control over paracellular permeability. These investigations also highlighted zonulin's contribution to innate immunity by transiently increasing permeability to expel microbial threats and prevent excessive bacterial in the . A seminal review by Alessio Fasano in Physiological Reviews synthesized emerging evidence linking zonulin dysregulation to chronic inflammation, autoimmune conditions, and oncogenesis, positioning it as a central player in epithelial barrier . Subsequent research has raised concerns about the reliability of commercial assays for measuring zonulin levels, with studies indicating that these tests may detect unrelated proteins rather than pre-HP2, complicating its use as a for . Advancements from 2020 to 2025 further expanded zonulin's clinical relevance. A 2020 study in Nature Communications demonstrated that zonulin triggers arthritis onset by compromising intestinal barrier integrity, allowing microbial translocation that initiates systemic autoimmunity in susceptible models. Complementing this, a 2023 prospective cohort analysis in Pediatrics established elevated serum zonulin as a preclinical biomarker for celiac disease autoimmunity in genetically at-risk children, with levels rising significantly months before autoantibody detection.

Molecular Structure and Biochemistry

Protein Composition

Zonulin is identified as the uncleaved precursor of (pre-HP2), a 47-kDa that belongs to the haptoglobin family of proteins. This precursor form retains its full polypeptide chain without the proteolytic cleavage that occurs in mature , distinguishing it structurally from the processed protein. itself is encoded by the HP gene on , with zonulin representing the intact, signaling-competent variant specific to the HP2 allele. Zonulin is the full uncleaved pre-HP2 precursor, consisting of approximately 347 residues, including an N-terminal , an alpha chain (142 residues), and a C-terminal beta chain linked by a . Key domains within this sequence include the alpha chain, which facilitates protein-protein interactions, and motifs in the N-terminal portion that enable signaling functions, such as binding to receptors like PAR2 for modulating cellular responses. These structural features are conserved across individuals carrying the HP2 , with the sequence showing homology to immunoglobulin light chains, particularly in the variable regions that support its regulatory roles. Zonulin is primarily produced in the liver, where haptoglobin synthesis occurs as part of the acute-phase response, and in intestinal epithelial cells, contributing to local barrier regulation. Serum levels of zonulin predominantly reflect its release from the intestinal epithelium rather than hepatic production, as intestinal stimuli trigger its secretion into the bloodstream. This production is genetically determined, with zonulin expression absent in individuals homozygous for the HP1 allele, who lack the duplicated exons present in HP2 that encode the extended precursor.

Activation and Release Mechanisms

Zonulin exists as the intact precursor protein pre-haptoglobin-2 (pre-HP2), a approximately 47 kDa single-chain polypeptide that serves as the physiologically active form capable of modulating . Proteolytic processing of pre-HP2 by enzymes such as cleaves it into α- and β-subunits to form mature haptoglobin-2 (HP2), thereby inactivating its permeability-regulating function. This cleavage neutralizes zonulin's ability to interact with epithelial receptors and induce barrier changes. The release of zonulin from intestinal epithelial cells and possibly other tissues is triggered by specific luminal and environmental stimuli. Gluten-derived peptides, particularly , bind to the on the apical surface of enterocytes, activating a MyD88-dependent pathway that promotes zonulin and subsequent increase in paracellular permeability. Bacterial components, including the zonula occludens (Zot) produced by , similarly induce zonulin release by mimicking host signaling cascades. Environmental factors such as exposure to enteric viruses, including , have also been implicated in stimulating zonulin , contributing to transient barrier opening during . Upon release, zonulin binds to (PAR2) on the basolateral membrane of epithelial cells, triggering transactivation of the (EGFR) through an EGF-like domain in its structure. This PAR2-EGFR interaction activates downstream , leading to (PKC) stimulation and subsequent reorganization of the cytoskeleton, which disassembles tight junctions. The resulting and redistribution facilitate zonulin's in transiently increasing . As a member of the haptoglobin family, zonulin participates in the acute-phase response, with its serum levels rising in conditions of or epithelial stress to signal barrier integrity challenges. Elevated circulating zonulin concentrations thus serve as an indicator of ongoing gut barrier dysfunction, reflecting heightened release in response to physiological or pathological stressors. This modulation ultimately contributes to brief opening without causing permanent damage under normal conditions.

Physiological Functions

Regulation of Epithelial Tight Junctions

Zonulin regulates epithelial s by binding to (PAR2) on the apical surface of epithelial cells, which transactivates (EGFR). This receptor engagement initiates intracellular signaling cascades that activate the α (PKCα) isoform and myosin light chain kinase (MLCK). PKCα activation leads to phosphorylation of zonula occludens-1 (ZO-1) and myosin-1C, while MLCK phosphorylates myosin II regulatory light chain, promoting actin-myosin contraction and redistribution of tight junction components. These signaling events cause reversible disassembly of tight junction complexes, primarily through displacement of ZO-1 from the and reduced interactions with and claudins. The resulting reconfiguration increases paracellular permeability, allowing controlled passage of macromolecules while maintaining overall gut barrier integrity. Specifically, is internalized, and claudins undergo phosphorylation-dependent alterations in pore selectivity, enhancing flux across the barrier in a transient manner. The regulatory effects of zonulin are dose-dependent, with higher concentrations eliciting greater increases in permeability, and time-limited, peaking at 15-30 minutes post-stimulation before gradual restoration of tight junctions within 1-4 hours and full recovery by 48 hours. This reversibility ensures physiological modulation without permanent disruption. Beyond the intestinal epithelium, zonulin extends its regulatory function to endothelial barriers, including the blood-brain barrier, where PAR2 and EGFR expression facilitates similar disassembly of tight junctions composed of analogous proteins like claudin-5. This mechanism supports zonulin's broader role in modulating permeability across various tissue barriers.

Role in Gut Barrier Integrity

Zonulin serves as the primary physiological regulator of intestinal tight junctions, enabling dynamic control of paracellular permeability to support nutrient absorption and immune surveillance in the proximal . By transiently modulating proteins such as ZO-1, zonulin allows selective passage of macromolecules and leukocytes across the epithelial barrier, facilitating efficient digestion and monitoring of luminal contents without compromising overall integrity. This process is essential for adapting the gut barrier to postprandial demands, where increased permeability aids in the uptake of dietary components while maintaining a sealed environment against excessive exposure. A critical protective role of zonulin involves defending against microbial overgrowth through transient junction opening. In response to small intestinal bacterial presence, zonulin induces reversible disassembly, promoting water secretion into the lumen via hydrostatic pressure gradients to flush out microorganisms and reinforce innate immunity. This mechanism ensures microbial by expelling potential colonizers before they establish dominance, thereby preserving the sterile proximal environment. Zonulin maintains homeostatic balance in the gut barrier by precisely modulating trafficking to underlying immune cells, fostering tolerance to harmless luminal entities. Its levels are calibrated to permit controlled sampling of antigens for immune education without provoking sustained leakiness, thus upholding the equilibrium between mucosal immunity and barrier impermeability. This regulation occurs independently of chronic disruptions, with permeability returning to baseline within hours to days post-stimulation. Interactions with the indirectly influence zonulin release via bacterial products, which act as physiological triggers to fine-tune barrier adaptability. Enteric microorganisms in the stimulate zonulin secretion in a host-dependent manner, enhancing microbiota-epithelial to support selective permeability and prevent dysregulated microbial . This bidirectional regulation promotes a stable microbial conducive to optimal .

Pathophysiological Implications

Involvement in Autoimmune Diseases

Zonulin plays a central role in the pathogenesis of celiac disease by mediating gluten-induced disruption of intestinal barrier integrity. In individuals with , such as those carrying or alleles, ingestion of —a component of —binds to the on intestinal epithelial cells, triggering MyD88-dependent release of zonulin. This zonulin release leads to disassembly of tight junctions, increasing paracellular permeability and allowing gliadin peptides to translocate across the epithelial barrier, where they provoke an aberrant immune response involving T-cell activation and autoantibody production against . Serum zonulin levels are significantly elevated in active celiac disease, with studies showing a marked rise in the months preceding clinical diagnosis in at-risk children, correlating with heightened and disease onset. Levels normalize upon adherence to a , underscoring zonulin's direct involvement in disease activity. Note that while serum zonulin is widely studied as a of , there is ongoing debate regarding the reliability of commercial assays, which may not specifically detect the true zonulin protein (pre-haptoglobin-2) and could measure structural analogs instead. This controversy warrants caution in interpreting elevated levels across diseases. Beyond celiac disease, elevated zonulin and resultant "leaky gut" contribute to the initiation and progression of other systemic autoimmune conditions by facilitating the exposure of autoantigens to the . In , zonulin upregulation precedes increased , promoting the translocation of environmental triggers like that may initiate against pancreatic beta cells in genetically susceptible individuals. Similarly, in and , dysregulated zonulin impairs gut barrier function, allowing luminal antigens to enter the circulation and drive systemic inflammation, loss of , and joint or . This shared mechanism highlights zonulin's role in the environmental modulation of polygenic autoimmune predisposition across these disorders. Experimental evidence from mouse models further supports zonulin's causal involvement in autoimmune . In collagen-induced models, zonulin levels rise prior to clinical symptoms, coinciding with early intestinal barrier dysfunction and reduced expression of proteins like ZO-1 and . Pharmacological inhibition of zonulin signaling with larazotide acetate prevents this permeability increase, preserves barrier integrity, and attenuates onset by limiting immune cell transmigration from the gut to synovial tissues, demonstrating zonulin's necessity for disease progression. Zonulin also influences autoimmune and neuroinflammatory processes through the microbiota-gut-brain axis, where barrier breach enables microbial products to exacerbate autoimmunity. A 2023 systematic review outlines how dysbiosis-induced zonulin release disrupts intestinal tight junctions, permitting bacterial translocation and proinflammatory cytokines to cross the blood-brain barrier, thereby promoting in conditions like autism spectrum disorder and . In autism, elevated serum zonulin correlates with severity and gastrointestinal symptoms, linking gut permeability to social and behavioral deficits via inflammatory pathways. For Parkinson's, zonulin-mediated barrier dysfunction facilitates α-synuclein propagation and dopaminergic neuron loss through enteric . These findings position zonulin as a modulator of microbiota-driven extending to neurological manifestations.

Associations with Metabolic and Infectious Disorders

Zonulin levels are elevated in individuals with obesity, where plasma concentrations correlate with the severity of fatty liver and measures of adiposity such as body mass index and waist-to-hip ratio. In type 2 diabetes, increased circulating zonulin is associated with glucose dysregulation and insulin resistance, potentially driven by enhanced intestinal permeability that allows translocation of bacterial lipopolysaccharide (LPS), a key mediator of metabolic endotoxemia. Similarly, in non-alcoholic fatty liver disease (NAFLD), higher serum zonulin concentrations are linked to steatosis severity and insulin resistance, with LPS translocation exacerbating hepatic inflammation and lipid accumulation. Zonulin facilitates entry during infections by reversibly increasing , as observed in acute viral where host-dependent zonulin secretion impairs epithelial tight junctions, aiding microbial clearance but potentially prolonging exposure. In , elevated zonulin levels are implicated in sustained gut permeability, contributing to viral persistence, , and , with correlations to disease severity and mortality. A 2025 systematic review and meta-analysis published in Medicine analyzed serum zonulin in liver cirrhosis, finding significantly elevated levels associated with increased intestinal permeability, bacterial translocation, and complications such as hepatic encephalopathy and infections. Zonulin dysregulation contributes to microbiota dysbiosis by promoting leaky gut, which alters microbial composition and exacerbates conditions like irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), where elevated serum zonulin correlates with symptom severity and barrier dysfunction. In IBS, higher zonulin levels are comparable to those in other permeability-related disorders and link to stool frequency and abdominal pain. For IBD, zonulin-mediated permeability changes amplify dysbiosis-driven inflammation, independent of primary autoimmune triggers.

Clinical and Research Applications

Use as a Biomarker

Zonulin can be measured non-invasively in serum or fecal samples using enzyme-linked immunosorbent assay () kits, providing a practical means to assess . Elevated levels in serum or fecal samples can indicate increased gut barrier dysfunction, correlating with conditions involving leaky gut, though thresholds vary by and population (e.g., >30 ng/mL in some fecal assays). Fecal zonulin measurements offer similar insights, particularly in pediatric populations, where they align with markers like calprotectin for monitoring . A key predictive application emerged from a 2023 of genetically at-risk children, which demonstrated that serum zonulin levels rise significantly months before the onset of celiac disease , potentially serving as an early warning indicator influenced by factors like exposure. This temporal precedence highlights zonulin's utility in forecasting barrier-related in high-risk groups. Clinically, zonulin assays aid in monitoring inflammatory bowel disease (IBD) flares, where fecal levels correlate with disease activity and calprotectin, enabling non-invasive tracking of remission or exacerbation. In metabolic disorders such as , reduced serum zonulin following interventions or reflects improved barrier integrity and treatment efficacy. Additionally, zonulin screening identifies leaky gut in at-risk populations, such as those with predisposition, supporting preventive strategies. Despite these advantages, zonulin's reliability is hampered by inter-individual variability stemming from genetic factors, including the HP2 , which elevates baseline levels and risk in susceptible individuals. Dietary influences, such as intake of proteins or certain micronutrients, can also modulate zonulin concentrations, complicating interpretation. Furthermore, its lack of specificity limits zonulin to a general indicator of permeability rather than a diagnostic for particular conditions. The validity of commercial zonulin ELISAs has been questioned, as they may not specifically measure the active pre-HP2 form and often show poor with direct permeability tests like the lactulose-mannitol .

Therapeutic Targeting and Inhibitors

Larazotide acetate, a synthetic eight-amino acid developed by Alessio Fasano's team at and licensed to 9 Meters Biopharma (formerly Innovate Biopharmaceuticals), serves as a leading zonulin for treating intestinal hyperpermeability in celiac disease. This orally administered agent competitively inhibits zonulin signaling by interfering with its binding to the proteinase-activated receptor 2 (PAR2), thereby preventing zonulin-induced disassembly of epithelial tight junctions and reducing paracellular permeability. Preclinical studies have demonstrated that larazotide acetate restores barrier integrity in models of gluten-induced damage, limiting translocation and subsequent immune activation. Clinical trials from 2020 onward have provided evidence of larazotide acetate's efficacy in modulating zonulin activity. In phase 2 studies involving celiac patients undergoing gluten challenge, larazotide acetate significantly reduced gastrointestinal symptoms, including , compared to , and attenuated gluten-induced increases in . Another phase 2 trial confirmed its safety and tolerability, showing dose-dependent inhibition of zonulin-mediated permeability increases during acute gluten exposure. However, the phase 3 trial (NCT03569007), evaluating larazotide acetate as an adjunct to , was discontinued in 2022 after interim analysis indicated failure to meet the primary endpoint of symptom reduction, though safety profiles remained favorable. In 2025, a small repurposed larazotide acetate for severe post-COVID in children, where it accelerated recovery by blocking zonulin-driven barrier disruption and reducing inflammatory markers. Beyond direct antagonists, indirect strategies to lower zonulin activity have shown promise. supplementation, particularly with strains like and , has been associated with reduced serum zonulin concentrations and enhanced protein expression in clinical studies of gut permeability disorders, thereby mitigating zonulin-mediated leakiness without targeting the pathway directly. Similarly, -degrading enzymes such as latiglutenase indirectly suppress zonulin release by hydrolyzing immunogenic peptides that trigger zonulin secretion via gliadin-induced signaling in celiac disease, as evidenced by decreased mucosal inflammation and permeability in phase 2 evaluations. Anti-zonulin antibodies are under preclinical investigation for autoimmune conditions, aiming to neutralize circulating zonulin and restore barrier , though human translation remains exploratory. Targeting zonulin holds future potential in metabolic disorders, where elevated zonulin contributes to endotoxemia and low-grade inflammation; preclinical data suggest antagonists like larazotide acetate could improve insulin sensitivity and lipid profiles by limiting translocation from the gut. Key challenges include ensuring pathway specificity to avoid unintended effects on normal barrier regulation and optimizing peptide delivery for sustained intestinal exposure, as systemic absorption is minimal. Ongoing research emphasizes combination therapies with dietary interventions to enhance zonulin modulation in permeability-related diseases.

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