Primitive epithelia (epiblasts) form tropoblastic germ layers through EMT. The primary mesenchyme that migrates after EMT is reinduced to secondary epithelium by mesenchymal-epithelial transition. Secondary epithelia differentiate to form new epithelial tissues and undergo a second round of EMT to form the cells of connective tissue, including astrocytes, adipocytes chondrocytes, osteoblasts, muscle cells, and fibroblasts. Mature secondary epithelia that form epithelial organs can also transform into primary tumors that later undergo EMT to metastasize. These processes are regulated by morphogenic cues and a variety of transcription factors, and are potentially plastic in their adaptation to new biologic circumstances.

Epithelial plasticity can lead to classical EMT (loss of cell-cell and cell-substratum attachments, new actin rearrangements, and gain of mobility) or reversible scatter, which looks like EMT but is not enduring and can revert. These events are regulated by ligand-inducible intrinsic kinase receptors on the cell surface, which modulate small GTPases, Smads, PI3Ks, MAP kinases, and the availability of β-catenin to coactivate LEF in the nucleus. Free levels of b-catenin are regulated by E-cadherin or APC/β-catenin/Axin complexes, the latter of which shuttle b-catenin between ubiquination or utilization in adherens junctions. Activation of nuclear transcription provides new transcriptional regulators (Snail, SIP1, Ets, and FTS-BP/CarG box binding factor) of the EMT proteome. The EMT proteome comprises proteins listed in Table 1. The variability of receptors, kinases, and the emergence of combined preferences for signaling pathways determine the plasticity unique to each epithelium.

Origin of fibroblasts during kidney fibrosis. (a) Fibrotic kidney which displays accumulation of numerous fibroblasts (blue arrow), damaged kidney tubules (yellow arrow), and blood vessels (green arrow). (b) Normal kidney with proper tubular structures and very few fibroblasts. (c) Schematic illustration of three possible mechanisms via which fibroblasts can originate during kidney injury. Recent experiments suggest that approximately 14–15% of fibroblasts are from bone marrow, 36% can arise via local EMT involving tubular epithelial cells under inflammatory stress, and the rest are likely contributed by proliferation of fibroblasts from all sources. (d) Systemic treatment of mice with renal fibrosis using recombinant human BMP-7 results in reversal of renal disease due to severe decrease in EMT-derived fibroblasts and potentially bone marrow–derived fibroblasts. Such events likely have a cascade of beneficial effects that decreasing the overall number of fibroblasts in the kidney, and attenuating fibrosis.