Journal of the American Society of Nephrology

Background Acute kidney injury (AKI) is a major contributor to morbidity, mortality, and healthcare utilization among hospitalized adults. Long-standing racial and ethnic inequities in U.S. healthcare--including unequal access to care, neighborhood disadvantage, and other structural factors--are known to influence kidney health, yet national data describing how these inequities manifest in AKI remain limited. Methods We conducted a retrospective, cross-sectional analysis of the 2022 National Inpatient Sample. AKI was identified using ICD-10-CM codes N17.x, and race/ethnicity followed HCUP categories. Descriptive analyses compared characteristics across groups. Survey-weighted logistic regression estimated adjusted odds of developing AKI, in-hospital mortality among AKI patients, and dialysis use, adjusting for demographics, payer, and comorbidities. Age-specific predicted AKI probabilities were derived from the adjusted model. Results AKI prevalence ranged from 15% to 23% across racial and ethnic groups. After adjustment, Black (OR 1.34), Native American (OR 1.08), and Other patients (OR 1.07) had higher odds of AKI, whereas Asian/Pacific Islander (OR 0.94) and Hispanic (OR 0.98) had slightly lower or similar odds. Among AKI hospitalizations, mortality was modestly lower for Black and Hispanic patients relative to White patients and higher for Asian/Pacific Islander and Native American patients. All non-White groups had higher odds of dialysis use. Age-specific curves showed persistent risk differences across adulthood. Conclusions Substantial racial disparities in AKI incidence, mortality, and dialysis use persisted after adjustment, reflecting broader structural inequities. Addressing these gaps will require both targeted clinical strategies and policy interventions focused on upstream determinants.

Metabolic dysfunction-associated kidney disease (MDAKD) is closely linked to dietary excess, but models that capture early kidney injury without obesity are limited. We fed male C57BL/6J (6J) and C57BL/6N (6N) mice a high-fat, high-sodium (HF/HNa) or control diet for 16 weeks. HF/HNa feeding did not alter body weight, adiposity, or total food intake; however, it increased dietary energy and sodium exposure, kidney mass, water intake, and urine volume. GFR declined modestly in 6J mice, whereas 6N mice maintained or slightly increased GFR. Both substrains showed increased urinary albumin, creatinine, KIM-1, and NGAL, while cystatin C rose predominantly in 6N mice, indicating strain-dependent tubular injury. Whole-kidney trichrome staining revealed increased fibrotic area with HF/HNa, particularly in 6N mice, without significant changes in glomerular morphology. In isolated renal mitochondria, oxygen consumption was preserved, but ATP production and ATP:O ratios were reduced, with unchanged citrate synthase activity and OXPHOS protein abundance, consistent with early mitochondrial bioenergetic uncoupling. Exploratory urinary proteomics in 6J mice identified HF/HNa-associated changes in proteins linked to tubular stress and extracellular matrix remodeling. These findings define an early MDAKD-like renal phenotype with strain-specific functional responses, tubular injury, fibrosis, and impaired mitochondrial ATP efficiency. Translational StatementMetabolic Dysfunction-Associated Kidney Disease (MDAKD) is a leading driver of chronic kidney disease (CKD) in the world. In addition to obesity and related comorbidities, renal mitochondrial dysfunction is thought to be a key contributor to the development of CKD in patients with MDAKD; however, few models recapitulate the progression of MDAKD. We couple well-established mouse models of obesity, namely the C57Bl/6J and C57Bl/6N mouse lines, with a high-fat, high-salt diet to induce renal mitochondrial dysfunction, leading to early stages of MDAKD as indicated by widespread fibrosis and mild reduction in glomerular filtration rate, though these effects were strain-dependent. We identify diet-induced mitochondrial dysfunction as a common feature in both mouse strains, suggesting impairments in mitochondrial respiration and oxidative ATP production are indeed a contributing factor to the development of MDAKD. This study highlights the role of energetic impairments in the pathogenesis of MDAKD and may guide future therapies for CKD.

Background: Patients with kidney failure undergoing maintenance hemodialysis suffer high rates of major adverse cardiovascular events(MACE) that are not accurately predicted by traditional cardiovascular risk models. There is an urgent need to identify novel, modifiable cardiovascular risk factors for these patients. Methods: We analyzed associations of 6287 circulating proteins with MACE among 1048 participants undergoing hemodialysis in the Chronic Renal Insufficiency Cohort(CRIC) (14-year follow-up) with validation in the Predictors of Arrhythmic and Cardiovascular Risk in End-Stage Renal Disease study(PACE) (7-year follow-up). In both cohorts, proteins were measured shortly after dialysis initiation and one year later. We compared protein-based risk models derived by elastic net regression to the Pooled Cohort Equations(PCE) optimized for these cohorts(Refit PCE), and to an Expanded Refit PCE that included Troponin T and N-terminal pro-B-type natriuretic peptide. Results: In CRIC, 149 proteins were associated with MACE at false discovery rate<0.05. Among 22 proteins significant at Bonferroni p<8x10-6, proteins that validated in PACE included Sushi von Willebrand factor type A EGF and pentraxin domain-containing protein 1(SVEP1), Complement component C7, R-spondin 4, Tenascin, Fibulin-3 and Fibulin-5. Complement pathways were prominent in network analyses. SVEP1 surpassed other markers by statistical significance, with CRIC HR per log2 1.8 (p=2.1x10-12) and HR per annual doubling 1.6 (p=6.8x10-6). For 2-year MACE, AUC(95%CI) for SVEP1 alone was 0.72(0.59, 0.84) in CRIC, and 0.73(0.63, 0.81) in PACE. SVEP1 surpassed the Expanded Refit PCE in CRIC (0.61 (0.48, 0.73)) (p=0.038). In the pooled CRIC + PACE cohort, SVEP1 AUC(95%CI) (0.79(0.70, 0.88)) surpassed Refit PCE (0.61(0.51, 0.72)) (p=0.004). Conclusions: SVEP1, a 390 kDa protein unlikely to be renally cleared, surpassed over 6000 other proteins and by itself outperformed traditional clinical risk models in predicting MACE in two populations of patients undergoing maintenance hemodialysis. Future studies should provide mechanistic insights behind these findings.

BackgroundDysregulation of phosphate homeostasis contributes to reduced longevity and vascular complications in chronic kidney disease and aging. This study investigates the role of TMEM174, a proximal tubule-specific protein, in regulating the phosphate co-transporter NPT2A and its subsequent impact on lifespan and vascular health. MethodsTMEM174 knockout (KO) mice (C57BL6/J and DBA/2J) were fed diets with varying phosphate concentrations (0.6% vs. 1.2%). In OKP cells, TIRF and FRET microscopy, alongside immunoprecipitation, were used to identify the TMEM174 protein regions essential for NPT2A binding and endocytosis. ResultsTMEM174 KO mice exhibited significantly shorter lifespans than wild-type controls. High phosphate diets exacerbated vascular calcification, stiffness, and mortality, while low phosphate diets rescued these phenotypes. In vitro, TMEM174 siRNA blocked PTH-induced NPT2A endocytosis, increasing its apical membrane retention. FRET and biochemical assays revealed that the C-terminal region of TMEM174 is essential for its association with NPT2A. While intact TMEM174 and N-terminal mutants (TMEM174{Delta}N) facilitated NPT2A degradation, C-terminal deletions (TMEM174{Delta}C) failed to associate with or degrade NPT2A. ConclusionsTMEM174 is a critical regulator of phosphate homeostasis and longevity. The C-terminal region of TMEM174 is specifically required for NPT2A endocytosis and degradation, identifying it as a potential therapeutic target for managing phosphate-related vascular complications.

Chronic kidney disease (CKD) affects over 850 million people worldwide and is characterized by progressive renal fibrosis driven by activated interstitial fibroblasts. Signaling by extracellular nucleotides and P2 receptors plays an important role in renal pathophysiology, yet its contribution to fibroblast activation and fibrosis remains poorly understood. Here, we investigated the expression and function of Gq/11-coupled P2Y receptors in renal interstitial fibroblasts and their involvement in experimental kidney fibrosis. Using highly selective RNA in situ hybridization, we detected P2Y1 (P2ry1) and P2Y6 (P2ry6) receptor expression in interstitial fibroblasts. Notably, P2Y6 expression was markedly upregulated in several experimental mouse models of renal fibrosis. Functional assays in primary cultured renal fibroblasts confirmed Gq/11-coupled P2Y receptor activity, as evidenced by transient intracellular Ca2+ elevations upon nucleotide stimulation. Primary cultured renal fibroblasts exhibited enhanced migration in response to extracellular uridine diphosphate (UDP). To assess the contribution of interstitial P2Y6 receptors to fibrosis progression, we employed an adenine-induced nephropathy model with or without the selective P2Y6 antagonist MRS2578. Pharmacological inhibition of P2Y6 significantly reduced the mRNA expression of the myofibroblast marker -smooth muscle actin and collagen I. Collectively, these findings suggest that upregulated P2Y6 receptor signaling promotes the transition of resident interstitial cells into myofibroblasts during renal fibrosis, likely by modulating fibroblast migration. Inhibition of P2Y6 signaling could represent a new strategy for reducing excessive renal fibrosis. TRANSLATIONAL STATEMENTThis study reveals the role of the P2Y6 receptor (P2ry6) in fibrotic processes in the kidney. P2Y6, a Gq/11 protein-coupled UDP-sensitive receptor, is expressed in renal interstitial PDGFR-{beta}-positive cells and macrophages. Its pharmacological inhibition significantly reduces fibrosis in the mouse adenine nephropathy model. Blocking P2Y6 therefore represents a promising therapeutic strategy for kidney diseases characterized by excessive scarring.

Withdrawal StatementmedRxiv has withdrawn this manuscript as it was submitted and made public without the full consent of all the authors. Therefore, this work should not be cited as reference for the project. If you have any questions, please contact the corresponding author.

BackgroundPersistent neurohormonal activation is a key driver of maladaptive remodeling and disease progression in heart failure (HF). Sodium-glucose cotransporter 2 inhibitors (SGLT2is) confer robust renoprotective effects in HF; however, the extent to which these benefits involve modulation of renal neurohormonal activity remains unclear. We hypothesized that SGLT2i-mediated renoprotection in HF is associated with attenuation of excessive renal neurohormonal activation. MethodsMale rats with myocardial infarction-induced HF and sham controls were fed standard chow or chow containing empagliflozin (EMPA, 300 mg/kg) for four weeks, followed by assessment of renal inflammatory and neurohormonal markers. Parallel in vitro studies in THP-1 macrophages and HK-2 proximal tubule cells evaluated the direct effects of EMPA on norepinephrine (NE)-dependent tubular inflammatory signaling. ResultsHF rats displayed higher renal cortical renin gene expression and angiotensin II concentrations, which remained unaffected by EMPA. Conversely, EMPA normalized the elevated urinary NE excretion and renal cortical NE content observed in HF rats. Given the inflammatory role of sympathetic hyperactivity, we assessed renal macrophage polarization. EMPA-treated HF rats showed reduced expression of pro-inflammatory markers (Tnf, Ccr2, Nos2, Il-6) and increased expression of markers associated with a reparative macrophage profile (Arg1, Mrc1, CD163), supported by higher CD206 macrophages in kidney sections. While EMPA did not directly alter THP-1 macrophage activation in vitro, it significantly reduced NE-induced SGLT2 expression and interleukin-6 (IL-6) release by HK-2 human proximal tubule epithelial cells. ConclusionThese findings support a model in which SGLT2 inhibitors confer renoprotection in HF by suppressing renal sympathetic hyperactivity, independently of the intrarenal renin-angiotensin system, thereby disrupting a maladaptive renal neuro-epithelial-immune axis and promoting a reparative macrophage phenotype. CLINICAL PERSPECTIVE Whats new?O_LIThis study identifies a renal neuro-epithelial-immune axis underlying empagliflozin-mediated renoprotection in heart failure. C_LIO_LIEmpagliflozin reduces renal cortical and urinary norepinephrine levels in heart failure without altering intrarenal renin-angiotensin system activity, revealing a distinct neurohumoral target of SGLT2 inhibition. C_LIO_LIThis sympatholytic effect is associated with a shift in renal macrophages toward a reparative (M2) phenotype, without changes in total macrophage abundance. C_LIO_LIEmpagliflozin blocks norepinephrine-induced SGLT2 upregulation, limiting proximal tubular glucose reabsorption and IL-6 production, and linking sympathetic signaling to renal inflammation. C_LI What are the clinical implications?O_LIOur findings provide a mechanistic basis for the additive cardiorenal benefits of SGLT2 inhibitors in heart failure, beyond conventional RAS-directed therapies. C_LIO_LITargeting renal sympathetic-driven inflammation may help preserve kidney function and attenuate the progression of cardiorenal syndrome. C_LIO_LISuppression of a renal neuroinflammatory pathway may help explain the early and sustained benefits of SGLT2 inhibitors across heart failure phenotypes, including nondiabetic patients. C_LI

Gabapentin and pregabalin are renally cleared gabapentinoids with markedly different pharmacokinetic profiles in chronic kidney disease: gabapentin half-life extends from 5-7 hours to 52-132 hours in advanced chronic kidney disease, while pregabalin accumulation is more predictable. In an active comparator new-user cohort of 33,791 adults aged [&ge;]40 years with hypertension initiating gabapentinoids (2018-2024) from the Rutgers Clinical Research Data Warehouse, chronic kidney disease substantially amplified gabapentin-associated dementia risk (hazard ratio 7.39, 95% confidence interval 3.43 to 15.92, P<0.001), whereas patients without chronic kidney disease showed near-null effect (hazard ratio 1.09, 95% confidence interval 0.89 to 1.34; P=0.41; interaction P<0.001). This effect was independent of prescribed dose: within the low-dose stratum, chronic kidney disease patients showed hazard ratio 5.06 versus 1.27 in patients without chronic kidney disease. Pre-existing chronic kidney disease conferred significantly elevated risk (hazard ratio 1.78; P=0.001), while incident chronic kidney disease showed a nonsignificant trend (hazard ratio 1.32; P=0.16), consistent with cumulative pharmacokinetic burden. Independent replication in the NIH All of Us Research Program Controlled Tier (N=47,079; hazard ratio 1.593, 95% confidence interval 1.349 to 1.882; P<0.001) confirmed the overall gabapentin-pregabalin signal; eGFR-staged analysis showed the expected pharmacokinetic pattern (mild CKD [eGFR [&ge;]45]: hazard ratio 1.15, not significant; severe CKD [eGFR <45]: hazard ratio 1.77, directionally elevated but underpowered with 51 events). Food and Drug Administration Adverse Event Reporting System data corroborated the renal mechanism (odds ratio 1.642 for renal events in elderly co-exposed patients). These converging findings suggest that chronic kidney disease is a clinically important modifier of gabapentin-associated cognitive risk, and that gabapentinoid selection in chronic kidney disease patients should integrate renal function status into prescribing decisions. Significance StatementGabapentin is the most prescribed gabapentinoid in the United States, with approximately 59 million annual prescriptions, and is entirely dependent on renal clearance. In this active comparator cohort study of 33,791 gabapentinoid initiators, chronic kidney disease amplified gabapentin-associated dementia risk nearly 7-fold compared with pregabalin, an effect that was independent of prescribed dose and persisted even among patients receiving low-dose gabapentin. External replication in the NIH All of Us Research Program and FDA pharmacovigilance data corroborated the signal. These findings suggest that current dose-adjustment guidelines for gabapentin in CKD may be insufficient to prevent cognitive harm, and that renal function status should be incorporated into gabapentinoid selection decisions.

BackgroundElevated RNA-binding protein HuR has been reported in patients with chronic kidney disease (CKD), but its specific pathogenic role remains unclear. Here, we investigated HuR involvement in progressive CKD induced by deoxycorticosterone acetate (DOCA) plus angiotensin II (Ang II) in mice and evaluated the therapeutic efficacy and mechanisms of the HuR inhibitor KH3. MethodsAdult male mice underwent uninephrectomy and were subjected to DOCA + Ang II infusion with 1% NaCl in drinking water. Mice were then treated with KH3 or vehicle for 3 weeks. Control mice received saline injections without DOCA and Ang II infusion. ResultsDOCA + Ang II infusion markedly increased HuR expression in circulating exosomes and kidney tissues, which was attenuated by KH3. KH3 halted the progression of albuminuria and improved renal function, and reduced kidney hypertrophy and glomerular and tubulointerstitial fibrosis compared with untreated DOCA + Ang II mice. These improvements were associated with reduced podocyte and tubular injury. KH3 also decreased renal macrophage infiltration and suppressed NF-{kappa}Bp65, Nox2, AKT phosphorylation, TGF-{beta}1, and Wisp1, consistent with reduced inflammation, oxidative stress, and fibrosis. In addition, KH3 partially lowered arterial blood pressure in DOCA + Ang II-infused mice, an effect that may involve suppression of SGLT2-associated profibrotic vascular responses, as supported by studies in cultured VSMCs and mesenteric resistance arteries. ConclusionsHuR is upregulated in DOCA + Ang II-induced renal and vascular injury and contributes to hypertensive, inflammatory, oxidative, and fibrotic responses in CKD. Pharmacologic inhibition of HuR-RNA interactions represents a promising therapeutic strategy for CKD. NOVELTY AND RELEVANCEO_ST_ABSWhat Is New?C_ST_ABSThis study identifies the RNA-binding protein HuR (ELAVL1) as a previously unrecognized upstream post-transcriptional regulator of blood pressure in hypertensive chronic kidney disease. We demonstrate for the first time that pharmacologic disruption of HuR-RNA interactions lowers arterial blood pressure in vivo. In addition, we uncover a novel HuR-SGLT2-vascular smooth muscle cell (VSMC) signaling axis, revealing that HuR regulates inducible vascular SGLT2 expression and Ang II-mediated vasoconstrictive responses. What Is Relevant?Hypertension in CKD arises from integrated renal and vascular dysfunction that is incompletely controlled by current therapies. Our findings are highly relevant because we identify HuR as a nodal post-transcriptional regulator that coordinates renal injury, vascular inflammation, and smooth muscle contractility, rather than acting within a single cell type or signaling pathway. Clinical and Pathophysiological ImplicationThese data support a model in which HuR-driven RNA regulatory programs amplify Ang II-dependent vascular hypercontractility and hypertension in CKD. Therapeutic targeting of HuR-RNA interactions represents a novel antihypertensive strategy that may complement renin-angiotensin-aldosterone system (RAAS) blockade and provides mechanistic insight into the blood pressure-lowering and vascular protective effects of SGLT2 inhibitors, including in non-diabetic CKD.

Uromodulin, a protein made uniquely by the kidney, is protective against acute kidney injury. An integrated transcriptomic and multiplexed spatial protein imaging was used to uncover early cellular and molecular pathophysiological mechanisms following murine kidney ischemia and reperfusion injury (IRI) and better define the role of Uromodulin at the early stage of injury. Six hours following IRI, there was a pan-nephronal transcriptomic response with activation of common pathways but also unique gene expression signatures for each nephron segment. Cell-cell communications and epithelial-immune spatial interactions most prominently involved thick ascending limbs and distal nephron segments with distinct immune zonation in the inner stripe of the outer medulla. Uromodulin deficiency swayed the tubular transcriptomic signatures towards more severe injury and inflammation with altered macrophage communication. Uromodulin deficiency also caused partial loss of immune zonation and a shift towards broader epithelial-immune interactions in the outer stripe and cortex. Uromodulin inhibited activation of the Nlrc4-dependent alternative inflammasome pathway in macrophages, where the production of IL-1{beta} predominantly targets other immune and collecting duct (CD) cells. Indeed, Uromodulin deficiency induced the expression of CD8 in CD cells which acquire a proinflammatory phenotype linked to spatial niches containing immune cells. The presence of CD8+ CD cells was validated in human kidney biopsies. In conclusion, our findings support a role for Uromodulin in spatially confining the immune system around TAL cells in the inner stripe away from the vulnerable outer stripe in early injury. Uromodulin also inhibits the inflammasome-mediated macrophage-epithelial crosstalk that could induce collecting duct cells towards more inflammatory signaling.

Background and objectivesDiagnostic disclosure practices for autosomal dominant polycystic kidney disease (ADPKD) vary and may influence patient experience and linkage to nephrology care. We characterized patient-reported diagnostic pathways, perceived timing, and disclosure experiences in the PK-DIAG survey. Design, setting, participants, and measurementsCross-sectional web-based survey in France (February 2019-August 2024) among adults with self-reported ADPKD, disseminated via patient organizations. Primary outcomes were poor tact (tact score 0-1 on a 0-5 scale) and very negative diagnostic disclosure experience (overall score 0-1 on a 0-5 scale). Multivariable logistic regression used complete-case analyses. ResultsAmong 1,021 respondents, diagnosis was commonly disclosed outside nephrology care; 49% reported disclosure by a radiologist. Poor tact was reported by 25% and was associated with radiologist (vs nephrologist) disclosure (adjusted odds ratio 2.50; 95% confidence interval 1.57-3.98). Very negative experience was reported by 29% and was associated with poor tact (adjusted odds ratio 4.55; 95% confidence interval 2.90-7.12) and information perceived as insufficient/unclear/inaccurate (adjusted odds ratio 2.52; 95% confidence interval 1.53-4.15). Most participants perceived diagnosis as timely (67%), while 18% perceived it as too early and 15% as too late. Distress (36%) or unmet psychological needs (40%) in the immediate post-disclosure period was common. ConclusionsADPKD diagnostic disclosure often occurred outside dedicated nephrology consultations and was frequently associated with poor tact and inadequate information. These findings support structured, guideline-aligned disclosure pathways incorporating timely counseling, psychosocial support, and rapid linkage to nephrology care. Key PointsO_LIIn PK-DIAG, initial disclosure of ADPKD frequently occurred outside nephrology care, most often by radiologists in radiology settings. C_LIO_LIAbout one quarter of respondents reported poor tact and 29% reported a very negative overall diagnostic disclosure experience. C_LIO_LIPoor tact and information perceived as insufficient/unclear/inaccurate were strongly associated with a very negative diagnostic experience. C_LI

BackgroundRenal biopsy provides important prognostic information for patients with chronic kidney disease (CKD), primarily through evaluation of cortical histopathological lesions, including interstitial fibrosis and tubular atrophy (IFTA). However, the prognostic significance of renal medullary lesions remains poorly understood. We investigated whether medullary pathological findings are independently associated with renal outcomes and whether they improve prognostic discrimination beyond conventional cortical assessments. MethodsThis single-center retrospective cohort study screened 1,136 adult patients who underwent native kidney biopsy between 2011 and 2023. After applying predefined inclusion and exclusion criteria, 488 patients with adequate medullary tissue were included in the final analysis. Medullary fibrosis, inflammatory cell infiltration, and cast formation were semi-quantitatively graded and evaluated as predictors of renal outcomes. The primary outcome was a composite of [&ge;]40% decline in estimated glomerular filtration rate (eGFR) or initiation of renal replacement therapy. Associations were assessed using Cox proportional hazards models with sequential adjustment for demographic factors, baseline eGFR, proteinuria, and cortical IFTA. Model discrimination was evaluated using Harrells concordance-index (C-index). ResultsDuring a median follow-up of 2.3 years, 112 patients (23.0%) reached the composite renal outcome. In multivariable analysis adjusted for age, sex, baseline eGFR, and proteinuria, medullary cast formation was significantly associated with adverse renal outcomes (hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.28-2.24). This association remained significant after additional adjustment for IFTA (HR 1.64, 95% CI 1.21-2.21), whereas medullary fibrosis lost significance after IFTA adjustment. Addition of medullary cast formation improved C-index by 0.016, indicating incremental prognostic value beyond conventional predictors. ConclusionMedullary cast formation is independently associated with renal outcomes and improves prognostic discrimination beyond established cortical parameters. Systematic evaluation of medullary lesions during routine kidney biopsy may enhance risk stratification in CKD. Prospective studies are warranted to clarify the causal role of medullary pathology in CKD progression.

BackgroundAutosomal dominant polycystic kidney disease (ADPKD) is a common inherited disorder marked by numerous renal cysts that impair kidney function, with about half of affected individuals progressing to kidney failure by midlife. Patients exhibit reduced circulating apelin, a ligand of the apelin receptor, known to regulate cardiovascular function including hypertension. We tested whether diminished apelin signaling contributes to cystogenesis and if exogenous apelin receptor activation can improve disease outcomes. MethodsPlasma samples from age- and sex-matched healthy controls and ADPKD participants were analyzed for circulating apelin peptides. To assess direct cystic effects, primary ADPKD renal epithelial cells were grown as 3D collagen-embedded cysts and treated with apelin agonists. Male and female Pkd1RC/RC; Pkd2+/- (PKD) mice were treated for 27 days with apelin agonists, vehicle, or the standard of care drug, Mozavaptan. Kidney and heart weight ratios, BUN, renal cAMP, and kidney transcriptional profiles were evaluated. ResultsCirculating apelin peptides were significantly reduced in ADPKD patients despite normal kidney function (eGFR, BUN, and creatinine). In vitro, both apelin and the small molecule apelin receptor agonist Azelaprag inhibited cyst growth. Apelin and Mozavaptan reduced kidney weight, cystic index, blood urea nitrogen and renal cAMP in PKD mice, whereas Azelaprag did not. Apelin downregulated expression of genes associated with cyst progression, including Lcn2 (Ngal), Postn, and Havcr1 (Kim-1). Mozavaptan, but not apelin, induced diuresis and reduced urinary concentration. ConclusionApelin receptor activation by exogenous apelin inhibited cAMP synthesis and cyst growth and improved kidney function in an orthologous mouse model of ADPKD. We propose that the apelin receptor may be a potential therapeutic target in ADPKD.

BackgroundThe Kidney Precision Medicine Project (KPMP) consortium aims to redefine chronic kidney disease (CKD) by integrating clinical, pathological, and molecular tissue data from kidney biopsies. Here, we demonstrate how biopsy data in CKD can clarify disease etiology and contribute to understandings of disease pathophysiology and clinical prognosis. MethodsThe KPMP is obtaining research kidney biopsies from individuals with CKD (defined as an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2 and/or albuminuria [&ge;]30 mg/g creatinine) and diabetes (enrolled as diabetes and CKD or DKD) or hypertension (enrolled as hypertension and CKD or HCKD). A team of kidney pathologists and nephrologists adjudicated the primary clinico-pathological diagnosis for 258 participants with CKD. We compared pathological features and kidney transcriptional signatures between participants with a primary adjudicated diagnosis of diabetic nephropathy and those with other causes of CKD. We developed a model using clinical and biomarker data that predicted the probability of diabetic nephropathy and tested associations of the signature with CKD progression among Chronic Renal Insufficiency Cohort (CRIC) participants with diabetes (n=229). ResultsAmong 183 participants enrolled as DKD, 102 (56%) had a primary adjudicated clinico-pathologic diagnosis of diabetic nephropathy. Among 75 participants enrolled as HCKD, 42 (56%) had a primary diagnosis of hypertension-associated kidney disease. Those with diabetic nephropathy, compared with other diagnoses, had more severe interstitial fibrosis, tubular atrophy, tubular injury, segmental sclerosis, and severe arteriolar hyalinosis, and single-nucleus and single-cell transcriptional analyses revealed upregulation of immune and inflammatory pathways and downregulation of oxidative phosphorylation. A combination of age, hemoglobin A1c, urine albumin-creatinine ratio, and serum KIM-1 and sTNFR1 predicted a clinico-pathologic diagnosis of diabetic nephropathy in the KPMP (AUC 0.82, 95% CI 0.75-0.89) and was associated with an increased risk of CKD progression among patients with diabetes enrolled in CRIC (HR 1.48 [95% CI 1.27-1.73] per 10% higher predicted probability of diabetic nephropathy). ConclusionIn common presentations of CKD, kidney biopsies may alter a priori impressions, reveal a diversity of diagnosis, structure, and function that is associated with clinical outcomes and can impact therapeutic decisions.

ObjectiveTo estimate chronic kidney disease (CKD) stage transition probabilities in patients with small renal masses (SRMs) using irregularly observed electronic health record (EHR) data, addressing challenges of interval censoring and irregular measurement intervals in real-world clinical practice. Data SourcesWe used EHR data from the University of Virginia Small Renal Mass (SRM) registry (2006-January 2026), capturing outpatient renal function data prior to any definitive treatment. CKD stages were defined using estimated glomerular filtration rate (eGFR) thresholds based on KDIGO guidelines. Study DesignThe final analytic cohort included 527 patients with at least two outpatient eGFR measurements prior to definitive treatment. We applied an expectation-maximization (EM) algorithm to estimate discrete-time CKD stage transition matrices while accounting for irregular follow-up and unobserved intermediate transitions. Transition matrices were estimated under 3-and 6-month cycle lengths overall as well as stratified by age and sex. Likelihood ratio tests were used to compare EM-based estimates with a naive one-step counting estimator. ResultsThe EM framework yielded clinically plausible transition structures dominated by self-transitions and progression primarily to adjacent CKD stages, with reduced spurious backward transitions relative to the naive estimator. Transition patterns were consistent across 3- and 6-month cycle lengths. Age-stratified analyses showed that older patients had slightly higher probabilities of progression to more advanced CKD stages compared with younger patients, whereas sex-stratified differences were minimal. Likelihood ratio comparisons supported the consistency of the EM-based models with the observed transition data in both the overall cohort and subgroup analyses. ConclusionsThe EM approach provides a principled and computationally efficient method for estimating CKD stage progression from irregularly observed EHR data, yielding transition matrices suitable for discrete-time decision-analytic and health economic models.

Background and objectiveKidney stone disease (KSD) is common and distinct monogenic forms with well-defined treatment pathways exist. However, it is unclear which patients should undergo genetic testing and the significance of monoallelic variants in SLC34A1, SLC34A3, CYP24A1, SLC7A9, and SLC3A1. We aimed to define monogenic KSD inheritance patterns, determine the diagnostic yield of genetic testing in selected and unselected cohorts, and establish the utility of standard serum biochemistry in highlighting those at risk of monogenic KSD. MethodsWe compared genetic and phenotypic data from individuals with and without KSD in the UK Biobank to determine inheritance patterns. We established the "number needed to test" (NNTT) to identify monogenic KSD in the UK Biobank and a specialist adult kidney stone nephrology clinic where patients had genetic testing based on age, recurrence, and family history. We examined the utility of standard serum biochemistry in identifying monogenic KSD in both settings. Key findings and limitationsMonogenic KSD associated with SLC34A3, SLC7A9, and SLC3A1 is inherited in an autosomal dominant manner and monogenic KSD associated with SLC34A1 and CYP24A1 in an autosomal recessive manner. A monogenic diagnosis was made in [~]1% of KSD in the UK Biobank (NNTT[~]90) and 15% of KSD in a specialist nephrology clinic (NNTT[~]7). In both settings, standard serum biochemistry failed to identify individuals at risk of monogenic KSD. Conclusions and clinical implicationsGenetic testing for monogenic KSD has utility in specialist settings where there is clinical suspicion of an inherited disorder even in the absence of biochemical abnormalities.

Poor outcomes in proteinuric kidney diseases are challenging to successfully manage therapeutically due to the heterogeneity of underlying disease pathogenesis and associated risk for progression. The role of cytoskeleton-associated proteins, including the scaffolding protein Anillin (ANLN), are of specific interest in kidney disease given the importance of actin dynamics in the kidneys specialized epithelial cell types. In this study, we identify the prevalence of genetic variants in ANLN, the gene encoding ANLN, in a cohort of deeply phenotyped individuals with non-diabetic proteinuric kidney disease. Thirty-one individuals (of 864 genotyped) harbor heterozygously expressed variants in ANLN; 7 unrelated individuals shared the same variant (I1109V) in the C-terminal pleckstrin homology (PH) domain, a region necessary for interaction with the plasma membrane. Kidney organoids generated from I1109V induced pluripotent stem cells from 1 of these individuals showed increased epithelial cell mitogen-activated protein kinase 8 network activity and apoptosis, which was enhanced by tumor necrosis factor alpha (TNF-) and phenocopied by actin polymerization inhibition. TNF--treated I1109V organoids also exhibited tubular lumen expansion. Knockdown and re-expression of the analogous ANLN variant in Xenopus laevis embryonic epithelia resulted in defects in cell-cell junction dynamics including wavy cell membranes exhibiting increased transverse movements as well as abnormal junctional F-actin remodeling in response to mechanical stress and leaky barrier function. Taken together, these results indicate that enhanced tubular epithelial cell death, perturbed cell-cell contacts and barrier function defects are associated with a novel ANLN variant discovered in individuals with non-diabetic proteinuric kidney disease. ONE SENTENCE SUMMARYEnhanced tubular epithelial cell death and perturbed cell-cell junction integrity and barrier function are associated with a novel Anillin coding variant discovered in a cohort of individuals with proteinuric kidney disease.

Diabetic nephropathy remains the leading cause of end-stage renal disease. The ZSF-1 rat model combines features known as the metabolic syndrome, such as type 2 diabetes mellitus, hypertension and obesity, developing progressive kidney disease. In this study, we investigated the nephroprotective mechanisms of the SGLT2 inhibitor empagliflozin, focusing on mitochondrial function. Obese ZSF-1 rats were randomized at 24 weeks of age to receive either placebo or empagliflozin for eight weeks, while lean ZSF-1 rats served as healthy controls. Kidney function, assessed by glomerular filtration rate (GFR), was significantly reduced in obese rats and was not improved by empagliflozin treatment. However, obese animals exhibited increased tubular injury, tubular cast formation, and elevated total and tubular proteinuria, all of which were attenuated by empagliflozin. Mitochondrial function was evaluated in freshly isolated cortical kidney mitochondria by measuring oxygen consumption. Obese ZSF-1 rats showed impaired respiratory capacity and reduced protein expression of oxidative phosphorylation (OXPHOS) complexes II, III, IV, and V, indicating mitochondrial dysfunction. Empagliflozin treatment improved mitochondrial function by enhancing complex I- and IV-linked respiration and restoring the expression of OXPHOS complexes II, III, and IV. In addition, empagliflozin treatment was linked to improved mitochondrial dynamics and modulation of autophagic activity, suggesting enhanced mitochondrial quality control. Overall, these findings demonstrate that empagliflozin exerts nephroprotective effects primarily at the tubular level in obese ZSF-1 rats. The beneficial effects appear to be mediated through improved mitochondrial function, enhanced mitochondrial integrity, and reduced tubular injury.

0BackgroundA Disintegrin and Metalloprotease 17 (ADAM17) is a key sheddase regulating multiple inflammatory and growth factor-related pathways implicated in diabetic kidney disease (DKD). While cell-specific deletion of ADAM17 has shown renoprotective effects, the impact of global ADAM17 ablation in the context of diabetes remains incompletely understood. MethodsWe investigated the effects of tamoxifen-induced global Adam17 deletion in a murine model of type 1 diabetes induced by streptozotocin. Renal function, structural injury, inflammatory responses, stress-related signalling pathways, and fibrotic remodelling were comprehensively assessed and compared between diabetic Adam17 knockout and control mice. ResultsDespite persistent hyperglycaemia and albuminuria, diabetic Adam17 knockout mice exhibited preservation of glomerular filtration rate and marked attenuation of diabetes-associated renal injury. Global Adam17 deletion reduced mesangial expansion and structural damage, limited macrophage infiltration and chemokine expression, and significantly attenuated fibrotic remodelling. At the molecular level, Adam17 deficiency was associated with selective modulation of stress-related signalling pathways, including reduced activation of the PI3K/Akt axis and partial preservation of mitochondrial stress regulators, without evidence of a generalized suppression of cellular stress responses. ConclusionsOur findings demonstrate that global deletion of ADAM17 confers robust protection against diabetes-induced kidney injury through coordinated attenuation of inflammatory activation, stress-related signalling, and fibrotic progression. These results highlight the context-dependent role of ADAM17 in diabetic kidney disease and support the concept that therapeutic strategies targeting ADAM17-related pathways may require tissue- and disease-specific modulation to achieve renoprotective effects.

Background and hypothesis Autosomal dominant polycystic kidney disease (ADPKD) affects over 12 million people worldwide including an estimated 30,000-70,000 in the United Kingdom (UK). Tolvaptan is the only disease-modifying therapy approved for rapidly progressing disease. Despite national guidance, prescribing rates were hypothesised to vary by kidney centre. Treatment may not always align with guidelines: some patients eligible for tolvaptan may not be initiated, while other patients initiated on tolvaptan may not meet eligibility criteria. This may have important consequences for healthcare costs and health-related quality of life. Methods The National Registry of Rare Kidney Diseases (RaDaR) collects longitudinal data from UK NHS kidney centres. This retrospective cohort study used routinely collected data (2016-2023) to examine tolvaptan prescribing across kidney centres. Kidney centre-level initiation patterns were described, assessed using mixed-effects logistic regression and visualised with funnel plots. Cost-effectiveness analyses combined observed prescribing practices under likely negotiated commercial discounts to estimate costs and quality-adjusted life year (QALY) consequences of prescribing at the national level. Results Our study included 3,609 people with ADPKD from 72 kidney centres. Patients eligible for tolvaptan who were not initiated accounted for 34.8% (292/839). Across centres, five (6.9%) initiated tolvaptan significantly more than expected among eligible participants, while one centre (1.4%) initiated significantly less. Nationally, this could result in up to {pound}53.7 million in lost savings (assuming a 60% medication price reduction) and result in up to 1,245 lost QALYs. Patients initiated on tolvaptan who were not eligible accounted for 26.1% (103/395). Only one centre had significantly fewer eligible patients than expected among initiated patients. Nationally, this could cost up to {pound}15.9 million (assuming a 60% medication price reduction). Conclusions There is evidence of variation in tolvaptan prescribing in the UK. A substantial proportion of patients eligible for tolvaptan were not initiated at the cohort-level, with evidence of variation between centres suggesting differences in treatment decision-making. A substantial proportion of patients initiated on tolvaptan were not eligible at the cohort-level, but there was limited evidence of variation between centres. Together, these findings raise questions regarding the potential consistency of clinical decision-making, equitable access to a sole disease-modifying therapy in a rare disease, alignment with national guidance, and effective use of healthcare resources.