Pirfenidone treatment attenuates fibrosis in autosomal dominant polycystic kidney disease

IntroductionAutosomal dominant polycystic kidney disease (ADPKD) is characterized by the formation of fluid filled cysts, progressive fibrosis and chronic inflammation, often leading to kidney failure. Renal fibrosis in ADPKD is primarily driven by myofibroblast activation and excessive extracellular matrix (ECM) accumulation, which contribute to disease progression. Here we investigated the therapeutic potential of pirfenidone, an antifibrotic drug, on myofibroblast activity, ECM production, and ADPKD progression. MethodsPrimary cultures of myofibroblasts from human ADPKD kidneys were treated with pirfenidone in vitro, and cell proliferation, migration, contractility and changes in ECM production were measured. In vivo, the effect of pirfenidone on cyst growth, fibrosis and renal function were determined in the Pkd1RC/RC male mouse model of ADPKD and wild type controls. ResultsAnalysis of single-nucleus RNA sequencing data of human ADPKD kidneys revealed that fibroblasts are a primary source of fibrous and cell-adhesive ECM, with higher ECM gene expression compared to normal human kidneys. Treatment of human ADPKD renal myofibroblasts with pirfenidone led to reduced ECM gene expression, cell proliferation, migration and contractility. In vivo, pirfenidone treatment in Pkd1RC/RC mice reduced renal fibrosis, collagen deposition, myofibroblast accumulation, pro-fibrotic gene expression and decreased TGF-{beta}/SMAD3 and mTOR signaling. While kidney cyst number remained unchanged, kidney size and cyst area were reduced, leading to improved kidney morphology and improved renal function in RC/RC mice. ConclusionThese findings suggest that pirfenidone mitigates renal fibrosis and preserves renal architecture in ADPKD, supporting its potential as a therapeutic strategy to inhibit fibrosis in ADPKD. Translational StatementAutosomal dominant polycystic kidney disease (ADPKD) is characterized by cyst growth and progressive renal fibrosis, which contributes significantly to kidney function decline. Current therapies predominantly target cyst expansion but do not adequately address fibrosis. Our study demonstrates that myofibroblasts are the principal source of extracellular matrix (ECM) deposition in ADPKD kidneys and that pirfenidone, an FDA-approved antifibrotic drug for idiopathic pulmonary fibrosis, effectively reduces myofibroblast activation, ECM production, and key profibrotic signaling pathways both in human ADPKD cells and in a rodent model. Importantly, pirfenidone treatment also decreased kidney enlargement and cyst growth without nephrotoxicity. These findings support the repurposing of pirfenidone as a complementary therapeutic strategy in ADPKD to target fibrotic remodeling alongside cystic disease. Clinical trials investigating pirfenidones safety and efficacy in ADPKD patients could potentially slow disease progression and improve renal outcomes.