Urine RAS Components in Mice and People with Type 1 Diabetes and Chronic Kidney Disease
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Articles in PresS. Am J Physiol Renal Physiol (May 3, 2017). doi:10.1152/ajprenal.00074.2017 Title: Urine RAS components in mice and people with type 1 diabetes and chronic kidney disease Running title: Urine RAS components in diabetic kidney disease Authors: Jan Wysocki, MD-PhD, Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA Anne Goodling, BA. Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA Mar Burgaya, Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA Kathryn Whitlock, MS. Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA John Ruzinski, BS. Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA Daniel Batlle, MD, Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 Maryam Afkarian, MD-PhD, Division of Nephrology, Department of Medicine, University of California, Davis, CA 95616 Corresponding author: Maryam Afkarian, MD-PhD, 4150 V Street, Suite 3500, Sacramento, CA 95817. Telephone: (916) 734-3774 Fax: (916) 734-7920. Email: [email protected]. Abstract word count: 250 Key words: diabetic kidney disease, renin angiotensin system, angiotensinogen, cathepsin D, angiotensin converting enzyme, angiotensin converting enzyme 2, aminopeptidase-A 1 Copyright © 2017 by the American Physiological Society. 1 ABSTRACT 2 The pathways implicated in diabetic kidney disease (DKD) are largely derived from animal models. To examine 3 if alterations in renin-angiotensin system (RAS) in humans are concordant with rodent models, we measured 4 concentration of angiotensinogen (AOG), cathepsin D (CTSD), angiotensin converting enzyme (ACE) and 5 ACE2 and enzymatic activities of ACE, ACE2 and aminopeptidase-A in FVB mice 13-20 weeks after treatment 6 with streptozotocin (n=9) or vehicle (n=15) and people with longstanding type 1 diabetes, with (n=37) or 7 without (n=81) DKD. In streptozotocin-treated mice, urine AOG and CTSD were 10.4- and 3.0-fold higher than 8 controls, respectively (p-values <0.001). Enzymatic activities of ACE, ACE2 and APA were 6.2-, 3.2- and 18.8- 9 fold higher, respectively, in diabetic animals (p-values <0.001). Angiotensin II was 2.4-fold higher in diabetic 10 animals (p-value 0.017). Compared to people without DKD, those with DKD had higher urine AOG (170 vs. 15 11 μg/g) and CTSD (147 vs. 31 μg/g). In people with DKD, urine ACE concentration was 1.8-fold higher (1.4 vs. 12 0.8 μg/g in those without DKD), while its enzymatic activity was 0.6-fold lower (1.0 vs. 1.6 x 109 RFU/g in those 13 without DKD). Lower ACE activity, but not ACE protein concentration, was associated with ACE inhibitor 14 (ACEI) treatment. After adjustment for clinical covariates, AOG, CTSD, ACE concentration and ACE activity 15 remained associated with DKD. In conclusion, in mice with streptozotocin-induced diabetes and humans with 16 DKD, urine concentrations and enzymatic activities of several RAS components are concordantly increased, 17 consistent with enhanced RAS activity and greater angiotensin II formation. ACEI use was associated with a 18 specific reduction in urine ACE activity, not ACE protein concentration, suggesting it may be a marker of 19 exposure to this widely-used therapy. 2 20 INTRODUCTION 21 Diabetic kidney disease is the leading cause of chronic and end-stage kidney disease in the United States and 22 worldwide.(2) Several biological pathways are implicated in the pathogenesis of diabetic kidney disease (DKD). 23 This information is largely obtained from animal models of DKD. However, animal models only partially 24 recapitulate the pathology and pathophysiology of human DKD.(5, 50) As such, the timing and extent of activity 25 of these pathways in the course of human DKD is not known. Given the dearth of research biopsies in human 26 DKD, information on pathway activity in human kidney biopsies obtained throughout the course of DKD is not 27 currently available. 28 Urine is a readily available, non-invasive bio-fluid, which is extensively used in clinical medicine and now 29 increasingly utilized for biomarker discovery.(16) Though formed initially as a filtrate of plasma, urine protein 30 composition is subsequently influenced by secretory and reabsorptive activities of the cells lining the length of 31 the nephron. Urine albumin and total urine protein quantity is a powerful clinical risk stratifier not only for 32 progression of kidney disease but also heart disease and mortality.(36) More recent evidence suggests that 33 urine protein composition may be able to inform on the underlying intrarenal pathogenic mechanisms.(13, 18, 34 21, 57, 59) This potential would open up new diagnostic avenues for the use of urine protein composition as a 35 personalized assay for tailoring treatment of kidney disease to the pathways active in each individual at a given 36 time. 37 We sought to comprehensively examine urine concentrations, and when possible enzymatic activities, of key 38 renin angiotensin system (RAS) components in an animal model of DKD, the FVB mice treated with 39 streptozotocin, as well as people with type 1 diabetes and DKD, compared to those with longstanding type 1 40 diabetes and no DKD. The examined RAS components included angiotensinogen, angiotensin converting 41 enzyme (ACE), ACE2, as well as cathepsin D (CTSD). The latter is a lysosomal protein capable of cleaving 42 angiotensinogen to angiotensin I, enabling ACE-independent angiotensin II generation.(24) In addition, we 43 examined enzymatic activity of aminopeptidase A (APA), which regulates angiotensin II concentration by 44 catalyzing its degradation to angiotensin III.(56) The RAS was selected as an exemplary pathway because it is 45 presumed to be overactive in DKD kidneys and its pharmacological suppression is part of current standards of 3 46 care. Our findings show concordance between the urine concentration and enzymatic activity of RAS pathway 47 proteins and the known intrarenal pathway activity and between rodent DKD models and human DKD. 48 Furthermore, in humans with DKD, urine ACE activity shows a negative correlation with use of ACE inhibitors 49 that may reflect suppression of ACE activity at the kidney level by these agents. 4 50 MATERIALS AND METHODS 51 Study cohort 52 People with type 1 diabetes, who were seen in the Diabetes Care Center (University of Washington) for 53 outpatient endocrinology care, were approached for participation in the Kidney Research Institute Diabetic 54 Kidney Disease Repository (University of Washington) and were enrolled into the repository after providing 55 informed consent. Demographic and clinical information was obtained from the electronic medical records and 56 a questionnaire filled by the participants. DKD was defined as either a urine ACR ≥300 mg/g or an eGFR <60 57 mL/min per 1.73 m2 and ACR ≥30 mg/g. People with longstanding diabetes but no evidence of overt DKD were 58 those with ≥30 years of type 1 diabetes, estimated GFR >90 mL/min per 1.73 m2, and ACR <300 mg/g. 59 Demographic and clinical data (age, race, sex, diabetes duration and RAS inhibitor use) were obtained from 60 the electronic medical records and confirmed by patient questionnaires (race, diabetes duration and RAS 61 inhibitor use). Diabetes type was extracted from the clinical notes, as ascertained by the endocrinologists 62 caring for the patients. Hemoglobin A1c and serum creatinine were obtained from the electronic medical 63 records at a time closest to the date of urine sample collection. Glomerular filtration rate was calculated from 64 the serum creatinine using CKD-EPI formula. (26) 65 A random clean-catch, mid-stream urine sample was collected and stored at 4oC after collection, until 66 processed. Urine samples were centrifuged at 4,700g for 15 minutes at 4oC and the supernatant collected, 67 aliquoted and stored at -80oC. The mean (standard deviation, SD) time from sample collection to storage at - 68 80oC was 5.7 (2.0) hours. The use of human samples and data were approved by the Institutional Review 69 Board of the University of Washington. 70 Experimental animals 71 Female FVB mice were acquired from Jackson Laboratories (Bar Harbor, ME). Animals were housed at the 72 Center for Comparative Medicine at Northwestern University Feinberg School of Medicine. Animal care and 73 procedures were approved by the Institutional Animal Care and Use Committee at Northwestern University and 74 in accordance with the NIH Guide for the Care and Use of Laboratory Animals and the institutional, state, and 75 federal guidelines. Streptozotocin (150 mg/kg, Sigma Chemical, St. Louis, MO) dissolved in sodium citrate 5 76 buffer pH 4.5 (streptozotocin-treated mice) or sodium citrate buffer pH 4.5 alone (non-diabetic vehicle controls) 77 was injected in two intraperitoneal injections to female FVB mice at 19 and 20 weeks of age. Spot urines were 78 collected 13 and 20 weeks after the last streptozotocin or vehicle injection (at 32 and 40 weeks of age, 79 respectively) and stored at -80oC. 80 Laboratory measurements in mouse urine samples 81 Albumin was measured by a quantitative solid-phase sandwich enzyme-Linked immunosorbent assay (ELISA) 82 (Albuwell M, Exocell, Philadelphia, PA). Creatinine was measured using the Jaffe method (Creatinine 83 Companion, Exocell, Philadelphia, PA). AOG was measured using a quantitative solid-phase sandwich ELISA 84 (IBL-America, Minneapolis, MN). CTSD was measured using a sandwich ELISA (OriGene Technologies, Inc, 85 Rockville, MD). ACE activity was measured in a high-throughput fluorimetric assay that uses the substrate 86 hippuryl-L-histidyl-L-leucine, as previously described.(48) The concentration of affinity purified recombinant 87 testis ACE showed direct linear relationship to the production of L-histidyl-L-leucine within the range of 0–4 10-4 88 nmol ACE.