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Kruzel-Davila E, Shemer R, Ofir A, Bavli-Kertselli I, Darlyuk-Saadon I, Oren-Giladi P, Wasser WG, Magen D, Zaknoun E, Schuldiner M, Salzberg A, Kornitzer D, Marelja Z, Simons M, Skorecki K. APOL1-Mediated Cell Injury Involves Disruption of Conserved Trafficking Processes. J Am Soc Nephrol 2016; 28:1117-1130. [PMID: 27864431 DOI: 10.1681/asn.2016050546] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 10/05/2016] [Indexed: 01/08/2023] Open
Abstract
APOL1 harbors C-terminal sequence variants (G1 and G2), which account for much of the increased risk for kidney disease in sub-Saharan African ancestry populations. Expression of the risk variants has also been shown to cause injury to podocytes and other cell types, but the underlying mechanisms are not understood. We used Drosophila melanogaster and Saccharomyces cerevisiae to help clarify these mechanisms. Ubiquitous expression of the human APOL1 G1 and G2 disease risk alleles caused near-complete lethality in D. melanogaster, with no effect of the G0 nonrisk APOL1 allele, corresponding to the pattern of human disease risk. We also observed a congruent pattern of cellular damage with tissue-specific expression of APOL1. In particular, expression of APOL1 risk variants in D. melanogaster nephrocytes caused cell-autonomous accumulation of the endocytic tracer atrial natriuretic factor-red fluorescent protein at early stages and nephrocyte loss at later stages. We also observed differential toxicity of the APOL1 risk variants compared with the APOL1 nonrisk variants in S. cerevisiae, including impairment of vacuole acidification. Yeast strains defective in endosomal trafficking or organelle acidification but not those defective in autophagy displayed augmented APOL1 toxicity with all isoforms. This pattern of differential injury by the APOL1 risk alleles compared with the nonrisk alleles across evolutionarily divergent species is consistent with an impairment of conserved core intracellular endosomal trafficking processes. This finding should facilitate the identification of cell injury pathways and corresponding therapeutic targets of interest in these amenable experimental platforms.
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Affiliation(s)
- Etty Kruzel-Davila
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of
| | | | - Ayala Ofir
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of
| | - Ira Bavli-Kertselli
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of
| | | | - Pazit Oren-Giladi
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of
| | - Walter G Wasser
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of.,Department of Nephrology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
| | - Daniella Magen
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of.,Genetics and Developmental Biology and
| | | | - Maya Schuldiner
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel; and
| | | | - Daniel Kornitzer
- Microbiology and Inflammation, Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Haifa, Israel
| | - Zvonimir Marelja
- Imagine Institute, Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Matias Simons
- Imagine Institute, Paris Descartes University-Sorbonne Paris Cité, Paris, France
| | - Karl Skorecki
- Department of Nephrology, Rambam Health Care Campus, Haifa, Israel; Departments of .,Genetics and Developmental Biology and
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Ma L, Chou JW, Snipes JA, Bharadwaj MS, Craddock AL, Cheng D, Weckerle A, Petrovic S, Hicks PJ, Hemal AK, Hawkins GA, Miller LD, Molina AJA, Langefeld CD, Murea M, Parks JS, Freedman BI. APOL1 Renal-Risk Variants Induce Mitochondrial Dysfunction. J Am Soc Nephrol 2016; 28:1093-1105. [PMID: 27821631 DOI: 10.1681/asn.2016050567] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/12/2016] [Indexed: 11/03/2022] Open
Abstract
APOL1 G1 and G2 variants facilitate kidney disease in blacks. To elucidate the pathways whereby these variants contribute to disease pathogenesis, we established HEK293 cell lines stably expressing doxycycline-inducible (Tet-on) reference APOL1 G0 or the G1 and G2 renal-risk variants, and used Illumina human HT-12 v4 arrays and Affymetrix HTA 2.0 arrays to generate global gene expression data with doxycycline induction. Significantly altered pathways identified through bioinformatics analyses involved mitochondrial function; results from immunoblotting, immunofluorescence, and functional assays validated these findings. Overexpression of APOL1 by doxycycline induction in HEK293 Tet-on G1 and G2 cells led to impaired mitochondrial function, with markedly reduced maximum respiration rate, reserve respiration capacity, and mitochondrial membrane potential. Impaired mitochondrial function occurred before intracellular potassium depletion or reduced cell viability occurred. Analysis of global gene expression profiles in nondiseased primary proximal tubule cells from black patients revealed that the nicotinate phosphoribosyltransferase gene, responsible for NAD biosynthesis, was among the top downregulated transcripts in cells with two APOL1 renal-risk variants compared with those without renal-risk variants; nicotinate phosphoribosyltransferase also displayed gene expression patterns linked to mitochondrial dysfunction in HEK293 Tet-on APOL1 cell pathway analyses. These results suggest a pivotal role for mitochondrial dysfunction in APOL1-associated kidney disease.
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Affiliation(s)
- Lijun Ma
- Department of Internal Medicine, Section on Nephrology, .,Center for Public Health Genomics
| | - Jeff W Chou
- Center for Public Health Genomics.,Division of Public Health Sciences, Department of Biostatistical Sciences
| | | | - Manish S Bharadwaj
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine
| | | | - Dongmei Cheng
- Department of Internal Medicine, Section on Molecular Medicine
| | | | | | | | | | | | | | - Anthony J A Molina
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine
| | - Carl D Langefeld
- Center for Public Health Genomics.,Division of Public Health Sciences, Department of Biostatistical Sciences
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology
| | - John S Parks
- Department of Internal Medicine, Section on Molecular Medicine
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, .,Center for Public Health Genomics.,Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Abstract
PURPOSE OF REVIEW The clinical utility of HDLs has been scrutinized upon the publication of Mendelian randomization studies showing no effect of HDL-cholesterol (HDL-C) modifying variants on cardiovascular disease (CVD) outcome. The failures of randomized controlled HDL-C-directed intervention trials have further fueled this skepticism. This general criticism originates from oversimplification that has equated 'HDL-C' with 'HDL' and misconceived both as the 'good cholesterol'. RECENT FINDINGS HDL particles are heterogeneous and carry hundreds of different lipids, proteins, and microRNAs. Many of them but not cholesterol, that is, HDL-C, contributes to the multiple protective functions of HDLs that probably evolved to manage potentially life-threatening crises. Inflammatory processes modify the composition of HDL particles as well as their individual protein and lipid components, and, as a consequence, also their functionality. Gain of dominant-negative functions makes dysfunctional HDL a part rather than a solution of the endangering situation. Quantification of HDL particle numbers, distinct proteins or lipids, and modifications thereof as well as bioassays of HDL functionality are currently explored toward their diagnostic performance in risk prediction and monitoring of treatment response. SUMMARY Any successful clinical exploitation of HDLs will depend on the identification of the most relevant (dys)functions and their structural correlates. Stringent or prioritized structure-(dys)function relationships may provide biomarkers for better risk assessment and monitoring of treatment response. The most relevant agonists carried by either functional or dysfunctional HDLs as well as their cellular responders are interesting targets for drug development.
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Deceased-Donor Apolipoprotein L1 Renal-Risk Variants Have Minimal Effects on Liver Transplant Outcomes. PLoS One 2016; 11:e0152775. [PMID: 27054572 PMCID: PMC4824450 DOI: 10.1371/journal.pone.0152775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/18/2016] [Indexed: 01/08/2023] Open
Abstract
Background Apolipoprotein L1 gene (APOL1) G1 and G2 renal-risk variants, common in populations with recent African ancestry, are strongly associated with non-diabetic nephropathy, end-stage kidney disease, and shorter allograft survival in deceased-donor kidneys (autosomal recessive inheritance). Circulating APOL1 protein is synthesized primarily in the liver and hydrodynamic gene delivery of APOL1 G1 and G2 risk variants has caused hepatic necrosis in a murine model. Methods To evaluate the impact of these variants in liver transplantation, this multicenter study investigated the association of APOL1 G1 and G2 alleles in deceased African American liver donors with allograft survival. Transplant recipients were followed for liver allograft survival using data from the Scientific Registry of Transplant Recipients. Results Of the 639 liver donors evaluated, 247 had no APOL1 risk allele, 300 had 1 risk allele, and 92 had 2 risk alleles. Graft failure assessed at 15 days, 6 months, 1 year and total was not significantly associated with donor APOL1 genotype (p-values = 0.25, 0.19, 0.67 and 0.89, respectively). Conclusions In contrast to kidney transplantation, deceased-donor APOL1 G1 and G2 risk variants do not significantly impact outcomes in liver transplantation.
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Friedman DJ, Pollak MR. Apolipoprotein L1 and Kidney Disease in African Americans. Trends Endocrinol Metab 2016; 27:204-215. [PMID: 26947522 PMCID: PMC4811340 DOI: 10.1016/j.tem.2016.02.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/05/2016] [Accepted: 02/08/2016] [Indexed: 02/06/2023]
Abstract
Genetic variants in the Apolipoprotein L1 (APOL1) gene cause high rates of kidney disease in African Americans. These variants, found only in individuals with recent African ancestry, confer enhanced innate immunity against African trypanosomes. Although they are among the most powerful disease-causing common variants discovered to date, we are just beginning to understand how they promote kidney injury. Since APOL1 is present in only a few primate species, much of our current knowledge has come from natural experiments in humans and in vitro studies while awaiting the development of transgenic animal models. Understanding more about the function of ApoL1 and how the high-risk variants behave differently from other ApoL1 molecules is a high priority in kidney disease research.
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Affiliation(s)
- David J. Friedman
- Beth Israel Deaconess Medical Center, Harvard Medical School, 99 Brookline Avenue, RN301, Boston, MA. 02215, 617 667 0253
| | - Martin R. Pollak
- Beth Israel Deaconess Medical Center, Harvard Medical School, 99 Brookline Avenue, RN325E, Boston, MA. 02215, 617 667 0461
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56
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Bruggeman LA, Wu Z, Luo L, Madhavan SM, Konieczkowski M, Drawz PE, Thomas DB, Barisoni L, Sedor JR, O'Toole JF. APOL1-G0 or APOL1-G2 Transgenic Models Develop Preeclampsia but Not Kidney Disease. J Am Soc Nephrol 2016; 27:3600-3610. [PMID: 27026370 DOI: 10.1681/asn.2015111220] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/15/2016] [Indexed: 11/03/2022] Open
Abstract
APOL1 risk variants are associated with kidney disease in blacks, but the mechanisms of renal injury associated with APOL1 risk variants are unknown. Because APOL1 is unique to humans and some primates, we created transgenic (Tg) mice using the promoter of nephrin-encoding Nphs1 to express the APOL1 reference sequence (G0) or the G2 risk variant in podocytes, establishing Tg lines with a spectrum of APOL1 expression levels. Podocytes from Tg-G0 and Tg-G2 mice did not undergo necrosis, apoptosis, or autophagic cell death in vivo, even in lines with highly expressed transgenes. Further, Tg-G0 and Tg-G2 mice did not develop kidney pathology, proteinuria, or azotemia as of 300 days of age. However, by 200 days of age, Tg-G2 mice had significantly lower podocyte density than age-matched WT and Tg-G0 mice had, a difference that was not evident at weaning. Notably, a pregnancy-associated phenotype that encompassed eclampsia, preeclampsia, fetal/neonatal deaths, and small litter sizes occurred in some Tg-G0 mice and more severely in Tg-G2 mice. Similar to human placenta, placentas of Tg mice expressed APOL1. Overall, these results suggest podocyte depletion could predispose individuals with APOL1 risk genotypes to kidney disease in response to a second stressor, and add to other published evidence associating APOL1 expression with preeclampsia.
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Affiliation(s)
- Leslie A Bruggeman
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center and
| | - Zhenzhen Wu
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center and
| | - Liping Luo
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center and
| | - Sethu M Madhavan
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center and
| | | | - Paul E Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota; and
| | - David B Thomas
- Department of Pathology, University of Miami, Miami, Florida
| | - Laura Barisoni
- Department of Pathology, University of Miami, Miami, Florida
| | - John R Sedor
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center and.,Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - John F O'Toole
- Division of Nephrology, Department of Medicine, MetroHealth Medical Center and
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Wahl P, Ducasa GM, Fornoni A. Systemic and renal lipids in kidney disease development and progression. Am J Physiol Renal Physiol 2016; 310:F433-45. [PMID: 26697982 PMCID: PMC4971889 DOI: 10.1152/ajprenal.00375.2015] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 12/22/2015] [Indexed: 12/14/2022] Open
Abstract
Altered lipid metabolism characterizes proteinuria and chronic kidney diseases. While it is thought that dyslipidemia is a consequence of kidney disease, a large body of clinical and experimental studies support that altered lipid metabolism may contribute to the pathogenesis and progression of kidney disease. In fact, accumulation of renal lipids has been observed in several conditions of genetic and nongenetic origins, linking local fat to the pathogenesis of kidney disease. Statins, which target cholesterol synthesis, have not been proven beneficial to slow the progression of chronic kidney disease. Therefore, other therapeutic strategies to reduce cholesterol accumulation in peripheral organs, such as the kidney, warrant further investigation. Recent advances in the understanding of the biology of high-density lipoprotein (HDL) have revealed that functional HDL, rather than total HDL per se, may protect from both cardiovascular and kidney diseases, strongly supporting a role for altered cholesterol efflux in the pathogenesis of kidney disease. Although the underlying pathophysiological mechanisms responsible for lipid-induced renal damage have yet to be uncovered, several studies suggest novel mechanisms by which cholesterol, free fatty acids, and sphingolipids may affect glomerular and tubular cell function. This review will focus on the clinical and experimental evidence supporting a causative role of lipids in the pathogenesis of proteinuria and kidney disease, with a primary focus on podocytes.
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Affiliation(s)
- Patricia Wahl
- Peggy and Harold Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida
| | - Gloria Michelle Ducasa
- Peggy and Harold Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida
| | - Alessia Fornoni
- Peggy and Harold Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida
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Olabisi OA, Zhang JY, VerPlank L, Zahler N, DiBartolo S, Heneghan JF, Schlöndorff JS, Suh JH, Yan P, Alper SL, Friedman DJ, Pollak MR. APOL1 kidney disease risk variants cause cytotoxicity by depleting cellular potassium and inducing stress-activated protein kinases. Proc Natl Acad Sci U S A 2016; 113:830-7. [PMID: 26699492 PMCID: PMC4743809 DOI: 10.1073/pnas.1522913113] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Two specific genetic variants of the apolipoprotein L1 (APOL1) gene are responsible for the high rate of kidney disease in people of recent African ancestry. Expression in cultured cells of these APOL1 risk variants, commonly referred to as G1 and G2, results in significant cytotoxicity. The underlying mechanism of this cytotoxicity is poorly understood. We hypothesized that this cytotoxicity is mediated by APOL1 risk variant-induced dysregulation of intracellular signaling relevant for cell survival. To test this hypothesis, we conditionally expressed WT human APOL1 (G0), the APOL1 G1 variant, or the APOL1 G2 variant in human embryonic kidney cells (T-REx-293) using a tetracycline-mediated (Tet-On) system. We found that expression of either G1 or G2 APOL1 variants increased apparent cell swelling and cell death compared with G0-expressing cells. These manifestations of cytotoxicity were preceded by G1 or G2 APOL1-induced net efflux of intracellular potassium as measured by X-ray fluorescence, resulting in the activation of stress-activated protein kinases (SAPKs), p38 MAPK, and JNK. Prevention of net K(+) efflux inhibited activation of these SAPKs by APOL1 G1 or G2. Furthermore, inhibition of SAPK signaling and inhibition of net K(+) efflux abrogated cytotoxicity associated with expression of APOL1 risk variants. These findings in cell culture raise the possibility that nephrotoxicity of APOL1 risk variants may be mediated by APOL1 risk variant-induced net loss of intracellular K(+) and subsequent induction of stress-activated protein kinase pathways.
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Affiliation(s)
- Opeyemi A Olabisi
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114; Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | - Jia-Yue Zhang
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | | | | | - Salvatore DiBartolo
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - John F Heneghan
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215; Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Johannes S Schlöndorff
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | - Jung Hee Suh
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | - Paul Yan
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215
| | - Seth L Alper
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215; Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - David J Friedman
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215; Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Martin R Pollak
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215; Harvard Medical School, Boston, MA 02215;
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Weckerle A, Snipes JA, Cheng D, Gebre AK, Reisz JA, Murea M, Shelness GS, Hawkins GA, Furdui CM, Freedman BI, Parks JS, Ma L. Characterization of circulating APOL1 protein complexes in African Americans. J Lipid Res 2015; 57:120-30. [PMID: 26586272 DOI: 10.1194/jlr.m063453] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Indexed: 11/20/2022] Open
Abstract
APOL1 gene renal-risk variants are associated with nephropathy and CVD in African Americans; however, little is known about the circulating APOL1 variant proteins which reportedly bind to HDL. We examined whether APOL1 G1 and G2 renal-risk variant serum concentrations or lipoprotein distributions differed from nonrisk G0 APOL1 in African Americans without nephropathy. Serum APOL1 protein concentrations were similar regardless of APOL1 genotype. In addition, serum APOL1 protein was bound to protein complexes in two nonoverlapping peaks, herein referred to as APOL1 complex A (12.2 nm diameter) and complex B (20.0 nm diameter). Neither of these protein complexes associated with HDL or LDL. Proteomic analysis revealed that complex A was composed of APOA1, haptoglobin-related protein (HPR), and complement C3, whereas complex B contained APOA1, HPR, IgM, and fibronectin. Serum HPR was less abundant on complex B in individuals with G1 and G2 renal-risk variant genotypes, relative to G0 (P = 0.0002-0.037). These circulating complexes may play roles in HDL metabolism and susceptibility to CVD.
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Affiliation(s)
- Allison Weckerle
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - James A Snipes
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Dongmei Cheng
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Abraham K Gebre
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Julie A Reisz
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Mariana Murea
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Gregory S Shelness
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Gregory A Hawkins
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Cristina M Furdui
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Barry I Freedman
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - John S Parks
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Lijun Ma
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
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