Is podocyte injury relevant in diabetic nephropathy? Studies in patients with type 2 diabetes

Altered vitamin D metabolism in type II diabetic mouse glomeruli may provide protection from diabetic nephropathy

The db/db mouse develops features of type II diabetes mellitus as the result of impaired signaling through its abnormal leptin receptor. In spite of accurate metabolic features of diabetes, renal disease manifestations in these mice are not as severe as in humans suggesting the presence of protective genes. There is a growing body of evidence in humans for the relevance of vitamin D in diabetes. Here we followed a large cohort of db/db mice and their non-diabetic db/+ littermates. Transcriptional profiling revealed significant upregulation of 23 genes involved in Ca2+ homeostasis and vitamin D metabolism in db/db glomeruli relative to db/+ glomeruli. Increased glomerular expression of vitamin D3 1alpha-hydroxylase, vitamin D binding protein, calbindins D9K and D28K, and calcyclin mRNA was confirmed by quantitative reverse transcription-polymerase chain reaction in 20-, 36-, and 52-week-old db/db glomeruli. Although vitamin D3 1alpha-hydroxylase protein was primarily expressed and upregulated in db/db renal tubules, it was also expressed in glomerular podocytes in vivo. Serum 1,25-dihydroxyvitamin D3 and urinary Ca2+ excretion were increased >3-fold in db/db mice compared to db/+ mice. Cultured glomerular podocytes had mRNA for vitamin D3 1alpha-hydroxylase, vitamin D receptor, and calbindin D28K, each of which was increased in high glucose conditions. High glucose also led to enhanced production of fibronectin and collagen IV protein, which was blocked by 1,25-dihydroxyvitamin D3. These results show that vitamin D metabolism is altered in db/db mice leading to metabolic and transcriptional effects. The podocyte is affected by paracrine and potentially autocrine effects of vitamin D, which may explain why db/db mice are resistant to progressive diabetic nephropathy.

Research into the glomerular podocyte--is it relevant to diabetic nephropathy?

The cause of proteinuria in renal disease is the subject of intensive research and, latterly, the podocyte, a specialized epithelial cell of the kidney glomerulus, has been the focus of much of this endeavour. It is a complex cell with functions and structural features that have an important role in the development of proteinuria. This review explores some of the characteristics of the podocyte and how abnormalities of its structure and function may have particular relevance to the development and progression of clinical diabetic nephropathy.

Comparison of methods for counting cells in the mouse glomerulus

BACKGROUND

Researchers have long been interested in counting the number of cells within the glomerulus. Investigators using different techniques have yielded conflicting results. The most direct method is to count the cells in serial sections from the entire glomerulus. This Exhaustive Count method is not usually practical. The disector/fractionator method counts the number of cells in a fraction of sections. The total is estimated from the product of the cell count and the reciprocal of the fraction. The Weibel-Gomez method determines the density of cells per glomerulus, then multiplies this density by glomerular volume to obtain cell number. In this study, we compared the disector/fractionator and Weibel-Gomez methods to identify a practical alternative for the time-consuming Exhaustive Count method.

METHODS

Glomeruli from a normal mouse kidney were completely sectioned and images obtained. Appropriate images were used to count glomerular cell number using each method.

RESULTS

The Exhaustive Count method yielded 213 +/- 22 (mean +/- SD) cells/glomerulus vs. the disector/fractionator average of 211 +/- 29 cells/glomerulus (p = 0.82). The Weibel-Gomez method average of 235 +/- 26 cells/glomerulus was statistically different from the Exhaustive Count method (p = 0.003).

CONCLUSION

The Weibel-Gomez produced a 10% overestimation, whereas the disector/fractionator method was unbiased and thus a good substitute for the Exhaustive Count method.

Pathophysiologic implications of reduced podocyte number in a rat model of progressive glomerular injury

Changes in podocyte number or density have been suggested to play an important role in renal disease progression. Here, we investigated the temporal relationship between glomerular podocyte number and development of proteinuria and glomerulosclerosis in the male Munich Wistar Fromter (MWF) rat. We also assessed whether changes in podocyte number affect podocyte function and focused specifically on the slit diaphragm-associated protein nephrin. Age-matched Wistar rats were used as controls. Estimation of podocyte number per glomerulus was determined by digital morphometry of WT1-positive cells. MWF rats developed moderate hypertension, massive proteinuria, and glomerulosclerosis with age. Glomerular hypertrophy was already observed at 10 weeks of age and progressively increased thereafter. By contrast, mean podocyte number per glomerulus was lower than normal in young animals and further decreased with time. As a consequence, the capillary tuft volume per podocyte was more than threefold increased in older rats. Electron microscopy showed important changes in podocyte structure of MWF rats, with expansion of podocyte bodies surrounding glomerular filtration membrane. Glomerular nephrin expression was markedly altered in MWF rats and inversely correlated with both podocyte loss and proteinuria. Our findings suggest that reduction in podocyte number is an important determinant of podocyte dysfunction and progressive impairment of the glomerular permselectivity that lead to the development of massive proteinuria and ultimately to renal scarring.

The number of podocyte and slit diaphragm is decreased in experimental diabetic nephropathy

PURPOSE

To determine the number of podocyte, slit diaphragms, slit diaphragm extensions and GBM thickness in diabetic nephropathy.

METHODS

Sixty "Rattus Wistar"of both sexes weighing 200-300 g were divided in two experimental groups: normal group 10 animals, and alloxan diabetic rats--50 animals. Alloxan was administered in a single IV dose of 42 mg/kg body weight. Body weight, water and food intake, diuresis, and blood and urine glucose were determined in both groups before alloxan injection and two weeks, six and twelve months after alloxan injection. Proteinuria was measured at 12 months in both groups. After 12 months animals were sacrificed, and the right kidney processed for electron microscopy.

RESULTS

Clear clinical and laboratory signs of severe diabetes were seen, in all alloxan-diabetic rats at all follow-up times. Glomerular basement membrane (GBM) thickening, podocyte number, and slit diaphragm number and extension were determined. GBM of all diabetic rats was significantly thicker (median=0.29 microm; semi-interquartile range=0.065 microm) than in the normal rats (0.23 microm; 0.035 microm). Diabetic rat podocyte number (8; 1), slit diaphragm number (4; 1), and slit diaphragm extension (0.021 microm; 0.00435 microm) were significantly lower than in normal rats (11; 1) and (7; 1.5), and (0.031 microm; 0.0058 microm). Diabetic rat proteinuria (0.060 mg/24 h; 0.037 mg/24 h) was higher than in normal rats (0.00185 mg/24 h; 0.00055 mg/24 h).

CONCLUSION

Experimental diabetes is associated with significant (p<0.05) changes in podocyte foot process, slit number, slit diaphragm extension, and GBM thickness.

Reduction in podocyte density as a pathologic feature in early diabetic nephropathy in rodents: prevention by lipoic acid treatment

Background

A reduction in the number of podocytes and podocyte density has been documented in the kidneys of patients with diabetes mellitus. Additional studies have shown that podocyte injury and loss occurs in both diabetic animals and humans. However, most studies in animals have examined relatively long-term changes in podocyte number and density and have not examined effects early after initiation of diabetes. We hypothesized that streptozotocin diabetes in rats and mice would result in an early reduction in podocyte density and that this reduction would be prevented by antioxidants.

Methods

The number of podocytes per glomerular section and the podocyte density in glomeruli from rats and mice with streptozotocin (STZ)-diabetes mellitus was determined at several time points based on detection of the glomerular podocyte specific antigens, WT-1 and GLEPP1. The effect of insulin administration or treatment with the antioxidant, α-lipoic acid, on podocyte number was assessed.

Results

Experimental diabetes resulted in a rapid decline in apparent podocyte number and podocyte density. A significant reduction in podocytes/glomerular cross-section was found in STZ diabetes in rats at 2 weeks (14%), 6 weeks (18%) and 8 weeks (34%) following STZ injection. Similar declines in apparent podocyte number were found in STZ diabetes in C57BL/6 mice at 2 weeks, but not at 3 days after injection. Treatment with α-lipoic acid substantially prevented podocyte loss in diabetic rats but treatment with insulin had only a modest effect.

Conclusion

STZ diabetes results in reduction in apparent podocyte number and in podocyte density within 2 weeks after onset of hyperglycemia. Prevention of these effects with antioxidant therapy suggests that this early reduction in podocyte density is due in part to increased levels of reactive oxygen species as well as hyperglycemia.

Streptozotocin (STZ) diabetes enhances benzo(alpha)pyrene induced renal injury in Sprague Dawley rats

Information is lacking regarding the biological response to environmental chemicals in the context of pre-existing disease. Benzo(alpha)pyrene (BaP), a polycyclic aromatic hydrocarbon, is a byproduct of combustion that causes renal injury and elicits a nephropathic response. This study evaluated the nephrotoxicity of BaP in normoglycemic and diabetic rats. Female Sprague Dawley rats were divided into four groups: normoglycemic-vehicle (NV), normoglycemic-BaP (N-BaP), diabetic-vehicle (DV) and diabetic-BaP (D-BaP). Diabetes was induced by intraperitoneal (ip) injection of streptozotocin (60 mg/kg, 1 ml/kg). Rats were injected (ip) with vehicle or 10 mg/kg BaP (1 ml/kg) once per week for 5 weeks. Urinary protein and albumin, plasma creatinine and light microscopy were performed to assess the effects of BaP on kidney function. Diabetes was confirmed by plasma glucose levels >400 mg/dl in the DV and D-BaP groups. BaP increased kidney weight and blood urea nitrogen (BUN) levels in the D-BaP relative to the DV group. No change in BUN was observed following 5 weeks of BaP treatment in the normoglycemic animals, however, kidney weight was increased (p=0.013) in the N-BaP relative to the NV animals. STZ diabetes increased susceptibility to BaP mediated renal damage following repeated treatment for 5 weeks when compared to age matched normoglycemic rats.

Role of altered renal lipid metabolism and the sterol regulatory element binding proteins in the pathogenesis of age-related renal disease

BACKGROUND

There are well-known changes in age-related renal function and structure, including glomerulosclerosis and decline in glomerular filtration rate (GFR). The purpose of this study was to identify a potential role for lipids in mediating age-related renal disease.

METHODS

Mice of five different age groups (3, 6, 12, 19, and 23 months old) were studied.

RESULTS

We have found that in C57BL/6 mice there was a progressive increase in age-related glomerulosclerosis [increase in periodic acid-Schiff (PAS) staining and accumulation of extracellular matrix proteins including type IV collagen and fibronectin], increased glomerular basement thickness and podocyte width and effacement, and increased proteinuria. These changes were associated with age-related increase in lipid accumulation as determined by increased Oil Red O staining in kidney sections. Biochemical analysis indicated that these lipid deposits corresponded to significant increases in renal triglyceride and cholesterol content. We have also found significant age-related increases in the nuclear transcription factors, sterol regulatory element-binding proteins (SREBP-1 and SREBP-2), protein abundance and increased expression or activity of their target enzymes that play an important role in lipid synthesis.

CONCLUSION

Our results indicated that there was an age-related increase in renal expression of SREBP-1 and SREBP-2 with resultant increases in lipid synthesis and triglyceride and cholesterol accumulation in the kidney. Because we have previously shown that increased expression of SREBPs in the kidney per se results in glomerulosclerosis and proteinuria, our data suggested that increased SREBPs' expression resulting in increased renal lipid accumulation may play an important role in age-related nephropathy.

The human glomerular podocyte is a novel target for insulin action

Microalbuminuria is significant both as the earliest stage of diabetic nephropathy and as an independent cardiovascular risk factor in nondiabetic subjects, in whom it is associated with insulin resistance. The link between disorders of cellular insulin metabolism and albuminuria has been elusive. Here, we report using novel conditionally immortalized human podocytes in vitro and human glomeruli ex vivo that the podocyte, the principal cell responsible for prevention of urinary protein loss, is insulin responsive and able to approximately double its glucose uptake within 15 min of insulin stimulation. Conditionally immortalized human glomerular endothelial cells do not respond to insulin, suggesting that insulin has a specific effect on the podocyte in the glomerular filtration barrier. The insulin response of the podocyte occurs via the facilitative glucose transporters GLUT1 and GLUT4, and this process is dependent on the filamentous actin cytoskeleton. Insulin responsiveness in this key structural component of the glomerular filtration barrier may have central relevance for understanding of diabetic nephropathy and for the association of albuminuria with states of insulin resistance.

Renal redox stress and remodeling in metabolic syndrome, type 2 diabetes mellitus, and diabetic nephropathy: paying homage to the podocyte

Type 2 diabetes mellitus has reached epidemic proportions and diabetic nephropathy is the leading cause of end-stage renal disease. The metabolic syndrome constitutes a milieu conducive to tissue redox stress. This loss of redox homeostasis contributes to renal remodeling and parallels the concurrent increased vascular redox stress associated with the cardiometabolic syndrome. The multiple metabolic toxicities, redox stress and endothelial dysfunction combine to weave the complicated mosaic fabric of diabetic glomerulosclerosis and diabetic nephropathy. A better understanding may provide both the clinician and researcher tools to unravel this complicated disease process. Cellular remodeling of podocyte foot processes in the Ren-2 transgenic rat model of tissue angiotensin II overexpression (TG(mREN-2)27) and the Zucker diabetic fatty model of type 2 diabetes mellitus have been observed in preliminary studies. Importantly, angiotensin II receptor blockers have been shown to abrogate these ultrastructural changes in the foot processes of the podocyte in preliminary studies. An integrated, global risk reduction, approach in therapy addressing the multiple metabolic abnormalities combined with attempts to reach therapeutic goals at an earlier stage could have a profound effect on the development and progressive nature to end-stage renal disease and ultimately renal replacement therapy.

Redox dependence of glomerular epithelial cell hypertrophy in response to glucose

Podocytes or glomerular epithelial cells (GECs) are important targets of the diabetic microenvironment. Podocyte foot process effacement and widening, loss of GECs and hypertrophy are pathological features of this disease. ANG II and oxidative stress are key mediators of renal hypertrophy in diabetes. The cellular mechanisms responsible for GEC hypertrophy in diabetes are incompletely characterized. We investigated the effect of high glucose on protein synthesis and GEC hypertrophy. Exposure of GECs to high glucose dose dependently stimulated [(3)H]leucine incorporation, but not [(3)H]thymidine incorporation. High glucose resulted in the activation of ERK1/2 and Akt/PKB. ERK1/2 pathway inhibitor or the dominant negative mutant of Akt/PKB inhibited high glucose-induced protein synthesis. High glucose elicited a rapid generation of reactive oxygen species (ROS). The stimulatory effect of high glucose on ROS production, ERK1/2, and Akt/PKB activation was prevented by the antioxidants catalase, diphenylene iodonium, and N-acetylcysteine. Exposure of the cells to hydrogen peroxide mimicked the effects of high glucose. In addition, ANG II resulted in the activation of ERK1/2 and Akt/PKB and GEC hypertrophy. Moreover, high glucose and ANG II exhibited additive effects on ERK1/2 and Akt/PKB activation as well as protein synthesis. These additive responses were abolished by treatment of the cells with the antioxidants. These data demonstrate that high glucose stimulates GEC hypertrophy through a ROS-dependent activation of ERK1/2 and Akt/PKB. Enhanced ROS generation accounts for the additive effects of high glucose and ANG II, suggesting that this signaling cascade contributes to GEC injury in diabetes.

Evidence linking glycated albumin to altered glomerular nephrin and VEGF expression, proteinuria, and diabetic nephropathy

BACKGROUND

Albumin modified by Amadori-glucose adducts has been linked to the development of diabetic nephropathy through its ability, independent of hyperglycemia, to activate protein kinase C-beta (PKC-beta), up-regulate the transforming growth factor-beta (TGF-beta) system, and stimulate expression of extracellular matrix proteins in glomerular cells, and by the demonstration that reducing the burden of glycated albumin ameliorates renal structural and functional abnormalities in the db/db mouse.

METHODS

To probe whether the salutary effects consequent to lowering glycated albumin, which include reduction of albuminuria, relate to an influence of the Amadori-modified protein on nephrin, the podocyte protein critical to regulation of protein excretion, and on the angiogenic vascular endothelial growth factor (VEGF), which induces microvascular permeability, diabetic db/db mice were treated with a small molecule that inhibits the nonenzymatic glycation of albumin.

RESULTS

Compared to nondiabetic db/m mice, diabetic controls exhibited increased urinary excretion of albumin and type IV collagen, elevated renal TGF-beta1 protein levels, reduced glomerular nephrin immunofluorescence and nephrin protein by immunoblotting, and increased glomerular VEGF immunostaining and renal VEGF protein content. Diabetic animals receiving test compound showed significant lowering of proteinuria, normalization of renal TGF-beta1 protein, and significant restoration of altered glomerular nephrin and VEGF expression.

CONCLUSION

The findings causally implicate the increased glycated albumin associated with the diabetic state in the abnormal renal nephrin and VEGF expression found in diabetes, thereby promoting proteinuria and glomerulosclerosis.

A 100-kDa urinary protein is associated with insulin resistance in offspring of type 2 diabetic patients

AIMS/HYPOTHESIS

One-third of normoalbuminuric type 1 diabetic patients show immunoreactive nephrin in urine. Offspring of type 2 diabetic patients are insulin-resistant and susceptible to the development of diabetes. We investigated whether the offspring of type 2 diabetic patients show nephrin in urine and whether possible nephrinuria is associated with insulin resistance.

METHODS

Urinary proteins from timed overnight urine collections from 128 offspring of type 2 diabetic patients and 9 control subjects were analysed by western blotting using an antibody against nephrin. Glucose metabolism was assessed by OGTT and IVGTT and the euglycaemic-hyperinsulinaemic clamp technique.

RESULTS

Of the offspring, 12.5% were strongly and 14.1% weakly positive for a 100-kDa urinary protein. All controls were negative. During the first 10 min of an IVGTT, the offspring strongly positive for the urinary protein had a higher insulin response than the offspring without the protein (3,700 vs 2,306 pmol l(-1)min(-1), p=0.007). Insulin sensitivity (the rate of whole-body glucose uptake divided by the steady-state insulin level x 100) was lower among the offspring strongly positive for the urinary protein than among the offspring negative for the protein (11.3 vs 15.8 micromol kg(-1)min(-1)pmol(-1)l(-1), p=0.008).

CONCLUSIONS/INTERPRETATION

A 100-kDa urinary protein detectable with a nephrin antibody is associated with insulin resistance in offspring of type 2 diabetic patients.

Podocyte hypertrophy, "adaptation," and "decompensation" associated with glomerular enlargement and glomerulosclerosis in the aging rat: prevention by calorie restriction

Whether podocyte depletion could cause the glomerulosclerosis of aging in Fischer 344 rats at ages 2, 6, 17, and 24 mo was evaluated. Ad libitum-fed rats developed proteinuria and glomerulosclerosis by 24 mo, whereas calorie-restricted rats did not. No evidence of age-associated progressive linear loss of podocytes from glomeruli was found. Rather, ad libitum-fed rats developed glomerular enlargement over time. To accommodate the increased glomerular volume, podocytes principally underwent hypertrophy, whereas other glomerular cells underwent hyperplasia. Stages of hypertrophy through which podocytes pass en route to podocyte loss and glomerulosclerosis were identified: Stage 1, normal podocyte; stage 2, nonstressed podocyte hypertrophy; stage 3, "adaptive" podocyte hypertrophy manifest by changes in synthesis of structural components (e.g., desmin) but maintenance of normal function; stage 4, "decompensated" podocyte hypertrophy relative to total glomerular volume manifest by reduced production of key machinery necessary for normal podocyte function (e.g., Wilms' tumor 1 protein [WT1], transcription factor pod1, nephrin, glomerular epithelial protein 1, podocalyxin, vascular endothelial growth factor, and alpha5 type IV collagen) and associated with widened foot processes and decreased filter efficiency (proteinuria); and stage 5, podocyte numbers decrease in association with focal segmental glomerulosclerosis. In contrast, in calorie-restricted rats, glomerular enlargement was minor, significant podocyte hypertrophy did not occur, podocyte machinery was unchanged, there was no proteinuria, and glomerulosclerosis did not develop. Glomerular enlargement therefore was associated with podocyte hypertrophy rather than hyperplasia. Hypertrophy above a certain threshold was associated with podocyte stress and then failure, culminating in reduced podocyte numbers in sclerotic glomeruli. This process could be prevented by calorie restriction.

Podocyte depletion causes glomerulosclerosis: diphtheria toxin-induced podocyte depletion in rats expressing human diphtheria toxin receptor transgene

Glomerular injury and proteinuria in diabetes (types 1 and 2) and IgA nephropathy is related to the degree of podocyte depletion in humans. For determining the causal relationship between podocyte depletion and glomerulosclerosis, a transgenic rat strain in which the human diphtheria toxin receptor is specifically expressed in podocytes was developed. The rodent homologue does not act as a diphtheria toxin (DT) receptor, thereby making rodents resistant to DT. Injection of DT into transgenic rats but not wild-type rats resulted in dose-dependent podocyte depletion from glomeruli. Three stages of glomerular injury caused by podocyte depletion were identified: Stage 1, 0 to 20% depletion showed mesangial expansion, transient proteinuria and normal renal function; stage 2, 21 to 40% depletion showed mesangial expansion, capsular adhesions (synechiae), focal segmental glomerulosclerosis, mild persistent proteinuria, and normal renal function; and stage 3, >40% podocyte depletion showed segmental to global glomerulosclerosis with sustained high-grade proteinuria and reduced renal function. These pathophysiologic consequences of podocyte depletion parallel similar degrees of podocyte depletion, glomerulosclerosis, and proteinuria seen in diabetic glomerulosclerosis. This model system provides strong support for the concept that podocyte depletion could be a major mechanism driving glomerulosclerosis and progressive loss of renal function in human glomerular diseases.

High glucose evokes an intrinsic proapoptotic signaling pathway in mesangial cells

BACKGROUND

In response to chronic hyperglycemia, microvascular cells undergo stress and injury, which can lead to cell death. We characterized a proapoptotic signaling pathway whereby high glucose evokes an intrinsic, caspase-9-dependent mechanism of cell death in human mesangial cells.

METHODS

Biochemical (caspase activity, cytochrome-c release, etc.) and morphologic (chromatin condensation and nuclear segmentation) features of apoptotic cell death were assessed in cultured human mesangial cells exposed to high glucose, a risk factor for mesangial cell injury and diabetic glomerulosclerosis. Proapoptotic signaling was also analyzed in the db/db murine model of kidney injury in diabetes.

RESULTS

Incubation in high glucose caused cytotoxicity and apoptosis in mesangial cells. High glucose stimulated mitochondrial release of cytochrome-c, cleavage of procaspase-9, and caspase-9 enzyme activity, suggesting an intrinsic pathway of proapoptotic signaling. In contrast, caspase-8 was unaffected by high glucose. A cell-permeable, caspase-9-selective inhibitor blocked caspase-3 activation and prevented chromatin condensation and nuclear segmentation in cells treated with high glucose. To determine whether an intrinsic signaling pathway occurs in the diabetic kidney in vivo, apoptosis was investigated in diabetic 8- and 16-week db/db murine kidneys. Effector caspases-3 and -7 were activated in diabetic db/db kidneys but not in age-matched nondiabetic db/m controls. At 16 weeks, apoptotic cells in db/db glomeruli were identified on the basis of nuclear segmentation and DNA fragmentation. Apoptosis of glomerular cells correlated with expansion of the mesangial matrix and with worsening of albuminuria. Consistent with an intrinsic signaling pathway, caspase-9 cleavage was elevated only in db/db kidneys, whereas activation of caspase-8 and caspase-12 was undetectable.

CONCLUSION

These findings support the hypothesis that hyperglycemia evokes an intrinsic pathway of proapoptotic signaling in mesangial cells. In addition, these results point to an important role for the intrinsic pathway in microvascular injury in the diabetic kidney in vivo.

From the periphery of the glomerular capillary wall toward the center of disease: podocyte injury comes of age in diabetic nephropathy

Nephropathy is a major complication of diabetes. Alterations of mesangial cells have traditionally been the focus of research in deciphering molecular mechanisms of diabetic nephropathy. Injury of podocytes, if recognized at all, has been considered a late consequence caused by increasing proteinuria rather than an event inciting diabetic nephropathy. However, recent biopsy studies in humans have provided evidence that podocytes are functionally and structurally injured very early in the natural history of diabetic nephropathy. The diabetic milieu, represented by hyperglycemia, nonenzymatically glycated proteins, and mechanical stress associated with hypertension, causes downregulation of nephrin, an important protein of the slit diaphragm with antiapoptotic signaling properties. The loss of nephrin leads to foot process effacement of podocytes and increased proteinuria. A key mediator of nephrin suppression is angiotensin II (ANG II), which can activate other cytokine pathways such as transforming growth factor-beta (TGF-beta) and vascular endothelial growth factor (VEGF) systems. TGF-beta1 causes an increase in mesangial matrix deposition and glomerular basement membrane (GBM) thickening and may promote podocyte apoptosis or detachment. As a result, the denuded GBM adheres to Bowman's capsule, initiating the development of glomerulosclerosis. VEGF is both produced by and acts upon the podocyte in an autocrine manner to modulate podocyte function, including the synthesis of GBM components. Through its effects on podocyte biology, glomerular hemodynamics, and capillary endothelial permeability, VEGF likely plays an important role in diabetic albuminuria. The mainstays of therapy, glycemic control and inhibition of ANG II, are key measures to prevent early podocyte injury and the subsequent development of diabetic nephropathy.

Diabetic nephropathy: the proteinuria hypothesis

BACKGROUND/AIMS

Proteinuria, nearly a universal finding in progressive kidney disease, has been the subject of frequent recent analyses in the renal literature. Proteinuria is a hallmark of diabetic nephropathy: microalbuminuria is the principal early predictor for progression of diabetic glomerulopathy, and proteinuria may be viewed as a measure of the severity and promoter of progression of nephropathy.

METHODS

This article critically reviews for the first time the full scope of diabetic proteinuria--complex molecular mechanisms, natural history, and analysis of treatment trials--in order to address the validity of 'the proteinuria hypothesis', i.e., that diabetic proteinuria is a modifiable determinant of renal progression. This hypothesis is analyzed in detail, including recent studies on the primary therapy of diabetic nephropathy, renin-angiotensin blockade.

RESULTS

As fully developed, this hypothesis consists of three postulates: that higher amounts of proteinuria predict progressive loss of function, that proteinuria reduction correlates with slowing progression, and that proteinuria is a surrogate endpoint for clinical trials. The latter postulate has not before been adequately linked to growing information about the first two postulates as they apply to diabetic kidney disease.

CONCLUSION

While diabetic nephropathy is a disease model for the potential use of proteinuria as a surrogate marker for renal progression, this shift in perspective will require prospective data from additional clinical trials, particularly of non-renin-angiotensin blocking drugs, to be complete.

Altered transcapillary escape of albumin and microalbuminuria reflects two different pathogenetic mechanisms

We studied the following in normo- and microalbuminuric hypertensive type 2 diabetic patients: 1) transcapillary escape rate of albumin (TERalb) and 2) expression of mRNA slit diaphragm and podocyte proteins in renal biopsies. Normoalbuminuric subjects had renal cancer, and kidney biopsy was performed during surgery. TERalb was evaluated by clearance of (125)I-albumin. Real-time PCR of mRNA slit diaphragm was measured in kidney specimens. Albumin excretion rate (AER) was by definition lower in normoalbuminuric subjects than in microalbuminuric subjects with typical diabetic glomerulopathy (group 1), in microalbuminuric subjects with normal or near-normal glomerular structure (group 2), and in microalbuminuric subjects with atypical diabetic nephropathy (group 3). This classification was based on light microscopy analysis of renal tissue. TERalb (%/h) was similar in normoalbuminuric and microalbuminuric group 1, 2, and 3 diabetic patients (medians: 14.1 vs. 14.4 vs. 15.7 vs. 14.9, respectively) (ANOVA, NS). mRNA expression of slit diaphragm proteins CD2AP, FAT, Actn 4, NPHS1, and NPHS2 was higher in normoalbuminuric patients than in microalbuminuric patients (groups 1, 2, and 3) (ANOVA, P < 0.001). All diabetic patients had greater carotid artery intimal thickness than normal control subjects using ultrasound technique (ANOVA, P < 0.01). In conclusion, the present study suggests that microalbuminuria identifies a subgroup of hypertensive type 2 diabetic patients who have altered mRNA expression of slit diaphragm and podocyte proteins, even before glomerular structure shows abnormalities using light microscopy analysis. On the contrary, altered TERalb and increased carotid artery intimal thickness are shown by all hypertensive type 2 diabetic patients, both with normal and altered patterns of AER.

New insights into the pathophysiology of diabetic nephropathy: from haemodynamics to molecular pathology

Although debated for many years whether haemodynamic or structural changes are more important in the development of diabetic nephropathy, it is now clear that these processes are interwoven and present two sides of one coin. On a molecular level, hyperglycaemia and proteins altered by high blood glucose such as Amadori products and advanced glycation end-products (AGEs) are key players in the development of diabetic nephropathy. Recent evidence suggests that an increase in reactive oxygen species (ROS) formation induced by high glucose-mediated activation of the mitochondrial electron-transport chain is an early event in the development of diabetic complications. A variety of growth factors and cytokines are then induced through complex signal transduction pathways involving protein kinase C, mitogen-activated protein kinases, and the transcription factor NF-kappaB. High glucose, AGEs, and ROS act in concert to induce growth factors and cytokines. Particularly, TGF-beta is important in the development of renal hypertrophy and accumulation of extracellular matrix components. Activation of the renin-angiotensin system by high glucose, mechanical stress, and proteinuria with an increase in local formation of angiotensin II (ANG II) causes many of the pathophysiological changes associated with diabetic nephropathy. In fact, it has been shown that angiotensin II is involved in almost every pathophysiological process implicated in the development of diabetic nephropathy (haemodynamic changes, hypertrophy, extracellular matrix accumulation, growth factor/cytokine induction, ROS formation, podocyte damage, proteinuria, interstitial inflammation). Consequently, blocking these deleterious effects of ANG II is an essential part of every therapeutic regiment to prevent and treat diabetic nephropathy. Recent evidence suggests that regression of diabetic nephropathy could be achieved under certain circumstances.

Estimation of podocyte number: a comparison of methods

BACKGROUND

The podocyte is the focus of much research into the mechanisms of renal disease progression, and the number of podocytes per glomerulus has thus become a parameter of much interest. When counting podocytes, the actual particle counted is the cell nucleus. The majority of published studies estimating podocyte number have used the method of Weibel and Gomez (1962). This makes assumptions about the shape and size of the cell nuclei and therefore has an inherent bias. In our studies we have used a more recent stereologic method--the disector/fractionator--that makes no assumptions about the shape or size of the cell nuclei and is therefore free of bias.

METHODS

We set out to compare the two methods, in both type 1 diabetic patients and normal controls, to determine whether eliminating bias and thus improving accuracy had any effect on the overall results. The Weibel-Gomez method estimates cell number from a single section through the glomerulus, whereas the disector/fractionator requires the glomerulus to be serially sectioned.

RESULTS

There was no significant difference between mean values obtained by the two methods, providing that the Weibel-Gomez estimate was performed on electron micrographs. However, the overall variance was high for all groups of patients, independent of the method employed.

CONCLUSION

Although the disector/fractionator is the theoretic gold standard method for podocyte number estimation, comparable estimates can be obtained by the Weibel-Gomez method provided they are made from electron micrographs. Thus the technical resources available may determine the choice of method employed. Investigators should be aware of the high degree of variability in the estimate, particularly when trying to detect small changes in podocyte number.

Structural alterations to the podocyte are related to proteinuria in type 2 diabetic patients

BACKGROUND

The podocyte is believed to play a key role in maintaining the integrity of the glomerular filtration barrier, and damage or loss has been linked to the development of albuminuria.

METHODS

Renal biopsies from 16 type 2 diabetic patients with nephropathy and 28 non-diabetic controls were analysed using light and electron microscopy.

RESULTS

Podocyte number per glomerulus was significantly lower in the type 2 patients compared with controls [mean (95% confidence interval) 464 (382-546) vs 589 (543-635), P = 0.004]. Mean glomerular volume was significantly increased in diabetic patients compared with controls [5.5 (4.9-6.1) vs 3.1 (2.7-3.5) x 10(6) microm(3), P<0.001], thus the diabetic patients demonstrated an even greater proportional reduction in podocyte density per glomerulus [88 (68-108) vs 201 (182-220)/10(6) microm(3), P<0.001]. Podocyte foot process width on both the filtration surface (FPWgbm) and mesangial surface (FPWmes) was significantly increased compared with controls [796 (708-884) vs 556 (460-908) nm, P = 0.001; 1108 (821-1394) vs 760 (555-1078) nm, P = 0.029, respectively]. There was a significant negative correlation between proteinuria and both podocyte number and podocyte density per glomerulus (r = -0.63, P = 0.009; r = -0.58, P = 0.018, respectively). There was a significant positive correlation between proteinuria and both FPWgbm and FPWmes (r = 0.64, P = 0.008, for both).

CONCLUSION

Podocyte loss occurs in type 2 diabetic nephropathy and is related to increasing proteinuria. Whether the accompanying glomerular enlargement and widening of foot processes are a cause of podocyte loss is uncertain. Longitudinal studies are required to determine the sequence of events leading to podocyte loss in diabetic nephropathy.

Repeated Streptozotocin Injections Cause Early Onset of Glomerulosclerosis in Mice

Diabetic nephropathy (DN), a major cause of end-stage chronic renal failure, is histologically characterized by glomerulosclerosis. To investigate the molecular mechanisms of DN, it is important to establish a stable model of glomerulosclerosis in mice, because genomic manipulation techniques (such as gene destruction or transgene insertion) are well established in rodent species. In this study, we found that repeated administrations of streptozotocin led to early onset of glomerular sclerotic lesions in C57BL/6 mice, accompanied with renal dysfunction. During the natural course of DN, glomerular endothelial cells decreased at 10 weeks after the start of streptozotocin-injections, whereas myofibroblastic mesangial cells became evident. Our results provide an animal tool to elucidate the molecular mechanisms of DN, for example to investigate vascular pathology in diabetic glomerular diseases.

New insights into the significance of microalbuminuria

PURPOSE OF REVIEW

This review summarizes recent work that has explored the association between microalbuminuria and adverse clinical outcomes in the presence and absence of diabetes.

RECENT FINDINGS

Recent investigations have documented the prevalence of microalbuminuria in the general community and have also highlighted the continuous relationship between the level of urinary albumin excretion and clinical endpoints. Even below traditional microalbuminuria thresholds, urinary albumin levels appear to correlate with clinical outcomes. Microalbuminuria is becoming increasingly recognized as an independent risk factor for cardiovascular morbidity and mortality. At least for subjects with type 2 diabetes and microalbuminuria, intensive, multifactorial interventions can reduce the risk of cardiovascular events by about 50%. Although several studies have found an association between microalbuminuria and surrogate measurements of vascular disease, the exact molecular mechanisms linking an increase in urinary albumin excretion and vascular disease are still unknown. Microalbuminuria also has a well-documented association with progressive diabetic renal disease but recent studies have suggested that the prognostic significance of microalbuminuria in this regard may not be as powerful as originally reported.

SUMMARY

Aggressive, multifactorial interventions, including the use of drugs that interrupt the renin-angiotensin system are strongly recommended for patients with diabetes and micro-albuminuria to ameliorate the progression of renal and vascular complications. This approach should also possibly apply to microalbuminuric subjects without diabetes. The relationship between microalbuminuria and progressive diabetic renal disease requires re-evaluation given temporal trends in the prevention and treatment of diabetic complications.