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Funke-Kaiser H, Unger T. The (pro)renin receptor as a pharmacological target in cardiorenal diseaes. Hypertens Res 2023; 46:2527-2534. [PMID: 37667044 DOI: 10.1038/s41440-023-01424-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/02/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
The (pro)renin receptor ((P)RR) is not only a member of the renin-angiotensin system (RAS) but also exerts several RAS-independent functions due to its multiple signal transductions pathways. In this mini-review, we shortly discuss the molecular functions of this receptor and its pathophysiological significance with a focus on cardiorenal diseases. Finally, we provide a short summary regarding a drug discovery and drug development program on small molecule-based renin/ prorenin receptor blockers (RERBs).
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Affiliation(s)
| | - Thomas Unger
- CARIM - School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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2
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Funke-Kaiser H, Unger T. The (Pro)renin Receptor - A Regulatory Nodal Point in Disease Networks. Curr Drug Targets 2023; 24:1093-1098. [PMID: 37885110 DOI: 10.2174/0113894501250617231016052930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/27/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023]
Abstract
Experimental inhibition of the (pro)renin receptor [(P)RR] is a promising therapeutic strategy in different disease models ranging from cardiorenal to oncological entities. Here, we briefly review the direct protein-protein interaction partners of the (P)RR and the plethora of distinct diseases in which the (P)RR is involved. The first structural work on the (P)RR using AlphaFold, which was recently published by Ebihara et al., is the center of this mini-review since it can mechanistically link the protein-protein interaction level with the pathophysiological level. More detailed insights into the 3D structure of the (P)RR and its interaction domains might guide drug discovery on this novel target. Finally, antibody- and small molecule-based approaches to inhibit the (P)RR are shortly discussed.
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Affiliation(s)
| | - Thomas Unger
- CARIM - School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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Culver SA, Akhtar S, Rountree-Jablin C, Keller SR, Cathro HP, Gildea JJ, Siragy HM. Knockout of Nephron ATP6AP2 Impairs Proximal Tubule Function and Prevents High-Fat Diet-Induced Obesity in Male Mice. Endocrinology 2021; 162:bqab200. [PMID: 34534267 PMCID: PMC8489432 DOI: 10.1210/endocr/bqab200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 12/24/2022]
Abstract
ATP6AP2 expression is increased in the nephron during high-fat diet (HFD) and its knockout (ATP6AP2 KO) reduces body weight (WT) in mice. We evaluated the contribution of ATP6AP2 to urinary glucose (UG) and albumin (Ualb) handling during HFD. We hypothesized that nephron ATP6AP2 KO increases UG and Ualb and minimizes HFD-induced obesity. Eight-week-old male C57BL/6J mice with inducible nephron-specific ATP6AP2 KO and noninduced controls were fed either normal diet (ND, 12% kcal fat) or HFD (45% kcal fat) for 6 months. ATP6AP2 KO mice on ND had 20% (P < 0.01) lower WT compared with controls. HFD-fed mice had 41% (P < 0.05) greater WT than ND-fed control mice. In contrast, ATP6AP2 KO abrogated the increase in WT induced by HFD by 40% (P < 0.05). Mice on HFD had less caloric intake compared with ND controls (P < 0.01). There were no significant differences in metabolic rate between all groups. UG and Ualb was significantly increased in ATP6AP2 KO mice on both ND and HFD. ATP6AP2 KO showed greater levels of proximal tubule apoptosis and histologic evidence of proximal tubule injury. In conclusion, our results demonstrate that nephron-specific ATP6AP2 KO is associated with glucosuria and albuminuria, most likely secondary to renal proximal tubule injury and/or dysfunction. Urinary loss of nutrients may have contributed to the reduced WT of knockout mice on ND and lack of WT gain in response to HFD. Future investigation should elucidate the mechanisms by which loss of renal ATP6AP2 causes proximal tubule injury and dysfunction.
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Affiliation(s)
- Silas A Culver
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Safia Akhtar
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Callie Rountree-Jablin
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Susanna R Keller
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Helen P Cathro
- Department of Pathology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - John J Gildea
- Department of Pathology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Helmy M Siragy
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
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Hoffmann N, Peters J. Functions of the (pro)renin receptor (Atp6ap2) at molecular and system levels: pathological implications in hypertension, renal and brain development, inflammation, and fibrosis. Pharmacol Res 2021; 173:105922. [PMID: 34607004 DOI: 10.1016/j.phrs.2021.105922] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/16/2021] [Accepted: 09/29/2021] [Indexed: 12/13/2022]
Abstract
The (pro)renin receptor [(P)RR, Atp6ap2] was initially discovered as a membrane-bound binding partner of prorenin and renin. A soluble (P)RR has additional paracrine effects and is involved in metabolic syndrome and kidney damage. Meanwhile it is clear that most of the effects of the (P)RR are independent of prorenin. In the kidney, (P)RR plays an important role in renal dysfunction by activating proinflammatory and profibrotic molecules. In the brain, (P)RR is expressed in cardiovascular regulatory nuclei and is linked to hypertension. (P)RR is known to be an essential component of the v-ATPase as a key accessory protein and plays an important role in kidney, brain and heart via regulating the pH of the extracellular space and intracellular compartments. V-ATPase and (P)RR together act on WNT and mTOR signalling pathways, which are responsible for cellular homeostasis and autophagy. (P)RR through its role in v-ATPase assembly and function is also important for fast recycling endocytosis by megalin. In the kidney, megalin together with v-ATPase and (P)RR is crucial for endocytic uptake of components of the RAS and their intracellular processing. In the brain, (P)RR, v-ATPases and megalin are important regulators both during development and in the adult. All three proteins are associated with diseases such as XLMR, XMRE, X-linked parkinsonism and epilepsy, cognitive disorders with Parkinsonism, spasticity, intellectual disability, and Alzheimer's Disease which are characterized by impaired neuronal function and/or neuronal loss. The present review focusses on the relevant effects of Atp6ap2 without assigning them necessarily to the RAS. Mechanistically, many effects can be well explained by the role of Atp6ap2 for v-ATPase assembly and function. Furthermore, application of a soluble (P)RR analogue as new therapeutic option is discussed.
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Affiliation(s)
- Nadin Hoffmann
- Institute of Physiology, University Medicine Greifswald, Friedrich-Ludwig-Jahn-Str. 15A, 17475, Greifswald, Germany
| | - Jörg Peters
- Institute of Physiology, University Medicine Greifswald, Friedrich-Ludwig-Jahn-Str. 15A, 17475, Greifswald, Germany.
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NADPH-Oxidase, Rho-Kinase and Autophagy Mediate the (Pro)renin-Induced Pro-Inflammatory Microglial Response and Enhancement of Dopaminergic Neuron Death. Antioxidants (Basel) 2021; 10:antiox10091340. [PMID: 34572972 PMCID: PMC8472832 DOI: 10.3390/antiox10091340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/12/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
Dysregulation of the tissue renin–angiotensin system (RAS) is involved in tissue oxidative and inflammatory responses. Among RAS components, renin, its precursor (pro)renin and its specific receptor (PRR) have been less investigated, particularly in the brain. We previously showed the presence of PRR in neurons and glial cells in the nigrostriatal system of rodents and primates, including humans. Now, we used rat and mouse models and cultures of BV2 and primary microglial cells to study the role of PRR in microglial pro-inflammatory responses. PRR was upregulated in the nigral region, particularly in microglia during the neuroinflammatory response. In the presence of the angiotensin type-1 receptor blocker losartan, to exclude angiotensin-related effects, treatment of microglial cells with (pro)renin induces the expression of microglial pro-inflammatory markers, which is mediated by upregulation of NADPH-oxidase and Rho-kinase activities, downregulation of autophagy and upregulation of inflammasome activity. Conditioned medium from (pro)renin-treated microglia increased dopaminergic cell death relative to medium from non-treated microglia. However, these effects were blocked by pre-treatment of microglia with the Rho-kinase inhibitor fasudil. Activation of microglial PRR enhances the microglial pro-inflammatory response and deleterious effects of microglia on dopaminergic cells, and microglial NADPH-oxidase, Rho-Kinase and autophagy are involved in this process.
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Prieto MC, Gonzalez AA, Visniauskas B, Navar LG. The evolving complexity of the collecting duct renin-angiotensin system in hypertension. Nat Rev Nephrol 2021; 17:481-492. [PMID: 33824491 PMCID: PMC8443079 DOI: 10.1038/s41581-021-00414-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
The intrarenal renin-angiotensin system is critical for the regulation of tubule sodium reabsorption, renal haemodynamics and blood pressure. The excretion of renin in urine can result from its increased filtration, the inhibition of renin reabsorption by megalin in the proximal tubule, or its secretion by the principal cells of the collecting duct. Modest increases in circulating or intrarenal angiotensin II (ANGII) stimulate the synthesis and secretion of angiotensinogen in the proximal tubule, which provides sufficient substrate for collecting duct-derived renin to form angiotensin I (ANGI). In models of ANGII-dependent hypertension, ANGII suppresses plasma renin, suggesting that urinary renin is not likely to be the result of increased filtered load. In the collecting duct, ANGII stimulates the synthesis and secretion of prorenin and renin through the activation of ANGII type 1 receptor (AT1R) expressed primarily by principal cells. The stimulation of collecting duct-derived renin is enhanced by paracrine factors including vasopressin, prostaglandin E2 and bradykinin. Furthermore, binding of prorenin and renin to the prorenin receptor in the collecting duct evokes a number of responses, including the non-proteolytic enzymatic activation of prorenin to produce ANGI from proximal tubule-derived angiotensinogen, which is then converted into ANGII by luminal angiotensin-converting enzyme; stimulation of the epithelial sodium channel (ENaC) in principal cells; and activation of intracellular pathways linked to the upregulation of cyclooxygenase 2 and profibrotic genes. These findings suggest that dysregulation of the renin-angiotensin system in the collecting duct contributes to the development of hypertension by enhancing sodium reabsorption and the progression of kidney injury.
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Affiliation(s)
- Minolfa C. Prieto
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA, USA.,Hypertension and Renal Center of Excellence, Tulane University School of Medicine, New Orleans, LA, USA.,
| | - Alexis A. Gonzalez
- Instituto de Química, Pontificia Universidad Católica de Valparaíso, Valparaiso, Chile
| | - Bruna Visniauskas
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - L. Gabriel Navar
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA, USA.,Hypertension and Renal Center of Excellence, Tulane University School of Medicine, New Orleans, LA, USA
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Quadri SS, Cooper C, Ghaffar D, Vaishnav H, Nahar L. The Pathological Role of Pro(Renin) Receptor in Renal Inflammation. J Exp Pharmacol 2021; 13:339-344. [PMID: 33776491 PMCID: PMC7989955 DOI: 10.2147/jep.s297682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/23/2021] [Indexed: 12/17/2022] Open
Abstract
(Pro)renin receptor (PRR) is the recently discovered component of the renin-angiotensin-aldosterone system (RAS). Many organs contain their own RAS, wherein PRR can exert organ-specific localized effects. The Binding of prorenin/renin to PRR activates angiotensin-dependent and independent pathways which leads to the development of physiological and pathological effects. Continued progress in PRR research suggests that the upregulation of PRR contributes to the development of hypertension, glomerular injury, and progression of kidney disease and inflammation. In the current review, we highlight the function of the PRR in renal inflammation in pathophysiological conditions.
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Affiliation(s)
- Syed S Quadri
- DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Knoxville, TN, USA
| | - Caleb Cooper
- DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN, USA
| | - Dawood Ghaffar
- DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Knoxville, TN, USA
| | - Hitesh Vaishnav
- DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Knoxville, TN, USA
| | - Ludmila Nahar
- Department of Medicine, School of Medicine/John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, USA
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Arthur G, Osborn JL, Yiannikouris FB. (Pro)renin receptor in the kidney: function and significance. Am J Physiol Regul Integr Comp Physiol 2021; 320:R377-R383. [PMID: 33470188 DOI: 10.1152/ajpregu.00259.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
(Pro)renin receptor (PRR), a 350-amino acid receptor initially thought of as a receptor for the binding of renin and prorenin, is multifunctional. In addition to its role in the renin-angiotensin system (RAS), PRR transduces several intracellular signaling molecules and is a component of the vacuolar H+-ATPase that participates in autophagy. PRR is found in the kidney and particularly in great abundance in the cortical collecting duct. In the kidney, PRR participates in water and salt balance, acid-base balance, and autophagy and plays a role in development and progression of hypertension, diabetic retinopathy, and kidney fibrosis. This review highlights the role of PRR in the development and function of the kidney, namely, the macula densa, podocyte, proximal and distal convoluted tubule, and the principal cells of the collecting duct, and focuses on PRR function in body fluid volume homeostasis, blood pressure regulation, and acid-base balance. This review also explores new advances in the molecular mechanism involving PRR in normal renal health and pathophysiological states.
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Affiliation(s)
- Gertrude Arthur
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky
| | - Jeffrey L Osborn
- Department of Biology, University of Kentucky, Lexington, Kentucky
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Chen Y, Xu C. The interaction partners of (pro)renin receptor in the distal nephron. FASEB J 2020; 34:14136-14149. [PMID: 32975331 DOI: 10.1096/fj.202001711r] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/11/2022]
Abstract
The (pro)renin receptor (PRR), a key regulator of intrarenal renin-angiotensin system (RAS), is predominantly presented in podocytes, proximal tubules, distal convoluted tubules, and the apical membrane of collecting duct A-type intercalated cells, and plays a crucial role in hypertension, cardiovascular disease, kidney disease, and fluid homeostasis. In addition to its well-known renin-regulatory function, increasing evidence suggests PRR can also act in a variety of intracellular signaling cascades independently of RAS in the renal medulla, including Wnt/β-catenin signaling, cyclooxygenase-2 (COX-2)/prostaglandin E2 (PGE2 ) signaling, and the apelinergic system, and work as a component of the vacuolar H+ -ATPase. PRR and these pathways regulate the expression/activity of each other that controlling blood pressure and renal functions. In this review, we highlight recent findings regarding the antagonistic interaction between PRR and ELABELA/apelin, the mutually stimulatory relationship between PRR and COX-2/PGE2 or Wnt/β-catenin signaling in the renal medulla, and their involvement in the regulation of intrarenal RAS thereby control blood pressure, renal injury, and urine concentrating ability in health and patho-physiological conditions. We also highlight the latest progress in the involvement of PRR for the vacuolar H+ -ATPase activity.
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Affiliation(s)
- Yanting Chen
- Institute of Hypertension, Sun Yat-sen University School of Medicine, Guangzhou, China.,Internal Medicine, Division of Nephrology and Hypertension, University of Utah and Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Chuanming Xu
- Internal Medicine, Division of Nephrology and Hypertension, University of Utah and Veterans Affairs Medical Center, Salt Lake City, UT, USA.,Center for Translational Medicine, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
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Zhang S, Breidenbach JD, Khalaf FK, Dube PR, Mohammed CJ, Lad A, Stepkowski S, Hinds TD, Kumarasamy S, Kleinhenz A, Tian J, Malhotra D, Kennedy DJ, Cooper CJ, Haller ST. Renal Fibrosis Is Significantly Attenuated Following Targeted Disruption of Cd40 in Experimental Renal Ischemia. J Am Heart Assoc 2020; 9:e014072. [PMID: 32200719 PMCID: PMC7428653 DOI: 10.1161/jaha.119.014072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Renal artery stenosis is a common cause of renal ischemia, contributing to the development of chronic kidney disease. To investigate the role of local CD40 expression in renal artery stenosis, Goldblatt 2‐kidney 1‐clip surgery was performed on hypertensive Dahl salt‐sensitive rats (S rats) and genetically modified S rats in which CD40 function is abolished (Cd40mutant). Methods and Results Four weeks following the 2‐kidney 1‐clip procedure, Cd40mutant rats demonstrated significantly reduced blood pressure and renal fibrosis in the ischemic kidneys compared with S rat controls. Similarly, disruption of Cd40 resulted in reduced 24‐hour urinary protein excretion in Cd40mutant rats versus S rat controls (46.2±1.9 versus 118.4±5.3 mg/24 h; P<0.01), as well as protection from oxidative stress, as indicated by increased paraoxonase activity in Cd40mutant rats versus S rat controls (P<0.01). Ischemic kidneys from Cd40mutant rats demonstrated a significant decrease in gene expression of the profibrotic mediator, plasminogen activator inhibitor‐1 (P<0.05), and the proinflammatory mediators, C‐C motif chemokine ligand 19 (P<0.01), C‐X‐C Motif Chemokine Ligand 9 (P<0.01), and interleukin‐6 receptor (P<0.001), compared with S rat ischemic kidneys, as assessed by quantitative PCR assay. Reciprocal renal transplantation documented that CD40 exclusively expressed in the kidney contributes to ischemia‐induced renal fibrosis. Furthermore, human CD40‐knockout proximal tubule epithelial cells suggested that suppression of CD40 signaling significantly inhibited expression of proinflammatory and ‐fibrotic genes. Conclusions Taken together, our data suggest that activation of CD40 induces a significant proinflammatory and ‐fibrotic response and represents an attractive therapeutic target for treatment of ischemic renal disease.
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Affiliation(s)
- Shungang Zhang
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Joshua D. Breidenbach
- Department of Medical Microbiology and ImmunologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Fatimah K. Khalaf
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Prabhatchandra R. Dube
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Chrysan J. Mohammed
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Apurva Lad
- Department of Medical Microbiology and ImmunologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Stanislaw Stepkowski
- Department of Medical Microbiology and ImmunologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Terry D. Hinds
- Department of Physiology and PharmacologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Sivarajan Kumarasamy
- Department of Physiology and PharmacologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Andrew Kleinhenz
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Jiang Tian
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Deepak Malhotra
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - David J. Kennedy
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Christopher J. Cooper
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Steven T. Haller
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
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Abstract
The (pro)renin receptor ((P)RR) was first identified as a single-transmembrane receptor in human kidneys and initially attracted attention owing to its potential role as a regulator of the tissue renin-angiotensin system (RAS). Subsequent studies found that the (P)RR is widely distributed in organs throughout the body, including the kidneys, heart, brain, eyes, placenta and the immune system, and has multifaceted functions in vivo. The (P)RR has roles in various physiological processes, such as the cell cycle, autophagy, acid-base balance, energy metabolism, embryonic development, T cell homeostasis, water balance, blood pressure regulation, cardiac remodelling and maintenance of podocyte structure. These roles of the (P)RR are mediated by its effects on important biological systems and pathways including the tissue RAS, vacuolar H+-ATPase, Wnt, partitioning defective homologue (Par) and tyrosine phosphorylation. In addition, the (P)RR has been reported to contribute to the pathogenesis of diseases such as fibrosis, hypertension, pre-eclampsia, diabetic microangiopathy, acute kidney injury, cardiovascular disease, cancer and obesity. Current evidence suggests that the (P)RR has key roles in the normal development and maintenance of vital organs and that dysfunction of the (P)RR is associated with diseases that are characterized by a disruption of the homeostasis of physiological functions.
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