Aristolochic Acid-induced Nephropathy Research Articles

Western diet exacerbates aristolochic acid-induced nephropathy in mice

Aristolochic acid (AA) ingestion causes Balkan nephropathy, characterized by tubular injury and progression to chronic kidney disease (CKD). AA is taken up by proximal tubule cells via organic anion transport (OAT3) and induces p53-mediated DNA damage, but little is known about modulating factors. The Western diet (WD) is rich in saturated fats, sugars, and salt and contributes to the development of metabolic disorders such as obesity and diabetes, but also to the progression of CKD. The aim of this study was to elucidate the impact of WD on AA-induced kidney injury. 5-week-old male C57BL6 mice were fed with WD or normal chow (NC) for 8 weeks, followed by administration of AA every 3 days at a dose of 3 mg/kg for 3 weeks. Samples were collected after a 3-week recovery period (n=4/group for vehicle; n=7-8/group for AA). The AA-induced increase in plasma creatinine and the reduction of hematocrit were significantly greater in WD vs NC. This was associated with increased kidney gene expression in WD vs NC of markers of DNA damage ( p53), injury ( Kim1 and Ngal), and inflammation ( Tnfa). The WD group had a greater body weight and, therefore, received a higher total dose of AA (0.73 and 0.6 mg), which may have worsened kidney injury. Therefore, in a second series, the same total dose of AA (0.9 mg) was administered to WD and NC groups. WD similarly increased the AA-induced fall in hematocrit and rise in plasma creatinine and renal p53, Kim1, Ngal, and Tnfa mRNA expression compared to the NC group. Moreover, WD increased renal mRNA expression of Oat3. These findings suggest that WD increases the susceptibility to AA nephrotoxicity, possibly through upregulation of OAT3. This model may be useful for studying the mechanistic impact of Western diet on the development and progression of CKD caused by nephrotoxic agents. Supported by National Institutes of Health (NIH) Grants RF1AG061296 (PM, VV), R01DK132690 (VV), and P30 DK079337 (VV), the Department of Veterans Affairs, and a fellowship of the Manpei Suzuki Diabetes Foundation (YO). This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Aristolochic acid-induced nephropathy is attenuated in mice lacking the neutral amino acid transporter B0AT1 (Slc6a19).

B0AT1 (Slc6a19) mediates absorption of neutral amino acids in the small intestine and in the kidneys, where it is primarily expressed in early proximal tubules (S1-S2). To determine the role of B0AT1 in nephropathy induced by aristolochic acid (AA), which targets the proximal tubule, littermate female B0AT1-deficient (Slc6a19-/-), heterozygous (Slc6a19+/-), and wild-type (WT) mice were administered AA (10 mg/kg ip) or vehicle every 3 days for 3 wk, and analyses were performed after the last injection or 3 wk later. Vehicle-treated mice lacking Slc6a19 showed normal body and kidney weight and plasma creatinine versus WT mice. The urinary glucose-to-creatinine ratio (UGCR) and urinary albumin-to-creatinine ratio (UACR) were two to four times higher in vehicle-treated Slc6a19-/- versus WT mice, associated with lesser expression of early proximal transporters Na+-glucose cotransporter 2 and megalin, respectively. AA caused tubular injury independently of B0AT1, including robust increases in cortical mRNA expression of p53, p21, and hepatitis A virus cellular receptor 1 (Havcr1), downregulation of related proximal tubule amino acid transporters B0AT2 (Slc6a15), B0AT3 (Slc6a18), and Slc7a9, and modest histological tubular damage and a rise in plasma creatinine. Absence of B0AT1, however, attenuated AA-induced cortical upregulation of mRNA markers of senescence (p16), inflammation [lipocalin 2 (Lcn2), C-C motif chemokine ligand 2 (Ccl2), and C-C motif chemokine receptor 2 (Ccr2)], and fibrosis [tissue inhibitor of metallopeptidase 1 (Timp1), transforming growth factor-β1 (Tgfb1), and collagen type I-α1 (Col1a1)], associated with lesser fibrosis staining, lesser suppression of proximal tubular organic anion transporter 1, restoration of Na+-glucose cotransporter 2 expression, and prevention of the AA-induced fivefold increase in the urinary albumin-to-creatinine ratio observed in WT mice. The data suggest that proximal tubular B0AT1 is important for the physiology of renal glucose and albumin retention but potentially deleterious for the kidney response following AA-induced kidney injury.NEW & NOTEWORTHY Based on insights from studies manipulating glucose transport, the hypothesis has been proposed that inhibiting intestinal uptake or renal reabsorption of energy substrates has unique therapeutic potential to improve metabolic disease and kidney outcome in response to injury. The present study takes this idea to B0AT1, the major transporter for neutral amino acids in the intestine and kidney, and shows that its absence attenuates aristolochic acid-induced nephropathy.

Basal renal phenotype and response to induction of aristolochic acid nephropathy in mice lacking the neutral amino acid transporter B0AT1 (SLC6A19)

Background B0AT1 (SLC6A19) mediates the reabsorption of neutral amino acids, including branched-chain amino acids (BCAA), in the intestine and kidney (expressed in early and mid-proximal tubule - S1/S2). Dietary restriction of BCAA has been proposed to improve metabolic health by inhibiting mTOR and inducing autophagy. Here we characterized basal kidney function and determined whether B0AT1 KO protects the kidney from aristolochic acid-induced nephropathy (AAN), a model of proximal tubular injury. Methods In male B0AT1 KO and littermate wild-type mice (WT) mice, we measured fractional renal amino acid excretion and performed renal FITC-sinistrin clearance studies under terminal anesthesia to determine renal creatinine handling. A set of female mice was injected with aristolochic acid (3 mg/kg i.p.) or vehicle every 3 days for 3 weeks, and kidneys were harvested 3 weeks later for RTqPCR analyses (n=7-16 mice per group). Results RTqPCR and Western blotting confirmed absence of renal B0AT1 mRNA in KO, associated with increased fractional renal excretion of neutral amino acids, including BCAA (to 20-40%), whereas plasma levels of BCAA were not changed. In vehicle-treated mice, plasma creatinine was slightly higher in KO vs WT (0.080±0.002 vs 0.074±0.002 mg/dl; *P<0.05). Clearance studies revealed a trend for lesser fractional excretion of creatinine in KO vs WT (P=0.057), suggesting lesser creatinine secretion contributed to higher plasma levels. Urinary albumin/creatinine ratio (UACR) and urinary glucose/creatinine ratio (UGCR) were tripled and doubled in female KO vs WT (180±18 vs 62±5 ng/μg*; 1.35±0.26 vs 0.70±0.06 mg/mg*), respectively, suggesting a modest impairment in proximal tubular albumin and glucose reabsorption. The renal expression of the alternative neutral amino acid transporter B0AT3 (SLC6A18), expressed in S1-S3, was reduced in KO (to 32±5% of WT*). This may be due to KO model generation, as B0AT1 and B0AT3 are co-expressed side-by-side on the same chromosome. Whole kidney CCR2 and KIM-1 mRNA expression were modestly higher in KO vs WT, which may reflect enhanced amino acid and glucose transport in the vulnerable S3 segment in the outer medulla. In the absence of robust effects on plasma creatinine, AAN significantly increased UACR vs vehicle in WT (+164±39 vs +52±14 ng/μg*) but not in KO (-18±30 vs +57±49 ng/μg) when measured after completion of injections. Moreover, increases in CCR2 and TIMP1 expression in response to AAN vs vehicle observed in WT (+206±28%; +203±45%) were attenuated in KO (+54±20%*; +81±39%*). Conclusions Genetic deletion of B0AT1 in male and female mice induces distinct effects on kidney transport beyond amino acids. Follow up studies with higher doses of AA are needed to more fully evaluate the nephroprotective potential of B0AT1 inhibition.

Potent Inhibitors of Organic Anion Transporters 1 and 3 From Natural Compounds and Their Protective Effect on Aristolochic Acid Nephropathy.

Organic anion transporters 1 and 3 (OAT1 and OAT3) play a critical role in renal drug-drug interactions and are involved in the nephrotoxicity of many anionic xenobiotics. To date, relatively little is known about the interaction of natural compounds with OAT1 and OAT3. Of the 270 natural compounds screened in the present study, 21 compounds inhibited OAT1 and 45 compounds inhibited OAT3. Further concentration-dependent studies identified 7 OAT1 inhibitors and 10 OAT3 inhibitors with IC50 values of <10 μM, and most of them were flavonoids, the most commonly ingested polyphenolic compounds in the diet and herbal products. Computational modeling of OAT1 and OAT3 revealed the important residues for the recognition of inhibitors. The two strongOAT inhibitors, namely wedelolactone and wogonin, were evaluated for their in vivo interactions with the OAT substrate aristolochic acid I (AAI), a natural compound causing aristolochic acid-induced nephropathy (AAN) in many species. The cytotoxicity of AAI increased in two OAT-overexpressing cell lines, with more cytotoxicity in OAT1-overexpressing cells, suggesting a more important role of OAT1 than OAT3 in AAN. Both wedelolactone and wogonin markedly increased serum AAI concentrations in AAI-treated rats and ameliorated kidney injuries in AAI-treated mice. To conclude, the present findings are of significant value in understanding natural compound-drug interactions and provide a natural source for developing treatments for AAN.

Protective Effects of Melatonin Against Aristolochic Acid-Induced Nephropathy in Mice.

Melatonin, a pineal hormone, is well known to regulate the sleep–wake cycle. Besides, the hormone has been shown to display pleiotropic effects arising from its powerful anti-oxidant and anti-inflammatory activities. Recent studies have reported that melatonin exerts protective effects in animal models of kidney disease. However, the potential effects of melatonin on aristolochic acid (AA)-induced nephropathy (AAN) have not yet been investigated. Here, we found that the administration of melatonin ameliorated AA-induced renal dysfunction, as evidenced by decreased plasma levels of blood urea nitrogen and creatinine and histopathological abnormalities such as tubular dilatation and cast formation. The upregulation of tubular injury markers after AA injection was reversed by melatonin. Melatonin also suppressed AA-induced oxidative stress, as evidenced by the downregulation of 4-hydroxynonenal and reduced level of malondialdehyde, and modulated expression of pro-oxidant and antioxidant enzymes. In addition, p53-dependent apoptosis of tubular epithelial cells, infiltration of macrophages and CD4+ T cells into damaged kidneys, and renal expression of cytokines and chemokines were inhibited by melatonin. Moreover, melatonin attenuated AA-induced tubulointerstitial fibrosis through suppression of the tumor growth factor-β/Smad signaling pathway. These results suggest that melatonin might be a potential therapeutic agent for AAN.

Tissue-resident natural killer cells exacerbate tubulointerstitial fibrosis by activating transglutaminase 2 and syndecan-4 in a model of aristolochic acid-induced nephropathy

Despite reports suggesting that tissue-resident natural killer (trNK) cells cause ischemic kidney injury, their contribution to the development of tubulointerstitial fibrosis has not been determined. This study hypothesized that the depletion of trNK cells may ameliorate renal fibrosis by affecting transglutaminase 2/syndecan-4 interactions. Aristolochic acid nephropathy (AAN) was induced in C57BL/6 mice as an experimental model of kidney fibrosis. The mice were treated with anti-asialo GM1 (ASGM1) or anti-NK1.1 antibodies to deplete NK cells. Although both ASGM1 and NK1.1 antibodies suppressed renal NKp46+DX5+ NK cells, renal NKp46+DX5− cells were resistant to suppression by ASGM1 or NK1.1 antibodies during the development of tubulointerstitial fibrosis in the AAN-induced mouse model. Western blot analysis showed that both antibodies increased the expression of fibronectin, transglutaminase 2, and syndecan-4. These findings indicate that trNK cells played an exacerbating role in tubulointerstitial fibrosis by activating transglutaminase 2 and syndecan-4 in the AAN-induced mouse model.

The transcription factor Twist1 in the distal nephron but not in macrophages propagates aristolochic acid nephropathy

Tubulointerstitial disease in the kidney culminates in renal fibrosis that portents organ failure. Twist1, a basic helix-loop-helix protein 38 transcription factor, regulates several essential biological functions, but inappropriate Twist1 activity in the kidney epithelium can trigger kidney fibrogenesis and chronic kidney disease. By contrast, Twist1 in circulating myeloid cells may constrain inflammatory injury by attenuating cytokine generation. To dissect the effects of Twist1 in kidney tubular versus immune cells on renal inflammation following toxin-induced renal injury, we subjected mice with selective deletion of Twist1 in renal epithelial cells or macrophages to aristolochic acid-induced chronic kidney disease. Ablation of Twist1 in the distal nephron attenuated kidney damage, interstitial fibrosis, and renal inflammation after aristolochic acid exposure. However, macrophage-specific deletion of Twist1 did not impact the development of aristolochic acid-induced nephropathy. Invitro studies confirmed that Twist1 in renal tubular cells underpins their susceptibility to apoptosis and propensity to generate pro-fibrotic mediators in response to aristolochic acid. Moreover, co-culture studies revealed that Twist1 in renal epithelia augmented the recruitment and activation of pro-inflammatory CD64+ macrophages. Thus, Twist1 in the distal nephron rather than in infiltrating macrophages propagates chronic inflammation and fibrogenesis during aristolochic acid-induced nephropathy.

Metabolomics analysis reveals the association between lipid abnormalities and oxidative stress, inflammation, fibrosis and Nrf2 dysfunction in aristolochic acid-induced nephropathy

Alternative medicines are commonly used for the disease prevention and treatment worldwide. Aristolochic acid (AAI) nephropathy (AAN) is a common and rapidly progressive interstitial nephropathy caused by ingestion of Aristolochia herbal medications. Available data on pathophysiology and molecular mechanisms of AAN are limited and were explored here. SD rats were randomized to AAN and control groups. AAN group was treated with AAI by oral gavage for 12 weeks and observed for additional 12 weeks. Kidneys were processed for histological evaluation, Western blotting, and metabolomics analyses using UPLC-QTOF/HDMS. The concentrations of two phosphatidylcholines, two diglycerides and two acyl-carnitines were significantly altered in AAI treated rats at week 4 when renal function and histology were unchanged. Data obtained on weeks 8 to 24 revealed progressive tubulointerstitial fibrosis, inflammation, renal dysfunction, activation of NF-κB, TGF-β, and oxidative pathways, impaired Nrf2 system, and profound changes in lipid metabolites including numerous PC, lysoPC, PE, lysoPE, ceramides and triglycerides. In conclusion, exposure to AAI results in dynamic changes in kidney tissue fatty acid, phospholipid, and glycerolipid metabolisms prior to and after the onset of detectable changes in renal function or histology. These findings point to participation of altered tissue lipid metabolism in the pathogenesis of AAN.

Low-molecular-weight chitosan scavenges methylglyoxal and N (ε)-(carboxyethyl)lysine, the major factors contributing to the pathogenesis of nephropathy.

Methylglyoxal (MG) can cause protein glycation, resulting in cell damage and dysfunction. Accumulation of MG and its downstream metabolite Nε-(carboxyethyl)lysine (CEL) has been identified in several variations of nephropathy, including diabetic, hypertensive, and gentamicin-induced nephropathies. In this study, we investigated the effects of low-molecular-weight chitosan (lmw-chitosan) on MG-induced carbonyl stress in aristolochic acid-induced nephropathy. We used a buffer to investigate whether MG could be scavenged by lmw-chitosan in vitro. In addition, we also used a mouse model of aristolochic acid-induced nephropathy, which exhibits 12-fold greater accumulation of MG in the kidneys than that found in control animals, to examine whether lmw-chitosan could decrease MG levels in vivo. Examination of the binding of lmw-chitosan with MG in vitro demonstrated that the concentration of lmw-chitosan necessary to achieve 50% inhibition was 4.60 µg mL−1. Treatment with lmw-chitosan (500 mg kg−1 day−1 orally) for 14 days significantly decreased renal MG accumulation from 212.86 ± 24.34 to 86.15 ± 33.79 µg g−1 protein (p < 0.05) and CEL levels from 4.60 ± 0.27 to 2.84 ± 0.28 µmol µg−1 protein (p < 0.05) in the aristolochic acid-induced nephropathy model. These data suggest that lmw-chitosan might represent a novel treatment modality for MG-related diseases such as nephropathy.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1106-4) contains supplementary material, which is available to authorized users.

Abstract PL02-02: Aristolochic acid-induced nephropathy and urothelial carcinoma: A preventable global disease

Abstract Balkan endemic nephropathy (BEN) is a chronic renal disease affecting residents of rural farming villages located near tributaries of the Danube river. Otherwise rare urothelial carcinomas of the upper urinary tract (UTUC) develop in ~ 50% of patients with BEN. Our studies of the etiology of this disease were informed by reports of a similar syndrome affecting ~ 100 Belgian women who ingested Aristolochia fangchi as part of a weight loss routine (1). In this case, the responsible toxin proved to be aristolochic acid (AA), a component of all Aristolochia plants. In the Balkans, a pilot epidemiologic study confirmed earlier reports that Aristolochia clematitis (birthwort) often is found as a weed growing in cultivated fields. Traditional methods used for harvesting and milling of wheat allowed seeds of this plant to contaminate grain used to prepare bread, a dietary staple among residents of the endemic region. Aristolactam (Al)-DNA adducts were detected in the renal cortex and urothelial tumor tissue of patients with BEN (2). Moreover, a pattern of A:T to T:A mutations unique to AA was demonstrated first in TP53 (3, 4) and, subsequently throughout the genome (5). Based on these observations, it was proposed that the name, BEN, be changed to aristolochic acid nephropathy (AAN). With respect to prevention of BEN, scientific designation of this environmental toxin is important to public health authorities as it legitimizes efforts to change traditional agricultural practices. The experimental methods developed in our studies proved indispensable in our subsequent efforts to demonstrate that AAN and UTUC are prevalent in Asian countries, where Aristolochia herbs have been used for medicinal purposes for centuries. For example, in Taiwan, where the incidence of UTUC and of chronic kidney disease are the highest in the world, at least one-third of the population has been prescribed herbs containing AA (6). Remarkably, the unique TP53 mutational signature for AA established in our studies of BEN was recapitulated in cases of UTUC from Taiwan (7). Moreover, aristolactam-DNA adducts, which persist for decades in the renal cortex, were detected in patients with the signature mutation spectrum in TP53, thereby documenting the relationship between exposure to AA and its mutagenic effects. Millions of people in China are estimated to have ingested Aristolochia herbal remedies, highlighting the potential morbiditity and mortality associated with the medicinal use of this family of herbs (8). Studies designed to document AA exposure in countries where Aristolochia herbs are used in the practice of traditional Chinese medicine are currently underway. Importantly, the nephrotoxic effects of AA are irreversible and its carcinogenic effects may not become manifest until 30 or more years after exposure. Thus, the development of non-invasive, biomarker-based tests that can be used to detect AA-induced UTUC are highly desirable, as this cancer is often curable by surgery if detected early in the course of the disease. (Research supported by grants from the NIEHS (ES04068) Fogarty International Center, Croatian Ministry of Science, Taiwan Dept of Health, Zickler Family Foundation and Henry and Marsha Laufer).

Cardiocrinum seeds as a replacement for Aristolochia fruits in treating cough

Aim of the study The antitussive Chinese herb Madouling derived from Aristolochia species is banned due to aristolochic acid-induced nephropathy. A substitute is found dispensed as Madouling in Taiwan. This study aims to determine the source plant and verify the antitussive properties of the Madouling substitute used in Taiwan. Materials and methods Forensically informative nucleotide sequencing (FINS) approach based on the trnL- trnF and psbA- trnH regions was applied to facilitate identification of the genuine species and substitute. The antitussive effect of both genuine Madouling and the substitute were evaluated in guinea pigs. Results FINS approach based on the trnL- trnF and psbA- trnH regions readily identified the sample of Madouling in Taiwan to the seeds of Cardiocrinum giganteum var. yunnanense. Ethanol extracts of the substitute showed significant antitussive properties in guinea pigs. Conclusion Cardiocrinum seeds may have potential as a replacement of Aristolochia fruits.

Patterns of interstitial inflammation during the evolution of renal injury in experimental aristolochic acid nephropathy

Interstitial inflammation is a prominent feature associated with the severity of renal injury and progressive kidney failure. We utilized an animal model of aristolochic acid (AA)-induced nephropathy (AAN) to assess patterns of infiltration and inflammation during the evolution of tubulointerstitial damage and to relate them to the development of fibrosis. Male Wistar rats receiving sc daily AA or vehicle were sacrificed between Days 1 and 35. Infiltrating mononuclear cells were characterized by immunohistochemistry. The kidney infiltrating T lymphocytes were phenotyped by flow cytometry. Urinary levels of Th-1/ Th-2 cytokines, of monocyte chemoattractant protein-1 and of active transforming growth factor-beta (TGF-beta) were measured. Tissue expression of phosphorylated smad 2/3 protein was used to examine the TGF-beta signalling pathway. In AA rats, monocytes/macrophages and T lymphocytes predominantly infiltrated areas of necrotic proximal tubular cells. The coexpressions of ED1 and/or Ki-67/MHCII by infiltrating cells reflected monocyte/macrophage proliferation and their activation, respectively. The accumulation of cytotoxic T lymphocytes was attested by severe signs of CD8+ cell tubulitis. The CD8/E-cadherin costaining confirmed intrarenal homing of CD8+CD103+ cells. Urinary levels of proinflammatory cytokines and of active TGF-beta significantly increased at Days 10 and 35. An early and persistent nuclear overexpression of phosphorylated smad 2/3 protein was detected in tubular and interstitial compartments. An early and massive interstitial inflammation characterized by activated monocytes/macrophages and cytotoxic CD8+CD103+ T lymphocytes is demonstrated for the first time during the progression of experimental AAN. The involvement in an interstitial fibrosis onset of active TGF-beta is highly suggested, at least via the psmad 2/3 intracellular signalling pathway.