Physiopathologie de la Néphropathie Diabétique

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1 Physiopathologie de la Néphropathie Diabétique Philippe Rieu Service de Néphrologie et de Transplantation UMR CNRS 6198 Reims Development of diabetic nephropathy GFR (ml/min) I II III IV V GFR Intermitent µalbuminuria Persistent µalbuminurie ( µg/j) Hypertension (15 %) GMB thickness mesangial expansion Proteinuria (Nephrotic in 10 %) Hypertension (80 %) Renal failure Glomerulosclerosis Protéinuria (g/d) 5 years 15 years Diabetes (years) Mogensen Diabetes :64

Relation entre excrétion urinaire d albumine et filtration glomérulaire chez des patients diabétiques de type 1 non traités par IEC. Marre M. et al. In Mogensen CE.

2 Relation entre excrétion urinaire d albumine et filtration glomérulaire chez des patients diabétiques de type 1 non traités par IEC. Marre M. et al. In Mogensen CE. The kidney and hypertension in diabetes mellitus, chapter 35, third. Boston, Dordrecht, London : Kluwer Academic publishers 1997 : Development of diabetic nephropathy GFR (ml/min) I II III IV V GFR Intermitent µalbuminuria Persistent µalbuminurie ( µg/j) Hypertension (15 %) GMB thickness mesangial expansion 4-15 ml/min/year Glomerulosclerosis ESRD Protéinuria (g/d) 5 years 15 years Diabetes (years) Mogensen Diabetes :64

3 RAAS and diabetic nephropathy GFR (ml/min) I II III IV V Captopril Placebo Protéinuria (g/d) 5 years 15 years Diabetes (years) Lewwis et al NEJM :1456 Proportion of patients with doubling of base-line creatinine Lewis et al NEJM :1456

4 RAAS and diabetic nephropathy GFR (ml/min) I II III IV V Captopril Placebo Captopril Placebo Protéinuria (g/d) 5 years 15 years Diabetes (years) Lewis et al NEJM :1456 Viberti et al JAMA : 275 RAAS and diabetic nephropathy GFR (ml/min) I II III IV V Candesartan Placebo Losartan Enalapril Placebo Captopril Placebo Captopril Placebo Protéinuria (g/d) 5 years 15 years Bilous et al Ann Intern Med :11 Mauer et al NEJM : 40 Diabetes (years) Lewis et al NEJM :1456 Viberti et al JAMA : 275

5 Proportion of patients with microalbuminuria Bilous et al Ann Intern Med :11 Proportion of patients with microalbuminuria Mauer et al NEJM : 40

6 Risk of Diabetic tissue damage Hyperglycemia Diabetic tissue damage Risk of Diabetic Nephropathy Risk of microalbuminuria Odds ratio Hemoglobin A1 (%) A.S. Krolewski, N Eng J Med, 1995, 332:1251

7 Risk of Diabetic Nephropathy Incidence of Nephropathy (%) Duration of Diabetes (years) A.R. Andersen, Diabetologia, 1983: 25:496 Blood-glucose control and risk of diabetic tissue damage Blood-glucose control Diabetic nephropathy DCCTRG: 1441 type 1 diabetes patients NEJM, 1993; 329:

8 Diabetic Nephropathy after pancreas transplantation T0 T5 T10 Fioretto et al. NEJM 1998; 339:69 Risk of Diabetic tissue damage Genetic determinants of Individual susceptibility Hyperglycemia Diabetic tissue damage Independent accelerating factors (e.g. HTA, hyperlipemia Brownlee Diabetes 2005, 54: 1615

9 Risk of Diabetic tissue damage Hyperglycemia Diabetic tissue damage Risk of Diabetic tissue damage Hyperglycemia Endothelial cells Mesangial cells High glucose Inside the cell Microvascular complications Diabetic nephropathy Diabetic tissue damage GLUT1

10 Overexpression of GLUT1 in mesangial cells Normoglycemia High glucose Inside the cell Diabetic tissue damage Heilig et al JCI :1802 Wang et al Am J Physiol Renal 2010 GLUT1 ECM In vitro Diabetic Glomerulosclerosis In vivo Risk of Diabetic tissue damage Hyperglycemia High glucose Inside the cell Diabetic tissue damage GLUT1

11 GLUT1 G6P Fructose 6P Fructose 1,6P Glycolysis Dihydroacetone P 3 P glyceraldehyde Diacylglyceride Pyruvate TCA cycle Methylglyoxal GLUT1 G6P Fructose 6P Fructose 1,6P Glycolysis Dihydroacetone P 3 P glyceraldehyde Diacylglyceride Pyruvate TCA cycle Methylglyoxal PKC ROS Brownlee Diabetes 2005, 54: 1615

12 Hyper glycemia GLUT1 Family of at least 12 isotypes PKC LY Ruboxistaurin enos ET-1 VEGF TGF β NF-κB NAD(P)H oxydase Collagen FN Meier et al, NDT :2421 Hyper glycemia GLUT1 pyruvate Brownlee Diabetes 2005, 54: 1615

13 Hyper glycemia GLUT1 Molecular damage ROS Signaling effect PKC enos NF-κB Angio PC Synthase tensinogen Brownlee Diabetes 2005, 54: 1615 Hyper glycemia GLUT1 ROS SOD1 SOD KO mice Acceleration of DN DeRubertis et al. Metabolism :1256 SOD TG mice Prevention of DN Craven et al. Diabetes :2114 DeRubertis et al. Diabetes :762

14 Hyper glycemia GLUT1 Modification of intracellular proteins Transcription factors Proteasome Queisser et al. Diabetes :660 Yao et al. J. Biol Chem :31038 Early Glycosylation Products H O C + CHOH Lys 2 H + C CH 2 (CHOH) 3 CHOH C O CH 2 OH (CHOH) 3 (CHOH) 3 CH 2 OH CH 2 OH Protein Schiff Base Amadori Product

15 + -Protein Schiff Base Amadori Product + -Protein Schiff Base Amadori Product OXIDATION O 2 - Dehydratation condensation fragmentation cyclisation... Advanced Glycation End-Products

16 Stress Carbonylé O O 2 - -Protein Arabinose Glyoxal Schiff Base -Protein Amadori Product O 2 - Dehydratation condensation fragmentation cyclisation... Advanced Glycation End-Products Carboxymethyllysine Pyrraline Pentosidine Glyoxal-lysine-dimer Methyl-glyoxal-lysine-dimer Lysylpyrropyrine Vesperlysine Dehydrofuroimidazole Crossline Imidazolone pan Crosspy Crossline Imidazolone pan Crosspy

17 Carboxymethyllysine Pyrraline Pentosidine Glyoxal-lysine-dimer Methyl-glyoxal-lysine-dimer Lysylpyrropyrine Vesperlysine Dehydrofuroimidazole Crossline Imidazolone pan Crosspy Crossline Imidazolone pan Crosspy AGE and Diabetic Nephropathy Injection of AGE in normal rats Glomerular hyperfiltration Glomerular hypertrophy GMB thickening Mesangial matrix expansion Proteinuria M. Sabbatini, Kidney int, 1992: 42:875 H. Vlassara, Proc Natl Acad Sci USA, 1994, 91:11704

18 AGE and Diabetic Nephropathy Injection of AGE in normal rats Aminoguanidine Glomerular hyperfiltration Glomerular hypertrophy GMB thickening Mesangial matrix expansion Proteinuria M. Sabbatini, Kidney int, 1992: 42:875 H. Vlassara, Proc Natl Acad Sci USA, 1994, 91:11704 AGE and Diabetic Nephropathy Diabetic rats Aminoguanidine Glomerular hyperfiltration Glomerular hypertrophy GMB thickening Mesangial matrix expansion Proteinuria OBP-9195 Soulis et al; Diabetes, 1991, 40:1328 S. Nakamura, Diabetes, 1997, 46:895

19 AGE receptors Protein cross linking RAGE AGE-R1 (P60/OST-48 protein) AGE-R2 (80 K-H phosphoprotein) AGE-R3 (galectin-3) Scavenger receptor

20 Extracellular matrix protein Cross-linking of ECM protein AGE Cross-linking of ECM protein Reduced susceptibility to proteolytic degradation Thickening of basement membrane and expansion of mesangial matrix

21 Diabetic Nephropathy : Staining for AGE Pentosidine CML Extracellular matrix protein Cross-linking of ECM protein Trapping of protein

22 AGE receptors Protein cross linking RAGE AGE-R1 (P60/OST-48 protein) AGE-R2 (80 K-H phosphoprotein) AGE-R3 (galectin-3) Scavenger receptor AGE receptors Protein cross linking RAGE AGE-R1 (P60/OST-48 protein) AGE-R2 (80 K-H phosphoprotein) AGE-R3 (galectin-3) Scavenger receptor

Activation Monocytes Endothelial cells Podocytes VEGF PDGF

23 Diabetic Nephropathy : Staining for RAGE N. Tanji, J Am Soc Nephrol :1656 AGE RAGE Cellular Activation Monocytes Endothelial cells Podocytes VEGF PDGF TGFβ Oxidant stress ICAM-1, VCAM-1 VEGF, TNF Thromboxane PAI-1, Tissue factor VEGF

24 AGE RAGE Cellular Activation Mesangials cells TGFβ Type IV Collagen Fibronectin Laminin Cohen et al, Am J Physiol, 1999, 276: F684 Scivittaro et al, Am J Renal Physiol, 2000, 278:F676 RAGE and Diabetic Nephropathy Diabetic mice RAGE Tg+ Glomerular hypertrophy GMB thickening Mesangial matrix expansion Proteinuria Y.Yamamoto, J Clin Invest, 2001, 108:261

25 Diabetic Nephropathy in RAGE-overexpressing mice DM + RAGETg + No difference in blood glucose, HbA1C, AGE DM + RAGETg - DM - RAGETg - DM - RAGETg + Y.Yamamoto, J Clin Invest, 2001, 108:261 RAGE and Diabetic Nephropathy Diabetic mice srage Anti-RAGE Glomerular hypertrophy GMB thickening Mesangial matrix expansion Proteinuria Wendt et al. AJP : 1123 Flyvbjerg et al, Diabetes :166

26 srage RAGE Cell activation Soluble RAGE-treated diabetic mice Wendt et al. AJP : 1123

Oldfield et al, JCI, 2001 108:1853 RAGE Cell activation TGF

27 RAGE expression in tubules Human diabetic nephropathy Immunostaining NRK 52E Cells Western Blot anti-rage Oldfield et al, JCI, :1853 RAGE Cell activation TGF β TGF β RAGE Cell activation Epithelial-myofibroblast transdifferenciation

28 induce EMT in vivo Oldfield et al, JCI, :1853 Diabetic nephropathy AGE inhibitors AGE Cross-linking of proteins Antidiabetic molecules Hyperglycemia GLUT1 Anti-RAGE High glucose Inside the cell RAGE AGE PKC ROS Diabetic nephropathy EMC proteins Cell damage Antioxydants PKC inhibitors

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For more information about how to cite these materials visit Author(s): Frank Brosius, M.D, 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Noncommercial Share Alike 3.0 License: http://creativecommons.org/licenses/by-nc-sa/3.0/