Osmotic polyuria: an overlooked mechanism in diabetic nephropathy.

Tubulo-interstitial pathology in diabetic nephropathy is thought to be caused by cell injury that is induced by high ambient glucose levels and increased proportions of glycated proteins. Other mechanistic hypotheses engage glomerular ultrafiltration of proteins and bioactive growth factors and their effects on tubular cells. Some scholars promote tubular ischaemia due to reduced peritubular blood flow as a response to glomerular injury. All of these mechanisms contribute to renal tubulo-interstitial injury in diabetic nephropathy. However, they do not well explain observations that have been made in studies of experimental animals and evaluations of human biopsies showing dilated collecting ducts in early diabetic nephropathy. Dilatation of distal nephron segments is routinely seen in human biopsies or in histological sections from experimental diabetic nephropathy and is reminiscent of similar findings in obstructive nephropathy. Moreover, it is these dilated tubules that are the primary source for pro-inflammatory and pro-fibrogenic cytokines and regulators. Based on this large body of observations from this laboratory and the published literature this narrative develops a novel hypothesis where hyperglycaemic, osmotic polyuria play important contributory roles in the initiation and progression of tubulo-interstitial injury in diabetic nephropathy.

Functional symbiosis between endothelium and epithelial cells in glomeruli.

In some capillary beds, pericytes regulate endothelial growth. Capillaries with high filtration capacity, such as those in renal glomeruli, lack pericytes. Glomerular endothelium lies adjacent to visceral epithelial cells (podocytes) that are anchored to and cover the anti-luminal surface of the basement membrane. We have tested the hypothesis that podocytes can function as endothelial supporting cells. Endothelial cells were outgrown from circulating endothelial progenitors of normal subjects and were extensively characterized. These blood outgrowth endothelial cells (BOECs) expressed endothelial markers, lacked stem cell markers, and expressed the angiopoietin-1 receptor, Tie-2, and the vascular endothelial growth factor (VEGF) receptor, Flk-1. Differentiated podocytes in culture expressed and secreted VEGF, which was upregulated 4.5-fold by high glucose. In complete medium, BOECs formed thin cell-cell connections and multicellular tubes on Matrigel, the in vitro correlate of angiogenesis. This was impaired in deficient media but rescued by co-incubation with Transwell Anopore inserts containing differentiated podocytes. To assess whether VEGF was the major podocyte-derived signal that rescued BOEC angiogenesis, we examined angiogenesis of control and Flk-1-deficient BOECs. Co-incubation with podocytes or addition of recombinant VEGF each rescued angiogenesis in control BOECs, but both failed to support maintenance and angiogenesis in Flk-1-deficient BOECs. Finally, co-culture with podocytes increased BOEC-proliferation. In concert, these findings suggest a model in which glomerular visceral epithelial cells function as pericyte-like endothelial supporting cells. Podocyte-derived VEGF is a required and sufficient regulator of vascular endothelial maintenance, and its upregulation in podocytes by high glucose may be the mechanism for the increased glomerular angiogenesis that is observed in vivo in early diabetic glomerular injury.

BMP7 is a podocyte survival factor and rescues podocytes from diabetic injury.

In early diabetic renal injury, there is podocyte drop-out (but no decrease in the number of other glomerular cells) which is thought to cause glomerular proteinuria and subsequent diabetic glomerular injury. We tested the hypothesis that early diabetic podocyte injury is caused, in part, by downregulation of bone morphogenetic protein-7 (BMP7) and loss of its autocrine function in murine podocytes. High glucose (HG; 25 mM) induces rounding of differentiated podocytes and changes in the distribution of F-actin but without quantitative changes in E-cadherin and the podocyte markers podocin, CD2AP, Neph1, or synaptopodin. HG reduces BMP7 secretion and activity but does not affect BMP receptor levels in murine podocytes. In these cells, BMP7 effectively activates smad5 (but not smad1) and raises p38 phosphorylation [which is also increased by transforming growth factor-beta (TGF-beta)]. HG as well as TGF-beta raise caspase-3 activity, increase apoptosis, and reduce cell survival which is, in part, blocked by BMP7. Knockdown and forced expression studies indicate that smad5 is required as well as sufficient for these actions of BMP7. These findings indicate that BMP7 is a differentiation and survival factor for podocytes, requires smad5, and can reduce diabetic podocyte injury.