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Activated protein C protects against diabetic nephropathy by inhibiting endothelial and podocyte apoptosis

Nature Medicine volume 13, pages 1349–1358 (2007)Cite this article

Abstract

Data providing direct evidence for a causative link between endothelial dysfunction, microvascular disease and diabetic end-organ damage are scarce. Here we show that activated protein C (APC) formation, which is regulated by endothelial thrombomodulin, is reduced in diabetic mice and causally linked to nephropathy. Thrombomodulin-dependent APC formation mediates cytoprotection in diabetic nephropathy by inhibiting glomerular apoptosis. APC prevents glucose-induced apoptosis in endothelial cells and podocytes, the cellular components of the glomerular filtration barrier. APC modulates the mitochondrial apoptosis pathway via the protease-activated receptor PAR-1 and the endothelial protein C receptor EPCR in glucose-stressed cells. These experiments establish a new pathway, in which hyperglycemia impairs endothelial thrombomodulin-dependent APC formation. Loss of thrombomodulin-dependent APC formation interrupts cross-talk between the vascular compartment and podocytes, causing glomerular apoptosis and diabetic nephropathy. Conversely, maintaining high APC levels during long-term diabetes protects against diabetic nephropathy.

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Figure 1: Hyperglycemia suppresses thrombomodulin (TM) expression and protein C activation in vivo.
Figure 2: Diabetic nephropathy is differentially modulated in mice with impaired or enhanced APC formation.
Figure 3: APC modulates glomerular apoptosis in diabetic nephropathy.
Figure 4: APC-dependent inhibition of apoptosis prevents nephropathy in diabetic ThbdPro/Pro mice.
Figure 5: APC prevents hyperglycemia-induced apoptosis in endothelial cells and podocytes, but not mesangial cells, in vitro.
Figure 6: APC inhibits mitochondrial-dependent apoptosis in high glucose–stressed endothelial cells through PAR-1 and EPCR.

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Acknowledgements

We thank S. Huntscha and C. Luckner for technical support. This work was supported by grants from the Deutsche Forschungsgemeinschaft (IS 67/2-1; IS 67/2-2) to B.I., a grant from the Novartis Stiftung to B.I. and T.C., a grant from the Lautenschläger Stiftung, and a European Association for the Study of Diabetes grant to A.B.

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Author notes

  1. Marcus A F Corat

    Present address: Present address: Centro Multidisciplinar para Investigação Biológica, Universidade Estadual de Campinas, Campinas 13083-877, SP, Brasil–Caixa Postal: 6095.,

  2. Berend Isermann, Ilya A Vinnikov and Thati Madhusudhan: These authors contributed equally to this work.

Authors and Affiliations

  1. Department of Medicine I and Clinical Chemistry, University of Heidelberg, INF 410, Heidelberg, 69120, Germany

    Berend Isermann, Ilya A Vinnikov, Thati Madhusudhan, Stefanie Herzog, Muhammed Kashif, Janusch Blautzik, Angelika Bierhaus & Peter P Nawroth

  2. The Blood Research Institute, Blood Center of Wisconsin, 8727 Watertown Plank Road, Milwaukee, 53226, Wisconsin, USA

    Marcus A F Corat & Hartmut Weiler

  3. Department of Medicine I, Nephrology, University of Heidelberg, INF 162, Heidelberg, 69120, Germany

    Martin Zeier

  4. Department of Medicine III, Cardiology, University of Heidelberg, INF 410, Heidelberg, 69120, Germany

    Erwin Blessing

  5. Department of Pediatric Nephrology, University of Heidelberg, INF 153, Heidelberg, 69120, Germany

    Jun Oh

  6. BioTechnology Discovery Research, Lilly Research Laboratories, Indianapolis, 46285, Indiana, USA

    Bruce Gerlitz, David T Berg & Brian W Grinnell

  7. Experimental Immunology Branch, National Cancer Institute, Building 10, Room 4B17, National Institutes of Health, Bethesda, 20892, Maryland, USA

    Triantafyllos Chavakis

  8. Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, and Howard Hughes Medical Institute, 825 N.E. 13th, Room A-205, Mail Box 45, Oklahoma City, 73104, Oklahoma, USA

    Charles T Esmon

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Contributions

B.I. conceptually designed, conducted and interpreted the experimental work and wrote the manuscript; I.A.V. did in vivo and ex vivo work; T.M. did ex vivo and in vitro work, S.H. did in vitro work; M.K. and J.B. did ex vivo work; M.A.F.C. did transgenic mouse work; M.Z. contributed to data analyses; E.B. and T.C. performed image analyses; J.O. contributed to podocyte in vitro work, B.G., D.T.B. and B.W.G. performed in vitro analyses of the D167F/D172K PC mutant; C.T.E. provided antibodies and helped interpret experimental work; H.W. helped generate APChigh mice and made ThbdPro/Pro mice available; A.B. helped design experiments; P.P.N. designed experiments and wrote the manuscript.

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Correspondence to Berend Isermann.

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Competing interests

C.T.E. holds a patent and license for the use of APC in sepsis and production of protein C from plasma. He also has patents on detecting circulating APC levels. B.W.G., D.T.B. and B.G. are employees of Lilly Research Laboratories, a division of Eli Lilly & Co., which produces recombinant human protein C for the treatment of severe sepsis.

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Isermann, B., Vinnikov, I., Madhusudhan, T. et al. Activated protein C protects against diabetic nephropathy by inhibiting endothelial and podocyte apoptosis. Nat Med 13, 1349–1358 (2007). https://doi.org/10.1038/nm1667

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