Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Circulating angiopoietin-like 4 links proteinuria with hypertriglyceridemia in nephrotic syndrome

Abstract

The molecular link between proteinuria and hyperlipidemia in nephrotic syndrome is not known. We show in the present study that plasma angiopoietin-like 4 (Angptl4) links proteinuria with hypertriglyceridemia through two negative feedback loops. In previous studies in a rat model that mimics human minimal change disease, we observed localized secretion by podocytes of hyposialylated Angptl4, a pro-proteinuric form of the protein. But in this study we noted high serum levels of Angptl4 (presumably normosialylated based on a neutral isoelectric point) in other glomerular diseases as well. Circulating Angptl4 was secreted by extrarenal organs in response to an elevated plasma ratio of free fatty acids (FFAs) to albumin when proteinuria reached nephrotic range. In a systemic feedback loop, these circulating pools of Angptl4 reduced proteinuria by interacting with glomerular endothelial αvβ5 integrin. Blocking the Angptl4–β5 integrin interaction or global knockout of Angptl4 or β5 integrin delayed recovery from peak proteinuria in animal models. But at the same time, in a local feedback loop, the elevated extrarenal pools of Angptl4 reduced tissue FFA uptake in skeletal muscle, heart and adipose tissue, subsequently resulting in hypertriglyceridemia, by inhibiting lipoprotein lipase (LPL)-mediated hydrolysis of plasma triglycerides to FFAs. Injecting recombinant human ANGPTL4 modified at a key LPL interacting site into nephrotic Buffalo Mna and Zucker Diabetic Fatty rats reduced proteinuria through the systemic loop but, by bypassing the local loop, without increasing plasma triglyceride levels. These data show that increases in circulating Angptl4 in response to nephrotic-range proteinuria reduces the degree of this pathology, but at the cost of inducing hypertriglyceridemia, while also suggesting a possible therapy to treat these linked pathologies.

Your institute does not have access to this article

Relevant articles

Open Access articles citing this article.

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

Figure 1: Elevated circulating Angptl4 levels are required for the development of hypertriglyceridemia in nephrotic syndrome.
Figure 2: The source of circulating Angptl4 in nephrotic syndrome.
Figure 3: Mechanisms of Angptl4 upregulation in peripheral organs in nephrotic syndrome.
Figure 4: Effect of circulating Angptl4 on proteinuria.
Figure 5: Circulating Angptl4 reduces proteinuria through its interaction with glomerular endothelial αvβ5 integrin.
Figure 6: Pathobiology of circulating Angptl4 in nephrotic syndrome.

References

  1. Vaziri, N.D. Molecular mechanisms of lipid disorders in nephrotic syndrome. Kidney Int. 63, 1964–1976 (2003).

    Article  Google Scholar 

  2. Marsh, J.B. & Drabkin, D.L. Experimental reconstruction of metabolic pattern of lipid nephrosis: key role of hepatic protein synthesis in hyperlipemia. Metabolism 9, 946–955 (1960).

    CAS  PubMed  Google Scholar 

  3. Merkel, M., Eckel, R.H. & Goldberg, I.J. Lipoprotein lipase: genetics, lipid uptake, and regulation. J. Lipid Res. 43, 1997–2006 (2002).

    CAS  Article  Google Scholar 

  4. Weinstock, P.H. et al. Severe hypertriglyceridemia, reduced high density lipoprotein, and neonatal death in lipoprotein lipase knockout mice. Mild hypertriglyceridemia with impaired very low density lipoprotein clearance in heterozygotes. J. Clin. Invest. 96, 2555–2568 (1995).

    CAS  Article  Google Scholar 

  5. Shearer, G.C. & Kaysen, G.A. Endothelial bound lipoprotein lipase (LpL) depletion in hypoalbuminemia results from decreased endothelial binding, not decreased secretion. Kidney Int. 70, 647–653 (2006).

    CAS  Article  Google Scholar 

  6. Ghiggeri, G.M. et al. Characterization of cationic albumin in minimal change nephropathy. Kidney Int. 32, 547–553 (1987).

    CAS  Article  Google Scholar 

  7. Clement, L.C. et al. Podocyte-secreted angiopoietin-like-4 mediates proteinuria in glucocorticoid-sensitive nephrotic syndrome. Nat. Med. 17, 117–122 (2011).

    CAS  Article  Google Scholar 

  8. Chugh, S.S., Clement, L.C. & Macé, C. New insights into human minimal change disease: lessons from animal models. Am. J. Kidney Dis. 59, 284–292 (2012).

    CAS  Article  Google Scholar 

  9. Sukonina, V., Lookene, A., Olivecrona, T. & Olivecrona, G. Angiopoietin-like protein 4 converts lipoprotein lipase to inactive monomers and modulates lipase activity in adipose tissue. Proc. Natl. Acad. Sci. USA 103, 17450–17455 (2006).

    CAS  Article  Google Scholar 

  10. Yoshida, K., Shimizugawa, T., Ono, M. & Furukawa, H. Angiopoietin-like protein 4 is a potent hyperlipidemia-inducing factor in mice and inhibitor of lipoprotein lipase. J. Lipid Res. 43, 1770–1772 (2002).

    CAS  Article  Google Scholar 

  11. Romeo, S. et al. Population-based resequencing of ANGPTL4 uncovers variations that reduce triglycerides and increase HDL. Nat. Genet. 39, 513–516 (2007).

    CAS  Article  Google Scholar 

  12. Yin, W. et al. Genetic variation in ANGPTL4 provides insights into protein processing and function. J. Biol. Chem. 284, 13213–13222 (2009).

    CAS  Article  Google Scholar 

  13. Clement, L.C. et al. Early changes in gene expression that influence the course of primary glomerular disease. Kidney Int. 72, 337–347 (2007).

    CAS  Article  Google Scholar 

  14. Liu, G., Clement, L., Kanwar, Y.S., Avila-Casado, C. & Chugh, S.S. ZHX proteins regulate podocyte gene expression during the development of nephrotic syndrome. J. Biol. Chem. 281, 39681–39692 (2006).

    CAS  Article  Google Scholar 

  15. Nakamura, T. et al. Sclerotic lesions in the glomeruli of Buffalo/Mna rats. Nephron 43, 50–55 (1986).

    CAS  Article  Google Scholar 

  16. Le Berre, L. et al. Extrarenal effects on the pathogenesis and relapse of idiopathic nephrotic syndrome in Buffalo/Mna rats. J. Clin. Invest. 109, 491–498 (2002).

    CAS  Article  Google Scholar 

  17. Neuger, L. et al. Effects of heparin on the uptake of lipoprotein lipase in rat liver. BMC Physiol. 4, 13 (2004).

    Article  Google Scholar 

  18. Chang, S.F., Reich, B., Brunzell, J.D. & Will, H. Detailed characterization of the binding site of the lipoprotein lipase-specific monoclonal antibody 5D2. J. Lipid Res. 39, 2350–2359 (1998).

    CAS  PubMed  Google Scholar 

  19. Nagase, S., Shimamune, K. & Shumiya, S. Albumin-deficient rat mutant. Science 205, 590–591 (1979).

    CAS  Article  Google Scholar 

  20. Kikuchi, H., Tamura, S., Nagase, S. & Tsuiki, S. Hypertriacylglycerolemia and adipose tissue lipoprotein lipase activity in the Nagase analbuminemic rat. Biochim. Biophys. Acta 744, 165–170 (1983).

    CAS  Article  Google Scholar 

  21. Kersten, S. et al. Caloric restriction and exercise increase plasma ANGPTL4 levels in humans via elevated free fatty acids. Arterioscler. Thromb. Vasc. Biol. 29, 969–974 (2009).

    CAS  Article  Google Scholar 

  22. Staiger, H. et al. Muscle-derived angiopoietin-like protein 4 is induced by fatty acids via peroxisome proliferator-activated receptor (PPAR)-δ and is of metabolic relevance in humans. Diabetes 58, 579–589 (2009).

    CAS  Article  Google Scholar 

  23. Georgiadi, A. et al. Induction of cardiac Angptl4 by dietary fatty acids is mediated by peroxisome proliferator-activated receptor β/δ and protects against fatty acid–induced oxidative stress. Circ. Res. 106, 1712–1721 (2010).

    CAS  Article  Google Scholar 

  24. Zhu, P. et al. Angiopoietin-like 4 protein elevates the prosurvival intracellular O2:H2O2 ratio and confers anoikis resistance to tumors. Cancer Cell 19, 401–415 (2011).

    CAS  Article  Google Scholar 

  25. Mandard, S. et al. The fasting-induced adipose factor/angiopoietin-like protein 4 is physically associated with lipoproteins and governs plasma lipid levels and adiposity. J. Biol. Chem. 281, 934–944 (2006).

    CAS  Article  Google Scholar 

  26. Zilleruelo, G., Hsia, S.L., Freundlich, M., Gorman, H.M. & Strauss, J. Persistence of serum lipid abnormalities in children with idiopathic nephrotic syndrome. J. Pediatr. 104, 61–64 (1984).

    CAS  Article  Google Scholar 

  27. Yu, X. et al. Inhibition of cardiac lipoprotein utilization by transgenic overexpression of Angptl4 in the heart. Proc. Natl. Acad. Sci. USA 102, 1767–1772 (2005).

    CAS  Article  Google Scholar 

  28. Avila-Casado, M.C. et al. Proteinuria in rats induced by serum from patients with collapsing glomerulopathy. Kidney Int. 66, 133–143 (2004).

    Article  Google Scholar 

  29. Ferris, M. et al. Patient recruitment into a multicenter randomized clinical trial for kidney disease: report of the focal segmental glomerulosclerosis clinical trial (FSGS CT). Clin. Transl. Sci. 6, 13–20 (2013).

    Article  Google Scholar 

  30. Chugh, S. et al. Aminopeptidase A: a nephritogenic target antigen of nephrotoxic serum. Kidney Int. 59, 601–613 (2001).

    CAS  Article  Google Scholar 

  31. Takemoto, M. et al. A new method for large scale isolation of kidney glomeruli from mice. Am. J. Pathol. 161, 799–805 (2002).

    Article  Google Scholar 

  32. Liu, G. et al. Neph1 and nephrin interaction in the slit diaphragm is an important determinant of glomerular permeability. J. Clin. Invest. 112, 209–221 (2003).

    CAS  Article  Google Scholar 

  33. Bengtsson-Olivecrona, G. & Olivecrona, T. Lipoprotein analysis—a practical approach. in Practical Approach Series (eds. Converse, C.A. & Skinner, E.R.) 169–185 (Oxford University Press, New York, 1992).

Download references

Acknowledgements

We thank investigators of the FSGS clinical trial for providing baseline plasma and urine samples from patients with FSGS; M. del Nogal-Avila (University of Alabama at Birmingham (UAB)) for selected real-time PCR studies; H. Donoro (UAB) for assistance with animal colony management; E. Soria (Instituto Nacional de Cardiologia) for immunogold electron microscopy studies; H. Chung (UAB) for advice on LPL assays; V. Kumar (UAB) for help in collecting Institutional Review Board–approved patient sera from transplant patients; D. Salant (Boston University) for γ2-NTS; A. Köster (Eli Lilly) for Angptl4−/− mice; M. Mitsuyama (Kyoto University) for Buffalo Mna rats; J. Brunzell (University of Washington) for 5D2 monoclonal antibody; F. Danesh (MD Anderson Cancer Center) for cultured rat glomerular endothelial cells; UAB–University of California-San Diego George O'Brien Center Core C for measuring urine and serum creatinine by mass spectrometry; UAB Nephrology Research and Training Center for equipment use; and UAB Research Foundation for filing patent PCT/US2011/039255 for the use of ANGPTL4 mutants as therapeutic agents for nephrotic syndrome. This work is supported by the US National Institutes of Health (R01DK077073 and R01DK090035 to S.S.C., K01DK096127 to L.C.C. and T32DK007545 to C.M.).

Author information

Authors and Affiliations

Authors

Contributions

L.C.C. maintained transgenic rat colonies and conducted rat experiments, developed stable cell lines and conducted imaging studies and selected gene expression studies. C.M. maintained the Itgb5−/− mouse colony and conducted mouse studies, did assays for Angptl4, V5-tagged proteins, triglycerides and free fatty acids and performed two-dimensional gel studies, western blotting, selected gene expression studies, protein interaction studies and albumin depletion studies. C.A.-C. interpreted and analyzed light microscopy, electron microscopy and immunogold electron microscopy studies. J.A.J. obtained blood and tissue from Nagase rats and provided useful advice on Nagase rat biology. S.K. conducted experiments with Angptl4−/− mice and made substantial contributions to the preparation and revision of the manuscript. S.S.C. acted as senior investigator, planned and supervised the study, generated mutant ANGPTL4 constructs to develop stable cell lines, conducted selected gene expression and animal studies and wrote and revised the manuscript with input from other authors.

Corresponding author

Correspondence to Sumant S Chugh.

Ethics declarations

Competing interests

S.S.C. is founder, president and chief executive officer of GDTHERAPY LLC and has filed patents related to the use of ANGPTL4 mutants (PCT/US2011/039255) and precursors of sialic acid, including ManNAc (PCT/US2011/039058), for the treatment of nephrotic syndrome. S.S.C. may benefit financially from these patents in the future.

Supplementary information

Supplementary Text and Figures

Supplementary Table 1 and Supplementary Figures 1–6 (PDF 9229 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Clement, L., Macé, C., Avila-Casado, C. et al. Circulating angiopoietin-like 4 links proteinuria with hypertriglyceridemia in nephrotic syndrome. Nat Med 20, 37–46 (2014). https://doi.org/10.1038/nm.3396

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nm.3396

Further reading

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing