Diabetic nephropathy (DN) is a major cause of end-stage renal disease, and therapeutic options for preventing its progression are limited. To identify novel therapeutic strategies, we studied protective factors for DN using proteomics on glomeruli from individuals with extreme duration of diabetes (ł50 years) without DN and those with histologic signs of DN. Enzymes in the glycolytic, sorbitol, methylglyoxal and mitochondrial pathways were elevated in individuals without DN. In particular, pyruvate kinase M2 (PKM2) expression and activity were upregulated. Mechanistically, we showed that hyperglycemia and diabetes decreased PKM2 tetramer formation and activity by sulfenylation in mouse glomeruli and cultured podocytes. Pkm-knockdown immortalized mouse podocytes had higher levels of toxic glucose metabolites, mitochondrial dysfunction and apoptosis. Podocyte-specific Pkm2-knockout (KO) mice with diabetes developed worse albuminuria and glomerular pathology. Conversely, we found that pharmacological activation of PKM2 by a small-molecule PKM2 activator, TEPP-46, reversed hyperglycemia-induced elevation in toxic glucose metabolites and mitochondrial dysfunction, partially by increasing glycolytic flux and PGC-1α mRNA in cultured podocytes. In intervention studies using DBA2/J and Nos3 (eNos) KO mouse models of diabetes, TEPP-46 treatment reversed metabolic abnormalities, mitochondrial dysfunction and kidney pathology. Thus, PKM2 activation may protect against DN by increasing glucose metabolic flux, inhibiting the production of toxic glucose metabolites and inducing mitochondrial biogenesis to restore mitochondrial function.

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We are grateful to all the fellows who participated in Medalist Kidneys collection, D. Anastasiou, J. Lee, C. Thomas and M. Lauterbach for their technical advice. We also thank the technical support from E. Yu, daily-oral-gavaging team members, Z. Zsengeller and E. Pernicone. We are grateful to M. Maurer, who gave us technical advice on human kidney pathology assessment. We thank C. Clish for plasma metabolomics analysis. We are grateful to J. Hourihan for technical advice and review of the manuscript. W. Qi was a recipient of awards from the Juvenile Diabetes Research Foundation and Mary Iacocca Research Foundation. Mouse podocytes and human podocytes cell lines were kind gifts from P.M. and J.K. This project was funded by NIH 1DP3DK112192-01 (G.L.K.); DK094333-01 (G.L.K. and H.A.K.), 1R24DK090961-01 (G.L.K.); DRC grant-P30DK036836-30 (G.L.K.); JDRF 8-2005-358 (G.L.K.); JDRF 18-2008-363 (G.L.K.); JDRF17-2011-47 (G.L.K.); and JDRF17-2013-310 (H.A.K.). Additional research support was provided by the Thomas Beatson, Jr Foundation, the Brehm Foundation and a research grant from Sanofi-Aventis (G.L.K.). Other co-authors were supported by the following funding: DK107339-02 (M.A.Y.); Harold Whitworth Pierce Charitable Trust Postdoctoral Fellowship (A.M.B.); R01 DK109015 and R00 DK090210 (C.W.L.) and JDRF CDA-2015-89-A-B (M.A.N.).

Author information


  1. Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA.

    • Weier Qi
    • , Hillary A Keenan
    • , Qian Li
    • , Atsushi Ishikado
    • , I-Hsien Wu
    • , Alison M Burkart
    • , Stephanie Hastings
    • , David Pober
    • , Christopher Cahill
    • , Monika A Niewczas
    • , Liane Tinsley
    • , Peter S Amenta
    • , Edward P Feener
    • , Robert C Stanton
    •  & George L King
  2. Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany.

    • Aimo Kannt
    • , Thorsten Sadowski
    •  & Anja Pfenninger
  3. Veterans Affairs Medical Center, Iowa City, Iowa, USA.

    • Mark A Yorek
    •  & Lawrence J Coppey
  4. Queen's University Belfast, Belfast, UK.

    • Samuel Lockhart
  5. Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, Illinois, USA.

    • Chong Wee Liew
    •  & Guifen Qiang
  6. State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College and Beijing Key Laboratory of Drug Target and Screening Research, Beijing, China.

    • Guifen Qiang
  7. Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

    • William J Israelsen
  8. Beth Israel Deaconess Medical Center, Division of Anatomic Pathology, Boston, Massachusetts, USA.

    • Isaac E Stillman
  9. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.

    • Matthew G Vander Heiden


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W.Q. designed and performed the experiments, analyzed the data and wrote the manuscript. H.A.K. assisted in the design of the Medalist study. Q.L., A.I., A.K., T.S., M.A.Y., S.L., L.J.C., A.P., C.W.L., G.Q., A.M.B. and W.J.I. provided technical support and/or critical discussions of the manuscript. I.-H.W. analyzed proteomics data. S.H. managed clinical data and samples. D.P. and L.T. performed all the clinical and some nonclinical statistical analysis and checked all the statistical analysis. C.C. performed electron-microscopy-related imaging work. M.A.N. analyzed metabolomics data. E.P.F. participated in proteomics analysis and critical review and discussion of the manuscript. M.G.V.H. provided technical advice on both TEPP-46 and Pkm2fl/fl mouse studies and constructs of pLHCX-Flag-mPKM2 and pLHCXFlag-mPKM1. I.E.S. and P.S.A. assessed all the human kidney pathology. R.C.S. provided critical review of the clinical data. G.L.K. supervised the project and wrote the manuscript. All the authors have reviewed the manuscript.

Competing interests

A.K., T.S. and A.P. are employees of Sanofi-Aventis.

Corresponding author

Correspondence to George L King.

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