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Pyruvate kinase M2 activation may protect against the progression of diabetic glomerular pathology and mitochondrial dysfunction

Abstract

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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Figure 1: Elevation of glucose metabolic enzymes in glomeruli from individual with diabetes, but without DN.
Figure 2: Regulation of PKM2 activity by high glucose and diabetes.
Figure 3: Pkm2 deletion in podocytes accelerates DN progression.
Figure 4: PKM2 activation normalizes abnormalities in glucose metabolism and mitochondrial function and prevents podocyte apoptosis induced by high glucose.
Figure 5: PKM2 activation reverses diabetes-induced defects in glucose metabolism and mitochondrial function in a mouse model of DN.
Figure 6: Pharmacologically activating PKM2 by TEPP-46 prevents the development of glomerular pathology.

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Acknowledgements

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.).

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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.

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Correspondence to George L King.

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

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Qi, W., Keenan, H., Li, Q. et al. Pyruvate kinase M2 activation may protect against the progression of diabetic glomerular pathology and mitochondrial dysfunction. Nat Med 23, 753–762 (2017). https://doi.org/10.1038/nm.4328

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