Integrated Proteo-Metabolomics of Urinary Extracellular Vesicles Reveals Early Molecular Divergence and Temporal Pathogenesis of Sepsis-Associated AKI

BackgroundSepsis-associated acute kidney injury (S-AKI) is a major contributor to morbidity and mortality in critically ill patients. However, the molecular mechanisms underlying its temporal progression remain poorly understood because conventional biomarkers primarily reflect renal dysfunction rather than disease pathogenesis. Urinary extracellular vesicles (uEVs), which carry kidney-derived molecular cargo, provide a promising platform for monitoring renal-specific biological alterations during disease progression. MethodsWe conducted a longitudinal multi-omics study of uEVs collected from 81 patients with sepsis, including 48 patients with S-AKI and 33 sepsis-only controls. Patients were randomly assigned to a discovery cohort (n = 52) and an independent validation cohort (n = 29). Urine samples were collected at Day 1, Day 4, and Day 8 after AKI diagnosis. High-resolution proteomic and metabolomic profiling was performed to characterize temporal molecular alterations. Enriched pathways identified in the discovery cohort were evaluated in the validation cohort using pathway-level concordance analysis. ResultsComparative analysis between S-AKI and sepsis-only patients identified distinct stage-specific molecular alterations throughout disease progression. At the early stage (Day 1), validated pathways included complement and coagulation cascades, ferroptosis, HIF-1 signaling, sphingolipid metabolism, and arachidonic acid metabolism, highlighting coordinated inflammatory, hypoxic, and lipid metabolic responses. During the mid-stage (Day 4), persistent activation of complement and coagulation cascades, ferroptosis, and HIF-1 signaling was accompanied by metabolic reprogramming involving alanine, aspartate and glutamate metabolism and tyrosine metabolism. Although limited sample availability reduced statistical power at Day 8, phenylalanine metabolism remained validated in the metabolomic analysis, suggesting persistent metabolic dysregulation during late-stage disease progression. ConclusionsThis study provides the first longitudinal, independently validated multi-omics characterization of human uEVs in S-AKI. By integrating proteomic and metabolomic profiling, we reveal the temporal evolution of renal-specific molecular pathways from early inflammatory and hypoxic responses to subsequent metabolic reprogramming. These findings establish uEV-based multi-omics as a promising strategy for molecular phenotyping of S-AKI beyond conventional clinical biomarkers and provide a valuable resource for future biomarker discovery and therapeutic target identification.