Perturbations in podocyte transcriptome and biological pathways induced by FSGS associated circulating factors.

Focal segmental glomerulosclerosis (FSGS) is frequently associated with heavy proteinuria and progressive renal failure requiring dialysis or kidney transplantation. However, primary FSGS also has 40-80% risk of recurrence of disease in the transplanted kidney (rFSGS). Multiple circulating factors have been proposed to contribute to the pathogenesis of primary and rFSGS. However, neither the factors nor the downstream effectors specific to individual factors have been identified. The tumor necrosis factor, TNF pathway activation by one or more circulating factors present in the sera of patients with FSGS has been supported by multiple studies. The proposed circulating factors include soluble urokinase-type plasminogen activator receptor (suPAR) and patient derived CD40 autoantibody (CD40autoAb) in the development and recurrence of FSGS. In a human in vitro model, using two novel human antibodies-anti uPAR (2G10) and anti CD40 antibody, we show that the podocyte injury caused by sera from FSGS patients is at least in part mediated by CD40 and suPAR. Additionally, we employ gene expression studies to compare the molecules and pathways activated in response to CD40 autoantibody from rFSGS patients (rFSGS/CD40autoAb) and suPAR, and delineate the unique pathways associated with FSGS injury and transcriptional podocyte alterations with targeted blockade of suPAR and CD40 pathways. Clinical ImpactFocal Segmental Glomerulosclerosis remains a disease without specific therapy for primary disease and high rate of recurrence after kidney transplantation. Circulating factors are implicated in the pathogenesis of FSGS but targeting them for therapy has remained elusive. We propose two potential therapeutic molecules for rFSGS treatment-a human anti-uPAR antibody (2G10) and a humanized anti-CD40 blocking antibody (Bristol Meyer Squibb, 986090) that reverse podocyte injury associated with FSGS in cultured podocytes and can be further tested in pre-clinical and clinical models. Furthermore, we use microarray profiling to identify transcriptional pathways specific to podocyte injury from patient-derived CD40 autoantibodies (rFSGS/CD40autoAb) and suPAR and selective blockade of these pathways to abrogate podocyte injury.