Glomerular Elastic Modulus and Gene Expression PatternsDefine Two Phases of Alport Nephropathy

Alport syndrome (AS), caused by COL4A3,4,5 mutations, leads to progressive glomerular disease and eventual kidney failure. In Col43-/- mice (C57BL/6 background), we found that increased glomerular capillary deformability (reduced Youngs modulus, E) appears 2-3 months before detectable proteinuria or elevated serum creatinine. This early change indicates that podocyte injury precedes traditional clinical markers of disease and corresponds to reduced podocyte adhesion and loss. Bulk and podocyte-enriched RNA-seq data, obtained from deconvoluting bulk RNA sequencing data, showed that starting at 4 months, endoplasmic reticulum (ER) stress and the unfolded protein response (UPR) steadily rise while extracellular matrix remodeling, inflammation, epithelial-mesenchymal transition, and maladaptive repair begin. By 7 months, pathology shifts toward widespread parenchymal fibrosis, interleukin, cytokine, and chemokine signaling, cytoskeleton disruption, metabolic failure, and podocyte dedifferentiation. Notably, administration of the chemical chaperone Tauro-Urso-Deoxcycholic Acid (TUDCA) from weaning reduced ER stress, preserved glomerular stiffness, minimized podocyte detachment and loss, normalized inflammatory, injury, and fibrotic gene expression, and halved proteinuria and serum creatinine at 7 months, preserving kidney structure. Differentially expressed podocyte enriched genes from 4-month Col43-/- (vs WT) mice were mapped to human orthologs in the NEPTUNE cohort. Four genes (CRB2, GPC6, NKD1, STX11) were associated with End Stage Renal Disease or 40% loss of eGFR (ESRD40). Collectively, our results identify these four genes and ER stress/UPR as key and treatable drivers of podocyte injury and disease progression in Alport syndrome, well before overt proteinuria, and highlight UPR activation and several genes as promising targets for disease-modifying therapies.