Antisense oligonucleotides ameliorate kidney dysfunction in podocyte specific APOL1 risk variant mice

APOL1 testing in clinical practice and opportunities for new therapies

PURPOSE OF REVIEW

The spectrum of kidney diseases caused by variation in the apolipoprotein L1 (APOL1) gene was identified in 2010 among patients with recent African ancestry. In the United States, inheriting two APOL1 risk variants (high-risk genotypes) markedly increases risk for solidified glomerulosclerosis, focal segmental glomerulosclerosis, collapsing glomerulopathy, lupus nephritis, and sickle cell nephropathy. Kidneys from African American deceased donors with APOL1 high-risk genotypes also fail more rapidly after transplant. One risk variant increases nephropathy risk in Africa. This review focuses on novel therapies targeting APOL1 and the changing landscape of APOL1 genotyping in patients at risk for APOL1-mediated kidney disease (AMKD).

RECENT FINDINGS

Renin-angiotensin-aldosterone system blockade and sodium-glucose cotransporter 2 inhibitors slow nephropathy progression but are not curative. Medications directly targeting APOL1 mRNA and blocking APOL1 protein effects are undergoing clinical trials in AMKD, including APOL1 small molecule inhibitors, an APOL1 antisense oligonucleotide, and a Janus kinase (JAK) signaling inhibitor to reduce APOL1 expression. Early results are promising and provide hope for well tolerated and effective therapies. If successful, more patients will need to be considered for APOL1 genotyping, and our approach to diagnosing and treating chronic kidney disease in populations with recent African ancestry will change dramatically.

SUMMARY

Mechanisms of APOL1 risk variant nephrotoxicity remain unclear; nonetheless, specific therapies for AMKD show great promise and may improve understanding of disease processes. With ongoing clinical trials and the potential for effective AMKD treatments, more widespread APOL1 genotyping will likely be needed.

SNA-modified antisense oligonucleotides: A new pathway for renal targeting?

Antisense oligonucleotides (ASOs) have emerged as a powerful class of therapeutics capable of suppressing gene expression with remarkable specificity. However, the clinical applications of ASOs have been limited by delivery challenges and toxicities, particularly when repeated or high dosing is required. In the study by Tsuboi et al., the authors present serinol nucleic acid (SNA)-modified gapmer ASOs that target the sodium-glucose cotransporter 2 (SGLT2) in mouse kidneys. With promising results, these SNA-modified ASOs display dose-dependent efficacy, prolonged knockdown, and importantly, a more favorable safety profile in both the kidney and liver compared with the 2'-MOE-modified counterpart. While some caveats remain-particularly around high-dose toxicity-these findings open the door to an approach that couples potency with improved tolerability, thereby highlighting SNA-modified ASOs as a potential next-generation platform for renal diseases.

Efficient and selective kidney targeting by chemically modified carbohydrate conjugates

We investigated a renal tubule-targeting carbohydrate (RENTAC) that can selectively deliver small-molecule and nucleic acid analogs to the proximal convoluted tubules of the kidney following systemic delivery in mice. We comprehensively evaluated anti-miR-21-peptide nucleic acid-RENTAC, and fluorophore-RENTAC conjugates in cell culture and in vivo. We established that RENTAC conjugates showed megalin- and cubilin-dependent endocytic uptake in the immortalized kidney cell line. In vivo biodistribution studies confirmed the retention of RENTAC conjugates in the kidneys for several days compared with other organs. Immunofluorescence staining confirmed the selective distribution of the RENTAC conjugates in proximal convoluted tubules. We further demonstrated proximal convoluted tubule targeting features of RENTAC conjugates in a folic acid-induced kidney fibrosis mouse model. As a biological readout, we targeted miR-33 using antisense peptide nucleic acid (PNA) 33-RENTAC conjugates in the fibrotic kidney disease model. The targeted delivery of PNA 33-RENTAC resulted in slower fibrosis progression and decreased collagen deposition. We also confirmed that the RENTAC ligand did not exert any adverse reactions. Thus, we established that the RENTAC ligand can be used for broad clinical applications targeting the kidneys selectively.

Precision medicine for focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) is one of the common causes of nephrotic syndrome in adults and children worldwide. FSGS consists of a group of kidney diseases classified based on specific histopathological features. The current classification of FSGS makes it difficult to distinguish individual differences in pathogenesis, disease progression, and response to treatment. In recent years, the spread of next-generation sequencing, updates in biological techniques, and improvements of treatment have changed our understanding of FSGS. In this review, we will discuss the use of genetic testing in patients with FSGS, explore its clinical significance from a genetic identification perspective, and introduce several new biomarkers, that may help in the early diagnosis of FSGS and guide the development of specific or targeted therapies, so as to understand the biological characteristics in FSGS. This will certainly help develop more effective and safer treatments and advance precision medicine.

Podocyte-targeted therapies - progress and future directions

Podocytes are the key target cells for injury across the spectrum of primary and secondary proteinuric kidney disorders, which account for up to 90% of cases of kidney failure worldwide. Seminal experimental and clinical studies have established a causative link between podocyte depletion and the magnitude of proteinuria in progressive glomerular disease. However, no substantial advances have been made in glomerular disease therapies, and the standard of care for podocytopathies relies on repurposed immunosuppressive drugs. The past two decades have seen a remarkable expansion in understanding of the mechanistic basis of podocyte injury, with prospects increasing for precision-based treatment approaches. Dozens of disease-causing genes with roles in the pathogenesis of clinical podocytopathies have been identified, as well as a number of putative glomerular permeability factors. These achievements, together with the identification of novel targets of podocyte injury, the development of potential approaches to harness the endogenous podocyte regenerative potential of progenitor cell populations, ongoing clinical trials of podocyte-specific pharmacological agents and the development of podocyte-directed drug delivery systems, contribute to an optimistic outlook for the future of glomerular disease therapy.

APOL1 nephropathy - a population genetics success story

PURPOSE OF REVIEW

More than a decade ago, apolipoprotein L1 ( APOL1 ) risk alleles designated G1 and G2, were discovered to be causally associated with markedly increased risk for progressive kidney disease in individuals of recent African ancestry. Gratifying progress has been made during the intervening years, extending to the development and clinical testing of genomically precise small molecule therapy accompanied by emergence of RNA medicine platforms and clinical testing within just over a decade.

RECENT FINDINGS

Given the plethora of excellent prior review articles, we will focus on new findings regarding unresolved questions relating mechanism of cell injury with mode of inheritance, regulation and modulation of APOL1 activity, modifiers and triggers for APOL1 kidney risk penetrance, the pleiotropic spectrum of APOL1 related disease beyond the kidney - all within the context of relevance to therapeutic advances.

SUMMARY

Notwithstanding remaining controversies and uncertainties, promising genomically precise therapies targeted at APOL1 mRNA using antisense oligonucleotides (ASO), inhibitors of APOL1 expression, and small molecules that specifically bind and inhibit APOL1 cation flux are emerging, many already at the clinical trial stage. These therapies hold great promise for mitigating APOL1 kidney injury and possibly other systemic phenotypes as well. A challenge will be to develop guidelines for appropriate use in susceptible individuals who will derive the greatest benefit.

African ancestry-derived APOL1 risk genotypes show proximal epigenetic associations

Apolipoprotein L1 (APOL1) coding variants, termed G1 and G2, are established genetic risk factors for a growing spectrum of diseases, including kidney disease, in individuals of African ancestry. Evidence suggests that the risk variants, which show a recessive mode of inheritance, lead to toxic gain-of-function changes of the APOL1 protein. Disease occurrence and presentation vary, likely due to modifiers or second hits. To understand the role of the epigenetic landscape in relation to APOL1 risk variants, we performed methylation quantitative trait locus (meQTL) analysis to identify differentially methylated CpGs influenced by APOL1 risk variants in 611 African American individuals. We identified five CpGs that were significantly associated with APOL1 risk alleles in discovery and replication studies, and one CpG-APOL1 association was independent of other genomic variants. Our study highlights proximal DNA methylation alterations that may help explain the variable disease risk and clinical manifestation of APOL1 variants.

Splice-Modulating Antisense Oligonucleotides as Therapeutics for Inherited Metabolic Diseases

The last decade (2013-2023) has seen unprecedented successes in the clinical translation of therapeutic antisense oligonucleotides (ASOs). Eight such molecules have been granted marketing approval by the United States Food and Drug Administration (US FDA) during the decade, after the first ASO drug, fomivirsen, was approved much earlier, in 1998. Splice-modulating ASOs have also been developed for the therapy of inborn errors of metabolism (IEMs), due to their ability to redirect aberrant splicing caused by mutations, thus recovering the expression of normal transcripts, and correcting the deficiency of functional proteins. The feasibility of treating IEM patients with splice-switching ASOs has been supported by FDA permission (2018) of the first "N-of-1" study of milasen, an investigational ASO drug for Batten disease. Although for IEM, owing to the rarity of individual disease and/or pathogenic mutation, only a low number of patients may be treated by ASOs that specifically suppress the aberrant splicing pattern of mutant precursor mRNA (pre-mRNA), splice-switching ASOs represent superior individualized molecular therapeutics for IEM. In this work, we first summarize the ASO technology with respect to its mechanisms of action, chemical modifications of nucleotides, and rational design of modified oligonucleotides; following that, we precisely provide a review of the current understanding of developing splice-modulating ASO-based therapeutics for IEM. In the concluding section, we suggest potential ways to improve and/or optimize the development of ASOs targeting IEM.