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What we need to know about lipid-associated injury in case of renal ischemia/reperfusion.


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What we need to know about lipid-associated injury in case of renal 1

ischemia/reperfusion 2

Pauline Erpicum1,2, Pascal Rowart2, Jean-Olivier Defraigne2,3, Jean-Marie Krzesinski1 and 3 François Jouret1,2 4 5 Affiliation: 6

1. Division of Nephrology, University of Liège academic Hospital (ULg CHU), Liège, 7

Belgium 8

2. Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular 9

Sciences, University of Liège, Liège, Belgium 10

3. Division of Cardio-Thoracic Surgery, University of Liège academic Hospital (ULg CHU), 11 Liège, Belgium 12 13 14 15 Correspondence: 16 François JOURET, MD, PhD 17

University of Liège Academic Hospital (ULg CHU), Division of Nephrology 18

Avenue Hippocrate, 13 – B4000 Liège, Belgium 19

Tel: +32.4.366.25.40; Fax: +32.4.366.21.37; e-mail: francois.jouret@chuliege.be 20


Running Title: Lipid-associated injury in renal ischemia/reperfusion 22


Keywords: ischemia/reperfusion, lipid metabolism, lipotoxicity 24 25 26 27 28 29 30 31 32


Abstract 33


Renal segmental metabolism is reflected by the complex distribution of the main energy 35

pathways along the nephron, with fatty acid oxidation preferentially used in the cortex area. 36

Ischemia/reperfusion injury (IRI) is due to the restriction of renal blood flow, rapidly leading 37

to a metabolic switch towards anaerobic conditions. Subsequent unbalance between energy 38

demand and oxygen/nutrient delivery compromises kidney cell functions, resulting to a 39

complex inflammatory cascade including the production of reactive oxygen species (ROS). 40

Renal IRI especially involves lipid accumulation. Lipid peroxidation is one of the major 41

events of ROS-associated tissue injury. Here, we briefly review the current knowledge of 42

renal cell lipid metabolism in normal and ischemic conditions. Next, we focus on renal lipid-43

associated injury, with emphasis on its mechanisms and consequences during the course of 44

IRI. Finally, we discuss preclinical observations aiming at preventing and/or attenuating lipid-45 associated IRI. 46 47 48 49


Ischemia/reperfusion (I/R) injury (IRI) is the leading cause of acute kidney injury 50

(AKI). The accumulation of lipids in renal parenchyma, also known as lipotoxicity (48), is 51

one of the multifactorial processes occurring in IRI (63). We briefly summarize renal lipid 52

metabolism in normal and ischemic conditions in order to help identify novel strategies to 53

prevent lipotoxicity. 54


Renal lipid metabolism in normal and ischemic conditions 56

The metabolic pathways are heterogeneously compartmented along the nephron (19). 57

Fatty acid oxidation (FAO) is the preferential source of kidney fuel (4, 29) and is active in all 58

parts of the nephron (19, 4). Fatty acids (FA) are provided to renal cells from (51) (i) 59

extracellular uptake, especially via FA transport proteins (such as CD36/Fatty Acid 60

Translocase (29) or Fatty Acid Transporter Protein 1,2 or 4 (22)); (ii) in situ cytosolic 61

synthesis (27); or (iii) release from intracellular processes, including triglyceride 62

(TG)/phospholipid (PL) hydrolysis. The relative contribution is not fully established (47). 63

Renal epithelial cells are also exposed to FA attached to albumin, with exacerbated toxicity in 64

proteinuric kidney diseases (4, 15). FA can be converted to fatty acyl-CoA (FA-CoA) which 65

enter the inner mitochondria matrix via the carnitine palmitoyl transferase (CPT) system (51). 66

There, FA-CoA is catabolized by cyclic FAO. In addition, peroxisomes metabolize very-long-67

chain FA in proximal tubule (PT) cells, as suggested by PT-restricted expression of the rate-68

limiting peroxisomal enzyme, acyl-CoA oxydase (ACOX) (55). FA can also be stored as TG 69

(Figure 1). 70

IRI results from a transient interruption of renal blood flow, leading to a switch from 71

aerobic to anaerobic metabolism (57). Ischemia rapidly induces the inhibition of FAO-72

associated enzymes in both mitochondria and peroxisomes (46), as well as the reduction of 73

CPT-1 activity (25). Changes in kidney metabolomic profiles during IRI emphasize the 74

alteration of metabolic pathways affecting glycolysis, tricaboxylic acid (TCA) cycle and lipid 75

metabolism (28, 56). Reperfusion is characterized by a sudden increase in oxygen 76

concentration, which results in an increased production of reactive oxygen species (ROS) – 77

albeit in species-associated variability (57, 62). I/R-generated ROS have (i) cell-specific and 78

(ii) concentration-dependent impact within the renal tissue, probably related to the differential 79

redox status between tubular and interstitial cells (31). Lipid peroxidation is a destructive 80

process, either directly by damaging membrane structure or indirectly by releasing toxic 81

reactive products, such as lipid aldehydes (6). 82


Mechanisms of lipid-associated injury 84

Lipotoxicity refers to “accumulation of excessive lipids in non-adipose tissues, leading 85

to cell dysfunction or death (48)”. This process has been reported in several forms of AKI, 86

especially in IRI (14, 37, 53, 63, 68). The relative contribution of lipotoxicity to the 87

multifactorial pathogenesis of IRI remains unknown (58). Accumulation of cholesterol (63, 88

67) and TG (63, 68) has been documented. TG are reported as nontoxic per se but are 89

reservoir of free FA (4, 20, 58). Furthermore, diacylglycerol (DG) and ceramide result from 90

failed esterification or breakdown of TG (58). Thus, cell overload by free FA and downstream 91

metabolites represent the main determinants of lipotoxicity (20, 58) . 92

Lipid accumulation in renal IRI is not fully understood (Figures 1 and 2). On the one 93

hand, a decrease in mitochondrial and peroxisomal FAO has been described during ischemia 94

(46) and reperfusion (21) periods. On the other hand, an increase of PL hydrolysis (56), FA 95

uptake (27, 68, 70) and lipid synthesis (27, 70) has been suggested. These cascades cause a 96

mismatch between FA availability versus utilization. TG accumulation may not only result 97

from alterations in TG and FA synthesis, but also from FA uptake and TG catabolism (27). 98

PL degradation during IRI arises from various processes (57), such as enhanced cytosolic, 99

mitochondrial and microsomal phospholipase A2 (PLA2) enzymatic activities (41) and [Ca2+]


alteration (60). However, total plasma membrane (PM) PL biomass appears well preserved ex 101

vivo after PT hypoxia (69).


Lipid accumulation in kidneys is either protective or toxic depending on the time 103

course of IRI and, therefore, the duration and extent of lipid overload (63). Initially, 104

cholesterol and TG accumulation may be considered as protective in stabilizing PM and 105

buffering free FA (34, 64, 66, 68). In an murine model of renal IRI, ischemia acutely results 106

in a 3- to 4-fold increment in renal cortex [cholesterol ester], which lasted for up to 2h post 107

reperfusion and which is mostly due to an increased flux of free cholesterol to the 108

endoplasmic reticulum (67). However, profound and sustained adenosine triphosphate (ATP) 109

depletion hampers the esterification of free FA to TG (57). TG progressively accumulate in 110

the renal cortex after ischemia. TG levels are already significantly increased at 1 day post 111

ischemia, with a peak at 1 week and a 3-week plateau (63). Such an ongoing accumulation of 112

lipids may partially contribute to the evolution from AKI to CKD after IRI (29, 51, 63). 113

Additionally, metabolomics have reported elevated levels of glycerol at early IRI time-points, 114

suggesting TG lipolysis as a source of free FA (56). Hence, when cell capacity for TG storage 115

is overpassed or in case of TG hydrolysis (48), lipid-induced cell dysfunction or death could 116

theoretically occur through multiple pathways (48): (i) protein acylation, (ii) opening of the 117


mitochondrial permeability transition pore (3, 11, 43) and altered mitochondrial energy 118

coupling (11, 43); (iii) membrane damage (37), (iv) release of proinflammatory/ proapoptotic 119

factors and activation of apoptotic pathways; (v) ferroptosis (1, 33, 39); and (vi) increased 120

cellular oxidative (23, 26, 49) and reticulum endoplasmic (RE) stresses (30). Particularly, the 121

cell death process called ferroptosis is associated with lipid peroxidation and is characterized 122

by the loss of activity of glutathione peroxidase 4 (Gpx4), a key enzyme in the repair of PM 123

(13). The functional loss of Gpx4 results in an iron-dependent lethal accumulation of lipid 124

hydro-peroxides (1). Lipid metabolism is closely related to cell sensitivity to ferroptosis since 125

the accumulation of polyunsaturated FA influences the extent of lipid peroxidation and, in 126

turn, ferroptosis (54). In addition, high levels of free FA may result in their auto-oxidation to 127

lipid peroxides, secondary to the overwhelming of RE metabolism capacity (46). The level of 128

lipid peroxides has been reported 250% higher in ischemic versus control kidneys in a rat 129

model of IRI (46). Moreover, FA accumulation is observed in persistently impaired ATP 130

production by mitochondria (3, 10, 12, 59). Non-esterified fatty acids (NEFA) may function 131

as protonophoric uncouplers of oxidative phosphorylation, as well as openers of the 132

mitochondrial permeability transition pore (10, 61). A decrease in mitochondrial membrane 133

potential and an abrogation of mitochondrial proton gradient are both involved in NEFA-134

induced protonophoric mitochondrial uncoupling (9, 10, 12). Finally, PLA2 also plays a key


role in ATP recovery following renal IRI. In an in vitro model using PT segments exposed to 136

hypoxia/reoxygenation, exposure to exogenous PLA2 lowered ATP concentration and


ATP/ADP ratio by 40 and 70%, respectively. This effect was most likely due to the release of 138

arachidonic acid from cell membranes (65). 139


Strategies to prevent lipid-associated injury in renal ischemia/reperfusion 141

The general approaches for the prevention or treatment of lipotoxicity include 142

measures that (i) decrease the global lipid content in target tissues by increasing lipid 143

catabolism and/or lipid excretion; (ii) transfer lipids towards adipose tissue; and (iii) target 144

critical pathways of FA-induced cell death (48) (Figure 2). 145

Agonists of peroxisome proliferator-activated receptor α (PPARα) have been widely 146

investigated in renal IRI. PPARα are ligand-activated transcription factors that belong to the 147

nuclear hormone receptor superfamily, of which target genes are involved in lipid metabolism 148

(18). In renal IRI, PPAR expression decreases (52). In preclinical studies, PPARα agonists, 149

like fibrates, are nephroprotective (8, 32, 44, 52). They help maintain FAO with FA as major 150

source of energy production, as well as prevent lipid accumulation and peroxidation (36). In 151


rats, administration of PPARα activators 5 days prior to renal I/R improved renal function, in 152

association with an increased mRNA and protein levels of ACOX and cytochrome P4A1 (45). 153

In a model of renal IRI in KAP2-PPARα transgenic mice, testosterone-induced up-regulation 154

of PPARα protected kidney function and morphology, notably via reduced formation of lipid 155

peroxidation products (32). Recently, polyacetylene glycoside has been reported to increase 156

both CPT-1 and PPARα expression in hypoxic tubular epithelial cells and mouse ischemic 157

kidneys, thereby leading to FAO enhancement and reduced lipotoxicity (70). Nevertheless, 158

the putative nephroprotection of fibrate-induced PPARα modulation in the clinical settings of 159

renal IRI remains unproven. 160

Another promising candidate concerns propinoyl-L-carnitine (7, 16, 24), a short-chain 161

acyl derivative of L-carnitine, which may (i) help restore tissue carnitine, the essential 162

cofactor for free FA uptake into mitochondrial matrix, and (ii) replenish mitochondrial TCA 163

intermediates (38). In an ex vivo rat model of IRI, ischemic preconditioning with propionyl-L-164

carnitine attenuated renal damage. Moreover, this compounds prevented delayed graft 165

function in a syngeneic rat model of kidney transplantation (38). Interestingly, in addition to 166

attenuated oxidative stress and improved energy metabolism, pretreatment with L-carnitine 167

significantly decreased the hydrolysate products of PL, including lysophosphatidylcholine and 168

free FA. These observations suggest a decreased activity of PLA2 (35). Similarly, the


upregulation of CPT-1 activity by C75 compound alleviated renal IRI in rats (25). 170

Other pharmacological interventions aiming at reducing the generation or effects of 171

ROS may block signaling pathways contributing to lipid-associated injury (40). These may 172

include (i) antioxidant enzymes, such as superoxide dismutase and catalase, (ii) ROS 173

scavengers, such as tempol (5), (iii) agents preventing ROS production, such as 174

desferrioxamine (17), and (iv) agents inhibiting ROS-generating enzymes, such as 175

allopurinol against xanthine oxidase (5). Despite extensive preclinical research in the field of 176

lipid peroxidation, most of the potential benefits have not yet been translated into clinical 177

practice. 178

Anti-ferroptosis compounds may also represent a pharmacological strategy for 179

ischemic conditioning (13). In a necroptosis-insenstitive murine model, the inhibition of 180

ferroptosis by the ferrostatin derivative 16-86 resulted in reduced levels of acyl-CoA 181

synthetase long-chain family member 4, a key enzyme of FA metabolism. Still, no benefit 182

was observed in IRI severity (39). Conversely, Linkermann et al. showed that the 183

administration of ferrostatin attenuated renal IRI in mice (33). Alpha-tocopherol and 184

desferoxamine have also been successfully tested in a murine model of IRI (2, 42). 185


Finally, several compounds have been studied against renal lipotoxicity, with no focus 186

on renal IRI (48), or in ischemic conditioning, with no focus on energy/lipid modulation. 187

Among them, pharmacological activators of AMP-activated protein kinase (AMPK) are of 188

particular interest in ischemic conditioning (50). AMPK is an energy sensor of which 189

downstream targets include the phosphorylative inhibition of acetyl-CoA carboxylase (ACC). 190

ACC is one of the central enzymes involved in FA homeostasis. ACC-induced carboxylation 191

of acetyl-CoA leads to the production of malonyl-CoA, a substrate for FA synthesis but also a 192

potent inhibitor of CPT-1 (24). One preclinical study reports a slight effect of AMPK-193

associated recovery of CPT-1 activity, with no effect on malondialdehyde levels (24). 194


Conclusion and perspectives 196

A better understanding of renal metabolism may help determine if and how lipid 197

modulation can be pharmacologically targeted to develop new approaches against IRI. 198

Combined therapies are most probably required to achieve an efficient renal conditioning. 199

Several compounds attenuating lipid-associated injury have been tested in preclinical models 200

of renal IRI, with promising observations. Still, well-designed prospective randomized 201

controlled clinical trials are needed to assess their translational relevance. 202


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stage” kidney disease. AJP Ren Physiol 301: F1334–F1345, 2011. 381

64. Zager RA, Burkhart KM, Johnson ACM, Sacks BM. Increased proximal tubular 382

cholesterol content: Implications for cell injury and “acquired cytoresistance.” Kidney 383

Int 56: 1788–1797, 1999.


65. Zager RA, Conrad DS, Burkhart K. Phospholipase A2: a potentially important 385

determinant of adenosine triphosphate levels during hypoxic-reoxygenation tubular 386

injury. J Am Soc Nephrol 7: 2327–2339, 1996. 387

66. Zager RA, Johnson A, Anderson K. Plasma membrane cholesterol: A critical 388

determinant of cellular energetics and tubular resistance to attack. Kidney Int 58: 193– 389

205, 2000. 390

67. Zager RA, Johnson A, Anderson K, Wright S. Cholesterol ester accumulation: An 391

immediate consequence of acute in vivo ischemic renal injury. Kidney Int 59: 1750– 392

1761, 2001. 393

68. Zager RA, Johnson ACM, Hanson SY. Renal tubular triglyercide accumulation 394

following endotoxic, toxic, and ischemic injury. Kidney Int 67: 111–121, 2005. 395

69. Zager RA, Sacks BM, Burkhart KM, Williams AC. Plasma membrane phospholipid 396

integrity and orientation during hypoxic and toxic proximal tubular attack. Kidney Int 397

56: 104–117, 1999. 398

70. Zhou Y, Du D, Liu S, Zhao M, Yuan Y, Li L, Chen Y, Lu Y, Cheng J, Liu J. 399

Polyacetylene glycoside attenuates ischemic kidney injury by co-inhibiting 400

inflammation, mitochondria dysfunction and lipotoxicity. Life Sci 204: 55–64, 2018. 401


403 404


Legends of the Figures 405


Figure 1. Schematic overview of lipid metabolism in renal tubular cell 407

The normal physiology is depicted in blue and detailed in text. Briefly, processes contributing 408

to fatty acid (FA) pool include: (i) extracellular uptake, (ii) in situ cytosolic synthesis or (iii) 409

release from intracellular processes. FA can be converted to fatty acyl-CoA (FA-CoA), which 410

enters the inner mitochondria matrix via the carnitine palmitoyl transferase (CPT) system. 411

There, FA-CoA is catabolized by cyclic FA oxidation (FAO). Peroxisomes metabolize very 412

long-chain FA. FA can also be stored into TG. AMPK is an energy sensor, with downstream 413

targets including the acetyl-CoA carboxylase (ACC). PPARα are ligand-activated 414

transcription factors of various genes involved in lipid metabolism. 415

(↓) or (↑) represent metabolism modulations caused by renal ischemia/reperfusion (I/R). 416

Decreased delivery of oxygen results in the lowering of the intracellular pH (due to 417

accumulation of lactic acid) and the [ATP] levels. I/R causes (i) a decrease of FAO with a 418

decline in CPT- activity 1 and the inhibition of FAO-associated enzymes in both 419

mitochondria and peroxisomes; and (ii) a downregulation of PPARα. Increased PLA2 activity 420

and FA uptake have been reported. Under circumstances of a mild ATP reduction (*), an 421

increased synthesis of lipids may also contribute to lipid accumulation (27). Of note, the I/R-422

associated metabolic changes sequentially occur during I/R. 423

ACC; acetyl-CoA carboxylase, ACOX, acyl coA oxidase; AMPK, AMP-activated protein


kinase ; ATP, adenosine triphosphate; CAT, carnitine translocase ; CPT; carnitine palmitoyl


transferase; DGAT, diglyceride acyltransferase; VLCFA, very long chain fatty acid; PLA2, 426

phospholipase A2; PPAR α, peroxisome proliferator-activated receptor α. Broken lines 427

indicate multi-step processes.

428 429

Figure 2. Lipid-associated injury in renal ischemia/reperfusion, and potential 430

pharmacological approaches 431

Renal ischemia/reperfusion (I/R) causes a mismatch between FA availability versus 432

utilization, leading to lipid accumulation. Lipid-induced cell dysfunction/death involve 433

multiple pathways (48): (i) protein acylation, (ii) opening of the mitochondrial permeability 434

transition pore (3, 11, 43) and altered mitochondrial energy coupling (11, 43); (iii) membrane 435

damage (37), (iv) release of proinflammatory/ proapoptotic factors and activation of apoptotic 436

pathways; (v) ferroptosis (1, 33, 39) and (vi) increased cellular oxidative (23, 26, 49) and 437

reticulum endoplasmic (RE) stresses (30). The panels represent strategies evaluated in 438


preclinical models to limit lipid-associated I/R injury. 439

AMPK, AMP-activated protein kinase ; CPT; carnitine palmitoyl transferase; FA, fatty acid;


PPAR α, peroxisome proliferator-activated receptor α.



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