Healing Switch Links Acute Kidney Injury to Fibrosis, Suggesting Way to Protect Kidney Function

Posted on March 7th, 2024 by Dr. Monica M. Bertagnolli

Healthy kidneys—part of the urinary tract—remove waste and help balance chemicals and fluids in the body. However, our kidneys have a limited ability to regenerate healthy tissue after sustaining injuries from conditions such as diabetes or high blood pressure. Injured kidneys are often left with a mix of healthy and scarred tissue, or fibrosis, which over time can compromise their function and lead to chronic kidney disease or complete kidney failure. More than one in seven adults in the U.S. are estimated to have chronic kidney disease, according to the Centers for Disease Control and Prevention, most without knowing it.

Now, a team of researchers led by Sanjeev Kumar at Cedars-Sinai Medical Center, Los Angeles, has identified a key molecular “switch” that determines whether injured kidney tissue will heal or develop those damaging scars.¹ Their findings, reported in the journal Science, could lead to new and less invasive ways to detect fibrosis in the kidneys. The research could also point toward a targeted therapeutic approach that might prevent or reverse scarring to protect kidney function.

In earlier studies, the research team found that a protein called Sox9 plays an important role in switching on the repair response in kidneys after acute injury.² In some cases, the researchers noticed that Sox9 remained active for a prolonged period of a month or more. They suspected this might be a sign of unresolved injury and repair.

By conducting studies using animal models of kidney damage, the researchers found that cells that turned Sox9 on and then back off healed without fibrosis. However, cells that failed to regenerate healthy kidney cells kept Sox9 on indefinitely, which in turn led to the production of fibrosis and scarring.

According to Kumar, Sox9 appears to act like a sensor, switching on after injury. Once restored to health, Sox9 switches back off. When healing doesn’t proceed optimally, Sox9 stays on, leading to scarring. Importantly, the researchers also found they could encourage kidneys to recover by forcing Sox9 to turn off a week after an injury, suggesting it may be a promising drug target.

The researchers also looked for evidence of this process in human patients who have received kidney transplants. They could see that, when transplanted kidneys took longer to start working, Sox9 was switched on. Those whose kidneys continued to produce Sox9 also had lower kidney function and more scarring compared to those who didn’t. 

The findings suggest that the dynamics observed in animal studies may be clinically relevant in people, and that treatments targeting Sox9 might promote kidneys to heal instead of scarring. The researchers say they hope that similar studies in the future will lead to greater understanding of healing and fibrosis in other organs—including the heart, lungs, and liver—with potentially important clinical implications.

References:

[1] Aggarwal S, et al. SOX9 switch links regeneration to fibrosis at the single-cell level in mammalian kidneys. Science. DOI: 10.1126/science.add6371 (2024).

[2] Kumar S, et al. Sox9 Activation Highlights a Cellular Pathway of Renal Repair in the Acutely Injured Mammalian Kidney. Cell Reports. DOI: 10.1016/j.celrep.2015.07.034 (2015).

NIH Support: National Institute of Diabetes and Digestive and Kidney Diseases