Diabetes is the major cause of chronic kidney disease worldwide (1) with treatment
options focused primarily on glucose control, blood pressure, lipid lowering, and
the blockade of the renin-angiotensin system (2). However, despite intensive metabolic
control and other interventions (3), the unrelenting decline in kidney function means
that for many patients the condition progresses to overt kidney failure. This underpins
the urgent need for novel approaches to manage the ever-increasing number of patients
with diabetes and chronic kidney disease.
One approach that is attracting attention is the use of compounds to bolster the natural
cytoprotective responses of the body. The transcription factor NF-E2–related factor
2 (Nrf2), together with its negative regulator, Kelch-like ECH-associated protein
1 (Keap1), is considered one of the most important cellular defense mechanisms to
combat oxidative stress (4) with a particular role in the regulation of phase II detoxifying
enzymes (Fig. 1). In particular, NADPH quinone oxidoreductase, glutathione S-transferase,
heme oxygenase-1, and γ-glutamylcysteine synthetase are well-studied targets of Nrf2
that are upregulated through the antioxidant response element found in the promoters
of these genes (5). Therefore, the coordinated upregulation of genes coding for detoxification,
antioxidant, and anti-inflammatory regulators is seen as a potential therapeutic strategy
to protect against insults such as inflammation and oxidative stress that are known
to be enhanced by the diabetic milieu.
FIG. 1.
Upregulation of phase II detoxifying enzymes by small molecule activators involves
activation of the Nrf2-Keap1 pathway. The transcription factor Nrf2 is held in an
inactive state in the cytoplasm through its interaction with two molecules of its
inhibitory partner, Keap1. Small molecule activators such as ebselen, sulforaphane,
and bardoxolone interact with cysteine residues within Keap1 causing its dissociation
from Nrf2. Specificity of a class of activator is thought to reside in the cysteine
(cys) residue it interacts with. Unbound Nrf2 then translocates into the nucleus where
it interacts with antioxidant response elements (AREs) of more than 300 genes. Upregulation
of these phase II detoxification enzymes protects the cell against oxidative stress.
Identification of clinically relevant small molecule activators of Nrf2 is offering
promise as a new avenue for treatment against diseases such as diabetic nephropathy.
(Adapted from Jung and Kwak [17].)
It is therefore not surprising that attention has focused on identifying small molecule
activators of the Nrf2/Keap1 pathway. Many chemically diverse activators have already
been identified (6), including the glutathione peroxidase-1 mimetic ebselen (7), sulforaphane
found in cruciferous vegetables (8), caffeic acid phenethylester from the bee product
propolis (9), cinnamic aldehyde (found in cinnamon bark), and most recently, bardoxolone
methyl (10,11). Many have shown promising actions relevant to diabetes complications.
For example, activation of Nrf2 by sulforaphane is able to suppress hyperglycemia-induced
oxidative stress and metabolic dysfunction in human microvascular endothelial cells
(8). A preclinical study by Zheng et al. (12) published in this edition of Diabetes
also demonstrates the potential utility of the Nrf2 agonists, sulforaphane and cinnamic
aldehyde, for improving the metabolic profile and reducing renal injury in mice with
streptozotocin-induced diabetes. Specifically, this treatment was associated with
reduced oxidative stress and attenuated induction of the profibrotic mediator transforming
growth factor-β, the growth inhibitory protein p21, and extracellular matrix proteins
in the diabetic kidney. Importantly, sulforaphane and cinnamic aldehyde failed to
protect against renal injury in diabetic Nrf2 knockout mice, suggesting that their
renoprotective actions are specifically mediated via activation of Nrf2. Furthermore,
specifically silencing Nrf2 also increased matrix synthesis.
Rather than directly targeting Nrf2, many agonists appear to work by suppressing its
endogenous inhibitor, Keap1. Indeed, the study by Zheng et al. (12) showed that the
specific silencing of Keap1 using small interfering RNA was able to reduce the expression
of transforming growth factor-β and matrix proteins in human renal mesangial cells
under both normal and high glucose conditions. However, limited knowledge of the structural
biology of Nrf2-Keap1 means that the precise way in which small molecule agents might
interact with Keap1 is still to be fully elucidated. One common feature appears to
be their reactivity with the sulfhydryl groups of the Keap1 protein. A recent study
by Kobayashi et al. (13), using a zebrafish model of a Keap1 mutation, has shown that
certain classes of Nrf2 activators display a greater propensity to modify certain
sulfhydryl groups within Keap1. In their classification, sulforaphane and several
other Nrf2 activators modified Cys151, while the prostaglandin activators required
Cys273 for their activation. Hydrogen peroxide, on the other hand, modified multiple
cysteine residues of Keap1 (14), suggesting that the specificity of these small molecule
activators may reside in the specific modifications of Keap1 cysteine residues. It
is likely that more detailed understanding of the molecular interactions between Nrf2-Keap1
and these small molecule activators will pave the way for additional therapeutic interventions.
Beyond actions on renal fibrosis, small molecule activators of Nrf2 may also have
direct actions on renal function. In a recently published double-blind, randomized,
placebo-controlled trial using the Nrf2 activator, bardoxolone methyl (15), rapid
improvements in the estimated glomerular filtration rate have been noted in patients
with type 2 diabetes and impaired renal function (estimated glomerular filtration
rate 20–45 ml/min/1.73 m2). That these changes were observed within 4 weeks and were
largely reversible when the drug was discontinued suggests a direct hemodynamic effect
of this strategy. Given that current intervention appears to slow the decline in renal
function by less than 1 ml/min/1.73 m2 per year at best (16), sustained improvements
with bardoxolone methyl of between 5–10 ml/min/1.73 m2 potentially represent a major
advance over standard therapies. Indeed, the result of this clinical trial is encouraging,
and it is sure to lead to a flurry of both preclinical and clinic activity to identify
additional Nrf2 activators with possibly even greater efficacy, as well as a deeper
understanding of the mode of action of this novel class of compound. If similar improvements
in kidney function with other novel activators can be reproduced, the strategy of
bolstering antioxidant defenses through modulations of Nrf2 will represent a new class
of therapy with potentially major advances over conventional therapy (17).