Introduction
Clinical and experimental studies have provided considerable evidence for the role of the renin-angiotensin system (RAS) in the development of hypertension and progression of renal diseases [
1,
2]. It is now established that all components of the RAS are widely distributed in several tissues, including the kidney [
3,
4]. The local RAS in the kidney has several pathophysiologic functions for not only regulating blood pressure but also renal cell growth and production of glomerulosclerosis, which is involved in the development of renal fibrosis [
5‐
8]. Indeed, previous studies have shown beneficial effects of angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin II (ang II) type 1 receptor (AT1R) blocker (ARB) on various renal diseases in rats and humans, often to an extent far greater than their effect on blood pressure [
9‐
11].
IgA nephropathy (IgAN) is now recognized to be the most common form of glomerulonephritis worldwide. It has been reported that more than 30% of cases progress to end-stage renal failure within 20 years [
12,
13]. In pediatric IgAN, glomerular lesion is characterized by an increased number of mesangial cells (MC) and accumulation of mesangial extracellular matrix (ECM), and this pathological change is thought to be an early and active lesion for IgAN [
14]. It is reported that treatment with ACEi and/or ARB provides antiproteinuric and renoprotective effects in normotensive pediatric patients with IgAN, suggesting that intrarenal action of ang II may play a critical role in the progression of pediatric IgAN [
15,
16]. Recently, a real-time polymerase chain reaction (RT-PCR) study using isolated glomeruli with IgAN revealed an increased expression of RAS components such as renin, angiotensinogen (AGT), and ACE, possibly followed by the production of ang II, an effector molecule of RAS, suggesting that the glomerular RAS activation might occur under this disease setting [
17]. In this study, AGT messenger ribonucleic acid (mRNA) levels were positively correlated with the mRNA expression of renin, ACE, and a fibrogenic cytokine transforming growth factor-β (TGF-β). AGT is the sole substrate for the RAS pathway, and it has been reported that AGT is present within the kidney and ang II is produced locally, independent of the circulating RAS [
18]. Interestingly, the increased expression of intrarenal AGT is directly involved in the disease progression in several rat models of renal injury [
19‐
22]. However, little information is available about protein expression in an RAS cascade from AGT to ang II and the association between glomerular RAS activation and pathological changes in childhood IgAN.
Therefore, in this study, the glomerular protein expression of RAS components such as AGT, ACE, ang II, and AT1R, as well as their association with the index of glomerular injury were examined to clarify the role of the RAS cascade, especially that of AGT in glomerular lesions of pediatric IgAN. Subsequently, we investigated the amplification mechanism of glomerular AGT expression leading to an increase of glomerular RAS activity using cultured human glomerular endothelial cells (GEC).
Discussion
Enhanced intrarenal RAS has been implicated in the development of hypertension and the progression of chronic renal diseases, including IgAN [
1,
2,
17]. Ang II, the major effector molecule of the RAS cascade, is a key mediator of glomerular hypertension as well as glomerular sclerosis through the induction of TGF-β [
5,
6]. However, glomerular expression of RAS components and their association with local RAS activity and injury has not been extensively studied in human subjects, especially pediatric patients with IgAN.
In this study, we demonstrated for the first time that both glomerular expression of AGT protein, a sole substrate for RAS cascade, and ang II were strikingly increased with GEC and MC in nephritic glomeruli of pediatric IgAN. As it is already known that ang II is locally produced within the glomerulus and RAS is present in glomerular cell types such as GEC, MC, and podocyte [
19,
20,
34], the increased expression of ang II seen in pediatric IgAN most likely reflects enhanced glomerular RAS activation under this disease setting.
We also demonstrated that there was a positive correlation between levels of glomerular AGT, ang II, and ang II-inducible factors (TGF-β and α-SM actin) and glomerular injury (cell proliferation and ECM accumulation), suggesting that the activated glomerular RAS cascade contributes to the development and progression of glomerular injury in pediatric IgAN. There are several studies investigating glomerular gene expression of RAS components in IgAN [
17,
24,
35,
36]. Most studies have shown an increased expression of renin,
AGT, and
ACE genes and decreased expression of
AT1R gene in nephritic glomeruli of IgAN. Furthermore, it has been shown that a negative feedback loop exists between ang II and its receptor, AT1R, in glomerular cells [
36]. Therefore, if there was a proportional increase in ang II as a result of increased upstream components of RAS, a proportional deactivation of
AT1R expression in IgAN would be expected. Here, we found a significantly greater expression of glomerular AGT protein and ang II peptides and a tendency for higher ACE protein levels and lower AT1R protein levels in pediatric IgAN compared with MGA patients, indicating that the glomerular AGT level may directly regulate the ang II activity under the coordination of ACE and AT1R expression and other ang II-producible enzyme activity. Various enzymes, including cathepsin and chymase, are involved in the RAS besides renin and ACE, which are classical enzyme synthesizing ang II from AGT [
37]. Indeed, approximately 40% of the ang II found in the kidney is generated by ACE-independent pathways [
38]. In any case, local levels of renin and ACE are not related to the synthesis of angII in situations where AGT levels are very high [
18,
20,
21]. Thus, the quantity of AGT might well be the most important element for the level of ang II production. Indeed, recent experimental studies using rat models of nephropathy indicated that enhanced intrarenal AGT expression is linked to the increased level of ang II production and contributes to the development of glomerular injury [
20‐
22,
39].
We previously disclosed the mechanisms and the role of ang II-induced ECM deposition through MC [
5,
6]. Ang II stimulates ECM synthesis through he induction of TGF-β expression in cultured rat MC [
5] and affects the plasminogen activator/plasminogen activator inhibitor-1 system to result in accelerated deposition of ECM [
6], which indicates that ang II can act as a potent fibrotic molecule independent of its effects on blood pressure. Ang II can also induce MC activation (α-SM actin positive) [
39‐
42]. In addition, experimental and human studies have shown that the degree of mesangial cellularity is associated with a high sensitivity to beneficial effects of ACEi and ARB on glomerular structure and proteinuria, suggesting that the glomerular ang II level may contribute to proliferation of MC [
43]. Thus, our findings obtained here that the level of glomerular ang II is associated with the levels of TGF-β and α-SM actin expression as well as glomerular injury characterized by cell proliferation and ECM accumulation are consistent with the recent view of ang II action.
GEC damage and dysfunction are early features of many types of GN [
44,
45]. Injury to GEC induces the secretion of various mediators, such as vasoactive substances, cytokines, and growth factors critical in the regulation of glomerular capillary tone and glomerular remodeling [
19,
46‐
48]. Lee et al. demonstrated that GEC injury results in increased AGT and TGF-β mRNA by GEC and MC in the subtotal nephrectomized rat model, suggesting that activated or injured endothelial cells synthesize AGT, triggering a cascade of ang II, TGF-β, and ECM protein gene expression with resultant development of the glomerular sclerotic lesion [
19]. Here we provide in vivo data showing a striking increase of GEC-AGT and ang II in patients with IgAN as well as in vitro data indicating the potential of GEC to synthesize AGT protein and stimulatory effects of ang II on GEC-AGT expression. Taken together, it seems likely that GEC plays a crucial role in the activation of local RAS, and self-amplifying properties of ang II production in GEC are associated with the glomerular hemodynamic changes and the development of progressive glomerular injury in human GN.
In general, RAS inhibitors are commonly used by chronic IgAN patients with hypertension or those with heavy proteinuria or initial impairment of renal function. We should stress that glomerular RAS activation could occur in pediatric IgAN without heavy proteinuria, hypertension, and renal impairment. IgAN patients in this study had a short-term observation period from onset to time of renal biopsy, renal lesions, characterized with mesangial proliferative changes, low-grade interstitial fibrosis, and tubular atrophy, indicating that they were diagnosed at an early stage of IgAN [
14,
49]. Thus, considering the accumulating evidence that ang II plays a critical role in MC activation as well as glomerular hemodynamic changes and development of glomerulosclerosis, early treatment with ACEi and/or ARB in pediatric IgAN, even in the absence of hypertension and/or severe proteinuria, is reasonable for preventing progression in IgAN.
In conclusion, our study showed that activated glomerular AGT expression is likely to be involved in local RAS activation, leading to enhanced local ang II production, in pediatric IgAN with normal blood pressure and normal renal function and, thereby, may trigger a dangerous RAS cascade resulting in overproduction of TGF-β and progression of glomerular injury. Moreover, a self-amplification loop of GEC-AGT production with ang II stimulation seems to drive the further injury of nephritic glomeruli in IgAN patients. These data provide a rationale for early intervention with RAS inhibitors in pediatric IgAN patients even in the absence of hypertension and/or impairment of renal function to prevent progression of glomerular injury.