Protecting the kidney and remote organs following renal ischemia

对肾脏和其他器官的缺血性损伤是致命的，而且费用昂贵。缺血性急性肾损伤 (AKI)发生在多达三分之二的重症监护患者和五分之一的住院成人中，约有170万人 这些病人每年死亡。然而，阿基的极高死亡率不是由肾衰竭本身引起的。 流行病学和临床数据支持AKI相关的远端器官功能障碍在穷人中的关键作用。 结果和死亡率。阿基还可导致慢性肾病（CKD），CKD进展至 终末期肾病（ESRD）和肾移植失败。虽然阿基和CKD是繁重的， ESRD可能特别危险;退伍军人的死亡率（约40%）在前90天内是巨大的。 ESRD护理。阿基目前没有治疗方法;因此，有效的阿基治疗是一个重要的未满足的医疗需求。 对肾缺血的强有力的、迅速的炎症和氧化应激反应已经被很好地证实。 被其他人和我们记录下来在肾缺血后也发现了远端器官的炎症， 但受伤的肾脏和远端器官之间的“串扰”也没有得到很好的理解。漏而有福分 审查资金，我们已经证明了基于成人细胞的疗法在多种模型中的有效性。 肾衰竭考虑到相对较少的细胞的巨大益处，我们假设细胞外囊泡（EV或 外泌体），一种非病毒生物制剂，是治疗效应物。我们发现 肾EV比原始细胞更有效，减少炎症和氧化应激， 改善缺血后的肾功能，即使在建立肾衰竭后给予。其他人已经 在肾损伤模型中显示EV的益处。我们现在建议定义抗炎和抗氧化- 抗肾EV在肾脏和远端器官中的作用，并确定特异性治疗货物。 我们的长期目标是开发有效的治疗方法，以改善退伍军人的预后。 肾损伤我们在本提案中的目标是定义获益的关键介质（包括抗炎 和抗氧化分子）在肾脏和远端器官中的作用，这些器官被EV改善，并决定了 电动汽车货物中的“活性成分”。我们的中心假设是，肾EV提供了多方面的治疗， 肾缺血性损伤，增加肾脏超氧化物和过氧化氢酶和抗炎细胞因子和皮肤 血小板EV不能减少炎症，也没有保护作用。这将使我们能够确定具体的 肾EV中的有益货物。我们将采用强大的空间转录组学技术来研究 缺血时的变化和EV时的改善。此外，我们将系统和远程器官 炎症是由局部缺血而不是尿毒症引起，EV可以改善炎症。根据我们初步的 数据，我们提出以下目标，以填补知识空白的机制，肾损伤和保护： 1.为了确定不同来源的细胞外囊泡对缺血后肾功能的疗效， 炎症和氧化应激。初步数据支持肾脏EV的疗效，但不支持血小板或皮肤EV。 我们将研究提高疗效的方法（包括缺血预处理）。我们还将比较 货物和对缺血性损伤的途径之间的影响，有益的肾EV和无效的EV， 以确定基本的治疗货物组分和肾损伤的最改变的途径。 2.确定肾缺血对远端器官炎症和氧化应激的影响， EV对肾缺血后炎症和器官功能的影响。 在这项工作的结论，我们希望已经确定了关键的炎症和氧化应激 缺血性肾损伤介质，肾缺血对远端器官炎症的影响，其他 有益于缺血后的特定机制和改善炎症和肾功能的EV货物。 预计这些结果将产生重大的积极影响，因为它们将提供强有力的证据- 基于进一步开发潜在疗法以改善阿基结局的原则证据。

Ischemic injury to the kidney and other organs is deadly and expensive. Ischemic acute kidney injury (AKI) occurs in up to two thirds of intensive care patients and 1 in 5 hospitalized adults with ~1.7 million of these patients dying annually. The very high mortality in AKI, however, is NOT caused by renal failure per se. Epidemiological and clinical data support the critical role of AKI-associated distant organ dysfunction in poor outcomes and mortality in AKI. AKI also can result in chronic kidney disease (CKD), progression of CKD to end stage renal disease (ESRD) and kidney transplant failure. While AKI and CKD are onerous, the transition to ESRD can be particularly perilous; mortality rates in Veterans (~40%) are huge in the first 90 days of ESRD care. AKI has no current treatment; thus, effective AKI therapy is an important unmet medical need. The robust, prompt inflammatory and oxidative stress response to renal ischemia has been well documented by others and by us. Inflammation in remote organs has also been found after renal ischemia, but the “crosstalk” between the injured kidney and remote organs is also not well understood. With Merit Review funding, we have demonstrated the effectiveness of adult-cell based therapies in multiple models of renal failure. Given the large benefits of relatively few cells, we hypothesized that extracellular vesicles (EV or exosomes), a non-viral biologic, released from the transplanted cells were the therapeutic effector. We found that renal EV were more effective than the originating cells, decreasing inflammation and oxidative stress and improving renal function postischemia, even when given after renal failure was established. Others have shown benefit with EV in renal injury models. We now propose to define the anti-inflammatory and anti-oxid- ant effects of renal EV in the kidney and remote organs and determine the specific therapeutic cargo. Our long-term goal is the development of effective therapies to improve outcomes in Veterans with renal insults. Our objective in this proposal is defining key mediators of benefit (including anti-inflammatory and anti-oxidative molecules) in the kidney and remote organs that are improved by EV and determine the “active ingredients” in EV cargo. Our central hypotheses are that renal EV provide a multi-faceted therapy for renal ischemic injury, increasing renal superoxide and catalase and anti-inflammatory cytokines and that skin and platelet EV do not decrease inflammation and are not protective. This will allow us to define the specific beneficial cargo in renal EV. We will employ the powerful technique of spatial transcriptomics to examine the changes with ischemia and improvements with EV. Furthermore, we posit that systemic and remote organ inflammation result from ischemia and not uremia and can be improved with EV. Based on our preliminary data, we propose the following aims to fill knowledge gaps in the mechanisms of renal injury and protection: 1. To define the efficacy of extracellular vesicles from different sources on postischemic renal function, inflammation and oxidative stress. Preliminary data support efficacy of renal, but not platelet or skin EV. We will examine means (including ischemic preconditioning) to improve efficacy. We will also compare cargo and the effects on pathways of ischemic injury between beneficial renal EV and ineffective EV in order to define the essential therapeutic cargo components and most altered pathways of renal injury. 2. To determine the effect of renal ischemia on inflammation and oxidative stress in remote organs and the effect of EV on inflammation and organ function following renal ischemia. At the conclusion of this work, we expect to have defined the key inflammatory and oxidative stress mediators of ischemic renal injury, the effects of renal ischemia on inflammation in remote organs, other specific mechanisms of benefit postischemia and the EV cargo that improve inflammation and renal function. The results are expected to have a significant positive impact in that they will provide the strong evidence- based proof of principle for further development of potential therapies to improve outcomes in AKI.