The standard of care for patients with Alport syndrome (AS) is angiotensin-converting enzyme (ACE) inhibitors. In autosomal recessive Alport (ARAS) mice, ACE inhibitors double lifespan. We previously showed that deletion of Itga1 in Alport mice [double-knockout (DKO) mice] increased lifespan by 50%. This effect seemed dependent on the prevention of laminin 211-mediated podocyte injury. Here, we treated DKO mice with vehicle or ramipril starting at 4 weeks of age. Proteinuria and glomerular filtration rates were measured at 5-week intervals. Glomeruli were analyzed for laminin 211 deposition in the glomerular basement membrane (GBM) and GBM ultrastructure was analyzed using transmission electron microscopy (TEM). RNA sequencing (RNA-seq) was performed on isolated glomeruli at all time points and the results were compared with cultured podocytes overlaid (or not) with recombinant laminin 211. Glomerular filtration rate declined in ramipril-treated DKO mice between 30 and 35 weeks. Proteinuria followed these same patterns with normalization of foot process architecture in ramipril-treated DKO mice. RNA-seq revealed a decline in the expression of Foxc2, nephrin (Nphs1), and podocin (Nphs2) mRNAs, which was delayed in the ramipril-treated DKO mice. GBM accumulation of laminin 211 was delayed in ramipril-treated DKO mice, likely due to a role for alpha 1 beta 1 integrin in CDC42 activation in Alport mesangial cells, which is required for mesangial filopodial invasion of the subendothelial spaces of the glomerular capillary loops. Ramipril synergized with Itga1 knockout, tripling lifespan compared with untreated ARAS mice. (c) 2023 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Alport syndrome (AS), a type IV collagen disorder, leads to glomerular disease and, in some patients, hearing loss. AS is treated with inhibitors of the renin–angiotensin system; however, a need exists for novel therapies, especially those addressing both major pathologies. Sparsentan is a single‐molecule dual endothelin type‐A and angiotensin II type 1 receptor antagonist (DEARA) under clinical development for focal segmental glomerulosclerosis and IgA nephropathy. We report the ability of sparsentan to ameliorate both renal and inner ear pathologies in an autosomal‐recessive Alport mouse model. Sparsentan significantly delayed onset of glomerulosclerosis, interstitial fibrosis, proteinuria, and glomerular filtration rate decline. Sparsentan attenuated glomerular basement membrane defects, blunted mesangial filopodial invasion into the glomerular capillaries, increased lifespan more than losartan, and lessened changes in profibrotic/pro‐inflammatory gene pathways in both the glomerular and the renal cortical compartments. Notably, treatment with sparsentan, but not losartan, prevented accumulation of extracellular matrix in the strial capillary basement membranes in the inner ear and reduced susceptibility to hearing loss. Improvements in lifespan and in renal and strial pathology were observed even when sparsentan was initiated after development of renal pathologies. These findings suggest that sparsentan may address both renal and hearing pathologies in Alport syndrome patients. © 2023 Travere Therapeutics, Inc and The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

In Alport mice, activation of the endothelin A receptor (ETAR) in mesangial cells results in sub-endothelial invasion of glomerular capillaries by mesangial filopodia. Filopodia deposit mesangial matrix in the glomerular basement membrane (GBM), including laminin 211 which activates NF-kappa B, resulting in induction of inflammatory cytokines. Herein we show that collagen alpha 1(III) is also deposited in the GBM. Collagen alpha 1(III) localized to the mesangium in wild-type mice and was found in both the mesangium and the GBM in Alport mice. We show that collagen alpha 1(III) activates discoidin domain receptor family, member 1 (DDR1) receptors both in vitro and in vivo. To elucidate whether collagen alpha 1(III) might cause podocyte injury, cultured murine Alport podocytes were overlaid with recombinant collagen alpha 1(III), or not, for 24 h and RNA was analyzed by RNA sequencing (RNA-seq). These same cells were subjected to siRNA knockdown for integrin alpha 2 or DDR1 and the RNA was analyzed by RNA-seq. Results were validated in vivo using RNA-seq from RNA isolated from wild-type and Alport mouse glomeruli. Numerous genes associated with podocyte injury were up- or down-regulated in both Alport glomeruli and cultured podocytes treated with collagen alpha 1(III), 18 of which have been associated previously with podocyte injury or glomerulonephritis. The data indicate alpha 2 beta 1 integrin/DDR1 co-receptor signaling as the dominant regulatory mechanism. This may explain earlier studies where deletion of either DDR1 or alpha 2 beta 1 integrin in Alport mice ameliorates renal pathology. (C) 2022 Boys Town National Research Hospital. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Previous work demonstrates that the hearing loss in Alport mice is caused by defects in the stria vascularis. As the animals age, progressive thickening of strial capillary basement membranes (SCBMs) occurs associated with elevated levels of extracellular matrix expression and hypoxia-related gene and protein expression. These conditions render the animals susceptible to noise-induced hearing loss. In an effort to develop a more comprehensive understanding of how the underlying mutation in the COL4A3 gene influences homeostasis in the stria vascularis, we performed vascular permeability studies combined with RNA-seq analysis using isolated stria vascularis from 7-week old wild-type and Alport mice on the 129 Sv background. Alport SCBMs were found to be less permeable than wild-type littermates. RNA-seq and bioinformatics analysis revealed 68 genes were induced and 61 genes suppressed in the stria from Alport mice relative to wild-type using a cut-off of 2-fold. These included pathways involving transcription factors associated with the regulation of pro-inflammatory responses as well as cytokines, chemokines, and chemokine receptors that are up- or down-regulated. Canonical pathways included modulation of genes associated with glucose and glucose-1-PO4 degradation, NAD biosynthesis, histidine degradation, calcium signaling, and glutamate receptor signaling (among others). In all, the data point to the Alport stria being in an inflammatory state with disruption in numerous metabolic pathways indicative of metabolic stress, a likely cause for the susceptibility of Alport mice to noise-induced hearing loss under conditions that do not cause permanent hearing loss in age/strain-matched wild-type mice. The work lays the foundation for studies aimed at understanding the nature of strial pathology in Alport mice. The modulation of these genes under conditions of therapeutic intervention may provide important pre-clinical data to justify trials in humans afflicted with the disease.

Abstract Background and Aims In Alport syndrome (AS), endothelin type A receptor (ETAR) activation plays a role in both renal and inner ear pathologies. Currently, angiotensin converting enzyme inhibitors or angiotensin II type 1 receptor (AT1R) blockers are the standard of care for patients with AS; however, these drugs have not been shown to improve hearing. Previously, we showed that sparsentan (SP), a dual ETAR/AT1R inhibitor, prevented increases in proteinuria, fibrosis, glomerulosclerosis, and glomerular basement membrane dysmorphology. The AS mouse model lifespan was extended when SP treatment was started at 3 weeks (W) of age (pre-proteinuric). Here we compare the effect of SP and the AT1R blocker losartan (LS) on lifespan and proteinuria in AS mice treated from 4 W, and on hearing loss and associated inner ear pathology in AS mice treated from 3 W to 8.75 W. Method Wild type (WT) and AS mice were treated daily with vehicle (V), 60, 120, or 200 mg/kg SP (SP60, SP120, or SP200) by oral gavage, or 20 mg/kg LS by daily oral gavage from 3-4 W of age and in drinking water at 10 mg/kg from 4-8.75 W. Three studies were conducted: early intervention for hearing from 3-8.75 W (V, SP120, and LS, n=5) or for assessment of laminin α2, laminin α5, and collagen IVα1 expression in stria vascularis from 3-7 W (V, SP200, and LS, n=7), and for lifespan with treatment from 3 W (V, n=10) or from 4 W (LS, SP60, or SP120, n=5). Urinary protein/creatinine (UP/C) was assessed weekly during the lifespan study. In the hearing study, the auditory brainstem response (ABR) assessed hearing ability and sensitivity to noise at 8-9 W (n=5). The cochleae were preserved and transmission electron microscopy was used to assess severity of strial pathology and to measure strial capillary basement membrane (SCBM) thickness (n=5-7). Accumulation of extracellular matrix in SCBM was determined in mice treated with V, SP200, or LS by immunofluorescence microscopy using antibodies to laminin α2, laminin α5, or collagen IVα1. Results In AS mice treated with SP from 4 W, SP120 significantly (P<0.05) increased median lifespan by 34 days compared to LS-treated mice, and by 50.5 days compared to V-treated mice (Figure 1). AS mice treated with SP60 or LS initiated at 4 W did not have a significant difference in lifespan compared to V. At 8 W, SP120 but not SP60 or LS significantly (P<0.05) attenuated the increase in UP/C compared to V (UP/C mg/mg mean±SD 8 W: 47±16 V; 31±6 LS; 61±44 SP60; 20±3 SP120). Notably, development of UP/C at 11 W in AS-SP120 mice was significantly attenuated (P<0.05) compared to that in AS-LS mice (UP/C mg/mg mean±SD 11 W: 58±8 LS; 77±51 SP60; 18±10 SP120). In hearing studies, although both SP120 and LS significantly (P<0.05) prevented SCBM thickening compared to AS-V mice (mean SCBM width±SD nm: 57.8±2.1 WT-V; 67.6±5.5 AS-V; 54.7±2.4 AS-SP120; 55.0±5.9 AS-LS), post-noise ABR thresholds at 16 kHz were significantly improved only in AS-SP120 mice compared to AS-V mice (*P<0.05; Figure 2). AS-LS post-noise hearing did not differ from that of AS-V mice. Moreover, SP200 tended to ameliorate increases in expression levels of laminin α2, laminin α5, and collagen IVα1 to a greater extent than LS in the SCBM of AS mice. Finally, dysmorphology of the stria vascularis was noted in LS but not SP120-treated AS mice. Conclusion SP120 provided significant nephroprotection in AS mice when treatment was started at 4 W, significantly extending lifespan beyond that of mice treated with LS while delaying the development of proteinuria. SP120 treatment in AS mice reduced the SCBM width. Moreover, SP120 treatment significantly attenuated noise-induced hearing loss in AS mice whereas LS was without effect. These pre-clinical studies, if successfully translated to the clinic, may suggest that sparsentan offers a novel, dual-therapeutic approach in AS by reducing both renal injury and hearing loss.

In 129 Sv autosomal Alport mice, the strial capillary basement membranes (SCBMs) progressively thicken between 5 and 9 weeks of age resulting in a hypoxic microenvironment with metabolic stress and induction of pro-inflammatory cytokines and chemokines. These events occur concomitant with a drop in endocochlear potential and a susceptibility to noise-induced hearing loss under conditions that do not permanently affect age/strain-matched littermates. Here we aimed to gain an understanding of events that occur before the onset of SCBM thickening. Alport stria has normal thickness and shows levels of extracellular matrix (ECM) molecules in the SCBMs commensurate with wild-type mice. Hearing thresholds in the 3-week Alport mice do not differ from those of wild-type mice. We performed RNAseq analysis using RNA from stria vascularis isolated from 3-week Alport mice and wild type littermates. Data was processed using Ingenuity Pathway Analysis software and further distilled using manual procedures. RNAseq analysis revealed significant dysregulation of genes involved in cell adhesion, cell migration, formation of protrusions, and both actin and tubulin cytoskeletal dynamics. Overall, the data suggested changes in the cellular architecture of the stria might be apparent. To test this notion, we performed dual immunofluorescence analysis on whole mounts of the stria vascularis from these same animals stained with anti-isolectin gs-ib4 (endothelial cell marker) and anti-desmin (pericyte marker) antibodies. The results showed evidence of pericyte detachment and migration as well as the formation of membrane ruffling on pericytes in z-stacked confocal images from Alport mice compared to wild type littermates. This was confirmed by TEM analysis. Earlier work from our lab showed that endothelin A receptor blockade prevents SCBM thickening and ECM accumulation in the SCBMs. Treating cultured pericytes with endothelin-1 induced actin cytoskeletal rearrangement, increasing the ratio of filamentous to globular actin. Collectively, these findings suggest that the change in type IV collagen composition in the Alport SCBMs results in cellular insult to the pericyte compartment, activating detachment and altered cytoskeletal dynamics. These events precede SCBM thickening and hearing loss in Alport mice, and thus constitute the earliest event so far recognized in Alport strial pathology.

Lysyl oxidase like-2 (LOXL2) is an amine oxidase with both intracellular and extracellular functions. Extracellularly, LOXL2 promotes collagen and elastin crosslinking, whereas intracellularly, LOXL2 has been reported to modify histone H3, stabilize SNAIL, and reduce cell polarity. Although LOXL2 promotes liver and lung fibrosis, little is known regarding its role in renal fibrosis. Here we determine whether LOXL2 influences kidney disease in COL4A3 (-/-) Alport mice. These mice were treated with a small molecule inhibitor selective for LOXL2 or with vehicle and assessed for glomerular sclerosis and fibrosis, albuminuria, blood urea nitrogen, lifespan, pro-fibrotic gene expression and ultrastructure of the glomerular basement membrane. Laminin alpha 2 deposition in the glomerular basement membrane and mesangial filopodial invasion of the glomerular capillaries were also assessed. LOXL2 inhibition significantly reduced interstitial fibrosis and mRNA expression of MMP-2, MMP-9, TGF-b1, and TNF-alpha. LOXL2 inhibitor treatment also reduced glomerulosclerosis, expression of MMP-10, MMP-12, and MCP-1 mRNA in glomeruli, and decreased albuminuria and blood urea nitrogen. Mesangial filopodial invasion of the capillary tufts was blunted, as was laminin a2 deposition in the glomerular basement membrane, and glomerular basement membrane ultrastructure was normalized. There was no effect on lifespan. Thus, LOXL2 plays an important role in promoting both glomerular and interstitial pathogenesis associated with Alport syndrome in mice. Other etiologies of chronic kidney disease are implicated with our observations.

The cochleae from a COL4A3-deficient mouse line were examined for defects that might shed light on the molecular mechanism of otopathology observed in humans with Alport syndrome. At the light microscopic level no obvious defects were observed. Immunohistochemical analysis using antibodies specific for the basement membrane collagen chains revealed the absence of the COL4A3 and COL4A4 chains throughout the membranous labyrinth. The COL4A5 chain was absent from all cochlear basement membranes except those in the vessels of the stria vascularis. Expression of the COL4A1 and COL4A2 chains was unchanged in the mutant. Electron microscopic examination of the cochlear basement membranes revealed significant thinning of the basement membrane running from the spiral limbus, down the inner sulcus, across the basilar membrane and up to the spiral prominence. Basement membranes that normally ensheathe the root cells were not detectable. In contrast, the basement membranes surrounding the vessels of the stria vascularis were significantly thickened in the mutant. This was associated with endothelial cell swelling and a marked decrease in internal capillary diameter. In severe cases, pathology was observed in the marginal cells with a loss of basolateral infoldings. Immunohistochemical analysis of the strial vessels revealed an increase in entactin and collagen COL4A1 and COL4A2 chains. Auditory-evoked brainstem response measurements suggest a small increase in thresholds across all frequencies when successive measurements on individual mutant mice were examined between 6 and 8 postnatal weeks. Combined, these results illustrate changes in the basement membranes of the strial vessels that bear resemblance to Alport glomerular basement membrane pathology. A closer look at this compartment in human Alport biopsy specimen may be warranted.

An immunofluorescence study was performed to examine the temporal and spatial patterns of expression for the different type IV collagen chains during postnatal cochlear development. At birth, the classical chains (4A1 and 4A2) were widely expressed, while the novel chains (4A3, 4A4, and 4A5) were completely absent. Activation of the novel chains was observed at 4 days of age, with intense, widely distributed immunostaining suggesting that most of the cells in the cochlea express the novel chains at this developmental stage. From day 8 through day 14, developmental inactivation of the novel chains results in a reduction of generalized immunoreactivity with a concomitant elevation of specific staining in the membranous structures bounding the interdental cells of the spiral limbus, the inner sulcus, the basilar membrane, and in a fibrous bed of staining radiating from the spiral prominence into the region of the spiral ligament which corresponds to the location of the root cell processes. This pattern of intense immunostaining for the novel chains persists through adulthood. The classical chains are expressed in these same anatomical regions only transiently (from day 6 to day 10), after which a gradual developmental inactivation leads to the adult expression pattern where classical collagen chains are found primarily in the perineurium, in the membranes surrounding the spiral ganglion cell bodies, and in the vascular basement membranes of the spiral ligament and the stria vascularis. The complex developmental pattern of expression for the type IV collagen chains in the murine cochlea is similar to that observed in the murine kidney, which is the other major site for basement membrane pathology in Alport syndrome.

Immunohistochemistry using antibodies specific for each of the basement membrane collagen chains was used to assess the location and composition of basement membranes in the mouse cochlea. The classical chains (COL4A1, 4A2) localized primarily in the osseous spiral lamina and in the capillaries of the spiral ligament. In contrast, the novel collagen chains (4A3, 4A4, and 4A5) localized to the interdental cells of the sulcus, the inner sulcus, the basilar membrane, and the region of type II fibrocytes in the spiral ligament. Antibodies against type 4A5 collagen also heavily stained the stria vascularis. Weak staining in the stria was observed with antibodies against 4A3. Basement membrane-associated proteins were also assessed. The basement membrane in the perineurium of the osseous spiral lamina immunostained using antibodies against laminin, heparan sulfate proteoglycan, and entactin. The basilar membrane contained only fibronectin in association with the novel collagen chains. The capillaries of the spiral ligament and the stria vascularis stained heavily for heparin sulfate proteoglycan and laminin. Generalized staining for laminin was observed in the spiral ligament. These results indicate that an abundance of basement membrane collagen containing extracellular matrix exists in the murine cochlea and that the composition of these matrices are surprisingly varied and tissue specific.