EDITORIALS www.jasn.
org
et al.14 are closely in line with previously published work from
the same group and are supported by other works on IRI.12,13
Clearly, it is important to consider what relevance this study
may hold for human health. The US experimental strategy
carried out by Gigliotti et al.14 in the mice is readily feasible in
human subjects and does not involve the use of a pharmaco-
logical agent. Indeed, many cholinergic pharmacological ago-
nists exhibit a narrow therapeutic index, limiting their clinical
use. Importantly, the noninvasive US regimen relies on US
settings within approved Food and Drug Administration
guidelines. Opportunities arising from the work by Gigliotti
et al.14 are numerous and promising, because many proce-
dures that carry a very high risk of AKI, such as cardiac surgery
with cardiopulmonary bypass, iodinated contrast intravenous
injection, or renal conditioning, are planned before transplan-
tation. In renal transplantation, enhanced IRI significantly
contributes to delayed graft function, which affects the future
of the transplanted organ.15 Moreover, brain death is associ-
ated with the termination of the CAP, which significantly con-
tributes to premortem systemic inflammation and worsening
of IRI in potential transplanted end organs.16 Other nonrenal
diseases could be modulated through CAP stimulation (e.g.,
myocardial ischemia, hepatic injury, sepsis, and endotoxemia),
significantly expanding the potential range of application of this
method. Finally, in searching for novel approaches to prevent
and even cure AKI, we believe that splenic US stimulation has a
bright future ahead.
DISCLOSURES
None.
REFERENCES
1. Kellum JA, Lameire N: KDIGO clinical practice guideline for acute kidney
injury. Available at: http://www.kdigo.org/clinical_practice_guidelines/
pdf/KDIGO%20AKI%20Guideline.pdf. Accessed June 1, 2013
2. Lewington AJ, Cerdá J, Mehta RL: Raising awareness of acute kidney
injury: A global perspective of a silent killer [published online ahead of
print May 1, 2013]. Kidney Int 10.1038/ki.2013.153
3. Eltzschig HK, Eckle T: Ischemia and reperfusion—from mechanism to
translation. Nat Med 17: 1391–1401, 2011
4. Andersson U, Tracey KJ: Neural reflexes in inflammation and immunity.
J Exp Med 209: 1057–1068, 2012
5. Rosas-Ballina M, Olofsson PS, Ochani M, Valdés-Ferrer SI, Levine YA,
Reardon C, Tusche MW, Pavlov VA, Andersson U, Chavan S, Mak TW,
Tracey KJ: Acetylcholine-synthesizing T cells relay neural signals in a
vagus nerve circuit. Science 334: 98–101, 2011
6. Li T, Zuo X, Zhou Y, Wang Y, Zhuang H, Zhang L, Zhang H, Xiao X: The
vagus nerve and nicotinic receptors involve inhibition of HMGB1 re-
lease and early pro-inflammatory cytokines function in collagen-induced
arthritis. J Clin Immunol 30: 213–220, 2010
7. de Jonge WJ, van der Zanden EP, The FO, Bijlsma MF, van Westerloo
DJ, Bennink RJ, Berthoud HR, Uematsu S, Akira S, van den Wijngaard
RM, Boeckxstaens GE: Stimulation of the vagus nerve attenuates
macrophage activation by activating the Jak2-STAT3 signaling path-
way. Nat Immunol 6: 844–851, 2005
8. Borovikova LV, Ivanova S, Zhang M, Yang H, Botchkina GI, Watkins LR,
Wang H, Abumrad N, Eaton JW, Tracey KJ: Vagus nerve stimulation
1342 Journal of the American Society of Nephrology
attenuates the systemic inflammatory response to endotoxin. Nature
405: 458–462, 2000
9. Wang H, Yu M, Ochani M, Amella CA, Tanovic M, Susarla S, Li JH, Wang
H, Yang H, Ulloa L, Al-Abed Y, Czura CJ, Tracey KJ: Nicotinic acetyl-
choline receptor alpha7 subunit is an essential regulator of inflammation.
Nature 421: 384–388, 2003
10. Wang H, Liao H, Ochani M, Justiniani M, Lin X, Yang L, Al-Abed Y,
Wang H, Metz C, Miller EJ, Tracey KJ, Ulloa L: Cholinergic agonists
inhibit HMGB1 release and improve survival in experimental sepsis.
Nat Med 10: 1216–1221, 2004
11. Chatterjee PK, Yeboah MM, Dowling O, Xue X, Powell SR, Al-Abed Y,
Metz CN: Nicotinic acetylcholine receptor agonists attenuate septic
acute kidney injury in mice by suppressing inflammation and protea-
some activity. PLoS One 7: e35361, 2012
12. Sadis C, Teske G, Stokman G, Kubjak C, Claessen N, Moore F, Loi P,
Diallo B, Barvais L, Goldman M, Florquin S, Le Moine A: Nicotine
protects kidney from renal ischemia/reperfusion injury through the
cholinergic anti-inflammatory pathway. PLoS One 2: e469, 2007
13. Yeboah MM, Xue X, Duan B, Ochani M, Tracey KJ, Susin M, Metz CN:
Cholinergic agonists attenuate renal ischemia-reperfusion injury in rats.
Kidney Int 74: 62–69, 2008
14. Gigliotti JC, Huang L, Ye H, Bajwa A, Chattrabhuti K, Lee S, Klibanov
AL, Kalantari K, Rosin DL, Okusa MD: Ultrasound prevents renal
ischemia-reperfusion injury by stimulating the splenic cholinergic anti-
inflammatory pathway. J Am Soc Nephrol 24: 1451–1460, 2013
15. Joosten SA, Sijpkens YW, van Kooten C, Paul LC: Chronic renal allograft
rejection: Pathophysiologic considerations. Kidney Int 68: 1–13, 2005
16. Hoeger S, Yard BA: Brain death-induced inflammation: Possible role of
the cholinergic anti-inflammatory pathway. In: The Brain-Dead Organ
Donor: Pathophysiology and Management, edited by Novitzky D, Cooper
DKC, New York, Springer Science, Business Media, 2013, pp 131–138
See related article, “Ultrasound Prevents Renal Ischemia-Reperfusion Injury by
Stimulating the Splenic Cholinergic Anti-Inflammatory Pathway,” on pages
1451–1460.
Galectin-3 and New-Onset CKD:
Marker or Mediator?
Pietro Ravani*†‡ and Brendan J. Barrett§
Departments of *Medicine and †Community Health Sciences,
University of Calgary, Calgary, Alberta, Canada; ‡Libin Cardiovascular
Institute of Alberta, University of Calgary, Calgary, Alberta, Canada;
and §Department of Medicine, Memorial University of Newfoundland,
Newfoundland, Canada
J Am Soc Nephrol 24: 1342–1344, 2013.
doi: 10.1681/ASN.2013050552
In the last 2 decades, the number of PubMed citations including
the term biomarker or marker has increased exponentially by
8.6% additional citations per year, from 9863 citations in 1992
Published online ahead of print. Publication date available at www.jasn.org.
Correspondence: Dr. Pietro Ravani, University of Calgary, Faculty of Medicine,
Foothills Medical Centre, 1403 29th Street NW, Calgary, Alberta, T2N 2T9
Canada. Email: pravani@ucalgary.ca
Copyright © 2013 by the American Society of Nephrology
J Am Soc Nephrol 24: 1339–1346, 2013

to 55,190 in 2012. The number of citations in nephrology has
increased by 9.7% per year, from 576 in 1992 to 3931 in 2012.
These studies examined diverse biologic clues, involving changes
in blood, urine, or body tissues of the levels or expression of
small molecules, proteins, enzymes, DNA, RNA, and antibodies.
The goals varied, but included attempts to gain insight into dis-
ease mechanisms, to develop new screening, diagnostic, or
treatment strategies, to assess the efficacy of interventions,
or to identify cases more likely to respond to treatment or
with worse prognosis.
This hectic hunt for the next promising biomarker is fueled
by the need for more reliable tools to inform clinical decision
making and health policy. In fact, in several medical disciplines,
including nephrology, disease cases are identified too late to
fully benefit from interventions of proven efficacy or referral to
specialist clinics. For example, guidelines recommend early
recognition of CKD and risk assessment, because timely
implementation of some available therapies can slow disease
progression and reduce the incidence of cardiovascular com-
plications.1,2 However, people with CKD are commonly re-
ferred to nephrologists late, usually when the estimated GFR
(eGFR) is ,30 ml/min per 1.73 m2.3,4 Case classification im-
provement resulting from the inclusion of proteinuria in ad-
dition to eGFR within the new CKD classification system5
suggests that combinations (panels) of biomarkers (biomarker
“signatures”) may be more useful than single-molecule indica-
tors. However, the quest for new biomarkers may take several
years, might cost hundreds of millions of dollars, and may never
translate into helpful clinical tools.6
In this issue of the JASN, O’Seaghdha et al.7 report data on
galectin-3, a soluble b-galactoside-binding lectin highly ex-
pressed in monocytes, which plays important regulatory roles
in inflammation, immunity, and cancer,8 and may be involved
in the pathogenesis of atherosclerosis,9,10 diabetes,11 and
asthma.12 Interest in galectin-3 is justified by its profibrotic
properties. Galectin-3 has been shown to promote TGF-
b–mediated activation of fibroblasts into matrix-secreting my-
ofibroblasts in liver13 and renal tissues.14 In hypertrophied
hearts, galectin-3 is upregulated and has a stimulatory effect
on macrophage migration, fibroblast proliferation, and devel-
opment of fibrosis.8 Higher levels of galectin-3 have been
linked to reduced eGFR in cross-sectional studies,15 new-onset
heart failure in Framingham Offspring participants,16 and
mortality in subjects with heart failure.17 Because the liver pri-
marily excretes galectin-3,18 elevations of its levels before overt
kidney disease would potentially make it a useful biomarker to
identify people at risk for CKD (e.g., those with diabetes or
hypertension). O’Seaghdha et al.7 hypothesized that galectin-
3 may predict new-onset CKD and progression of CKD in the
general population, and studied the association of galectin-3
measured at examination 6 (1995–1998) in 2450 Framing-
ham Offspring participants with follow-up data at examina-
tion 8 (2005–2008). Consistent with the study hypothesis,
galectin-3 predicted rapid decline in eGFR ($3 ml/min per
1.73 m2 per year) and new-onset CKD (eGFR ,60ml/min
J Am Soc Nephrol 24: 1339–1346, 2013
www.jasn.org EDITORIALS
per 1.73 m2), but not development of albuminuria (albumin/
creatinine ratio $17 mg/g for men or $25 mg/g for women).
This study is important for several reasons. First, it is the first
relatively large longitudinal population-based study reporting
data on the relationship between galectin-3 measured at
baseline in a cohort of people with normal kidney function
and distant clinical outcomes, including objective measures of
CKD. This temporality criterion is key to identifying exposure-
disease relationships that are potentially causal in nature.
Participants were assembled using prespecified criteria and
follow-up was relatively complete. Robustness of findings in
adjusted analyses (including age) and treating galectin-3 as
either a continuous or categorical variable supports the
observed association and suggests the existence of a biologic
gradient. Second, the relationship is biologically plausible.
CKD progression is characterized by development of tubu-
lointerstitial fibrosis19 and galectin-3 is a proven profibrotic
mediator, including in renal tissues.14 On the other hand, lack
of association between galectin-3 and occurrence of albumin-
uria suggests that this biomarker predicts tubulointerstitial
fibrosis but not glomerular injury. Finally, the findings from
this epidemiologic study are coherent with those from in vitro
and animal models, and analogous to those from studies in
patients with diabetes and cardiovascular disease.
Although promising, the associations found in this study
between levels of galectin-3 and distant renal events need to be
confirmed in different populations and settings to be gener-
alizable. The relatively weak associations described (i.e., 50%
risk increase per SD of log-galectin-3 concentration and rel-
atively low measures of net reclassification improvement) do
not exclude its potential role in a panel of prognostic bio-
markers. However, they reduce its appeal as diagnostic
(screening) marker considering that very high degrees of as-
sociation (i.e., odds ratios .80) are necessary if a biomarker-
based test is to yield .90% sensitivity and specificity ([0.9/0.1]/
[0.1/0.9]581).20 More importantly, the prognostic ability of
galectin-3 needs to be confirmed in prognostic studies includ-
ing internal derivation and external validation samples and
ultimately randomized controlled trials testing the role of the
addition of this new test (or a panel including galectin-3) to
data currently used for this purpose, including history, phys-
ical examination, and assessment of albuminuria and eGFR
trajectories. The new marker or panel would then be as-
sessed in a Bayesian way for its incremental knowledge add-
ing properties. Such studies would consider whether results
are consistent across different laboratories as well as whether
physicians can correctly interpret findings and use them to
make treatment decisions.6 Finally, whether galectin-3 is a dis-
ease mediator rather simply a marker of disease can be tested
with intervention studies looking at treatments with the po-
tential to attenuate the profibrotic effects of galectin-3.21
In summary, galectin-3 may be causally involved in mech-
anisms of tubulointerstitial fibrosis and CKD progression,
and it is easily measurable and independently associated with
renal end-points. Although galectin-3 may not be used as a
Editorials 1343
 EDITORIALS www.jasn.org
diagnostic biomarker, further studies may show stronger
associations with clinical end-points (i.e., greater odds ratios
of highest versus lowest percentiles of galectin-3 levels) in peo-
ple at risk. Validation studies and clinical trials are required to
establish whether galectin-3 can be considered a useful prog-
nostic marker or a mediator of kidney fibrosis and progressive
CKD, and therefore a target of new therapies to reduce the risk
of end stage kidney failure.
DISCLOSURES
None.
REFERENCES
1. Mann JF, Gerstein HC, Pogue J, Bosch J, Yusuf S: Renal insufficiency
as a predictor of cardiovascular outcomes and the impact of ramipril:
The HOPE randomized trial. Ann Intern Med 134: 629–636, 2001
2. Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL,
Salem DN, Levey AS, Sarnak MJ: Chronic kidney disease as a risk factor
for cardiovascular disease and all-cause mortality: A pooled analysis of
community-based studies. J Am Soc Nephrol 15: 1307–1315, 2004
3. Drey N, Roderick P, Mullee M, Rogerson M: A population-based study
of the incidence and outcomes of diagnosed chronic kidney disease.
Am J Kidney Dis 42: 677–684, 2003
4. Huisman RM: The deadly risk of late referral. Nephrol Dial Transplant
19: 2175–2180, 2004
5. Tonelli M, Muntner P, Lloyd A, Manns BJ, James MT, Klarenbach S,
Quinn RR, Wiebe N, Hemmelgarn BR; Alberta Kidney Disease Network:
Using proteinuria and estimated glomerular filtration rate to classify risk
in patients with chronic kidney disease: A cohort study. Ann Intern Med
154: 12–21, 2011
6. Ioannidis JP, Panagiotou OA: Comparison of effect sizes associated
with biomarkers reported in highly cited individual articles and in sub-
sequent meta-analyses. JAMA 305: 2200–2210, 2011
7. O’Seaghdha CM, Hwang SJ, Ho JE, Vasan RS, Levy D, Fox CS: Elevated
galectin-3 precedes the development of CKD. J Am Soc Nephrol 24:
1470–1477, 2013
8. de Boer RA, Voors AA, Muntendam P, van Gilst WH, van Veldhuisen DJ:
Galectin-3: A novel mediator of heart failure development and pro-
gression. Eur J Heart Fail 11: 811–817, 2009
9. Nachtigal M, Ghaffar A, Mayer EP: Galectin-3 gene inactivation reduces
atherosclerotic lesions and adventitial inflammation in ApoE-deficient
mice. Am J Pathol 172: 247–255, 2008
10. Papaspyridonos M, McNeill E, de Bono JP, Smith A, Burnand KG,
Channon KM, Greaves DR: Galectin-3 is an amplifier of inflammation in
atherosclerotic plaque progression through macrophage activation
and monocyte chemoattraction. Arterioscler Thromb Vasc Biol 28:
433–440, 2008
11. Mensah-Brown EP, Al Rabesi Z, Shahin A, Al Shamsi M, Arsenijevic N,
Hsu DK, Liu FT, Lukic ML: Targeted disruption of the galectin-3 gene
results in decreased susceptibility to multiple low dose streptozotocin-
induced diabetes in mice. Clin Immunol 130: 83–88, 2009
12. del Pozo V, Rojo M, Rubio ML, Cortegano I, Cárdaba B, Gallardo S,
Ortega M, Civantos E, López E, Martín-Mosquero C, Peces-Barba G,
Palomino P, González-Mangado N, Lahoz C: Gene therapy with
galectin-3 inhibits bronchial obstruction and inflammation in antigen-
challenged rats through interleukin-5 gene downregulation. Am J
Respir Crit Care Med 166: 732–737, 2002
13. Henderson NC, Mackinnon AC, Farnworth SL, Poirier F, Russo FP,
Iredale JP, Haslett C, Simpson KJ, Sethi T: Galectin-3 regulates my-
ofibroblast activation and hepatic fibrosis. Proc Natl Acad Sci U S A 103:
5060–5065, 2006
1344 Journal of the American Society of Nephrology
14. Henderson NC, Mackinnon AC, Farnworth SL, Kipari T, Haslett C,
Iredale JP, Liu FT, Hughes J, Sethi T: Galectin-3 expression and se-
cretion links macrophages to the promotion of renal fibrosis. Am J
Pathol 172: 288–298, 2008
15. Tang WH, Shrestha K, Shao Z, Borowski AG, Troughton RW, Thomas
JD, Klein AL: Usefulness of plasma galectin-3 levels in systolic heart failure
to predict renal insufficiency and survival. Am J Cardiol 108: 385–390, 2011
16. Ho JE, Liu C, Lyass A, Courchesne P, Pencina MJ, Vasan RS, Larson MG,
Levy D: Galectin-3, a marker of cardiac fibrosis, predicts incident heart
failure in the community. J Am Coll Cardiol 60: 1249–1256, 2012
17. de Boer RA, Lok DJ, Jaarsma T, van der Meer P, Voors AA, Hillege HL, van
Veldhuisen DJ: Predictive value of plasma galectin-3 levels in heart failure
with reduced and preserved ejection fraction. Ann Med 43: 60–68, 2011
18. Weigert J, Neumeier M, Wanninger J, Bauer S, Farkas S, Scherer MN,
Schnitzbauer A, Schäffler A, Aslanidis C, Schölmerich J, Buechler C:
Serum galectin-3 is elevated in obesity and negatively correlates with
glycosylated hemoglobin in type 2 diabetes. J Clin Endocrinol Metab
95: 1404–1411, 2010
19. Rodríguez-Iturbe B, Johnson RJ, Herrera-Acosta J: Tubulointerstitial dam-
age and progression of renal failure. Kidney Int Suppl (99): S82–S86, 2005
20. Rigatto C, Barrett BJ: Biomarkers and surrogates in clinical studies.
Methods Mol Biol 473: 137–154, 2009
21. Glinsky VV, Raz A: Modified citrus pectin anti-metastatic properties:
One bullet, multiple targets. Carbohydr Res 344: 1788–1791, 2009
See related article, “Elevated Galectin-3 Precedes the Development of CKD,”
on pages 1470–1477.
APOL1 and Progression of
Nondiabetic Nephropathy
Nicholette D. Palmer*† and Barry I. Freedman†‡
*Department of Biochemistry,†Center for Human Genomics and
Personalized Medicine Research, and ‡Department of Internal
Medicine, Section on Nephrology, Wake Forest School of Medicine,
Winston-Salem, North Carolina
J Am Soc Nephrol 24: 1344–1346, 2013.
doi: 10.1681/ASN.2013060589
African Americans are disproportionately affected by most
common causes of nephropathy and develop ESRD at rates
approximately 3.5 times higher than those in European
Americans.1 Population ancestry-based disparities in nondia-
betic nephropathy have recently been attributed to two var-
iants in the C-terminal domain of the apolipoprotein L1
gene (APOL1) on chromosome 22—G1: rs73885319 and
rs60910145, encoding two highly correlated nonsynonymous
amino acid changes, and G2: rs71785313, a two–amino acid
deletion.2 These alleles are nearly absent in populations of
Published online ahead of print. Publication date available at www.jasn.org.
Correspondence: Dr. Barry I. Freedman, Section on Nephrology, Wake Forest
School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-
1053. Email: bfreedma@wakehealth.edu
Copyright © 2013 by the American Society of Nephrology
J Am Soc Nephrol 24: 1339–1346, 2013