REVIEWS

ONCONEPHROLOGY

Metabolic reprogramming in clear cell

renal cell carcinoma
Hiromi I. Wettersten1, Omran Abu Aboud2, Primo N. Lara Jr3 and Robert H. Weiss2
Abstract | Research in many cancers has uncovered changes in metabolic pathways that control
tumour energetics and biosynthesis, so‑called metabolic reprogramming. Studies in clear cell
renal cell carcinoma (ccRCC) have been particularly revealing, leading to the concept that ccRCC
is a metabolic disease. ccRCC is generally accompanied by reprogramming of glucose and fatty
acid metabolism and of the tricarboxylic acid cycle. Metabolism of tryptophan, arginine and
glutamine is also reprogrammed in many ccRCCs, and these changes provide opportunities
for new therapeutic strategies, biomarkers and imaging modalities. In particular, metabolic
reprogramming facilitates the identification of novel and repurposed drugs that could potentially
be used to treat ccRCC, which when metastatic has currently limited long-term treatment
options. Further research and dissemination of these concepts to nephrologists and oncologists
will lead to clinical trials of therapeutics specifically targeted to tumour metabolism, rather than
generally toxic to all proliferating cells. Such novel agents are highly likely to be more effective
and to have far fewer adverse effects than existing drugs.

Tricarboxylic acid (TCA)

cycle
A series of chemical reactions
that comprises the oxidation
of acetyl-CoA to release stored
energy.
1
University of California,
San Diego, Sanford
Consortium for Regenerative
Medicine, Room 4810,
2880 Torrey Pines Scenic
Drive, La Jolla, California
92037–0695, USA.
2
Division of Nephrology,
University of California Davis,
Genome and Biomedical
Sciences Facility, Room 6311,
451 Health Sciences Drive,
Davis, California 95616, USA.
3
University of California Davis
Comprehensive Cancer
Center, 4501 X Street,
Suite 3003, Sacramento,
California 95817, USA.
Correspondence to R.H.W.
rhweiss@ucdavis.edu
doi:10.1038/nrneph.2017.59
Published online 8 May 2017
Cancer has historically been considered a disease of
uncontrolled cell proliferation mediated by oncogenes,
such as activating mutations in growth factor recep‑
tors1. However, since the initially puzzling observation
of enhanced glycolysis — an energetically inefficient
process — occurring in aggressive tumours despite
normoxia2, a steady stream of discoveries has linked
cancers to a variety of metabolic changes that are indi‑
rectly related to the more obvious phenotype of cell
proliferation. Several classical metabolic pathways are
increased, decreased or bypassed entirely in cancer cells
and many of these meta­bolic alterations, especially in
cancers of the kidney3,4, have now been directly linked
to oncogenic mutations5–7 (TABLE 1). This research has
led to the concept that altered metabolism, so‑called
metabolic reprogramming, is associated with a ‘success‑
ful’ kidney cancer. Such reprogramming enables rap‑
idly proliferating cancer cells to meet their basic needs
for augmented levels of cellular building components,
including DNA and membrane constituents, as well
as high levels of molecules that regulate the enhanced
tumour energetics.
Kidney cancer is one of the most studied and perhaps
the exemplar of malignancies characterized by metabolic
reprogramming8,9. Genes that are mutated in kidney
cancer are involved in a number of disparate pathways
that regulate various aspects of cellular metabolism,
such as oxygen and/or iron sensing, the tricarboxylic acid
(TCA) cycle, glutamine metabolism, and tumour energet‑
ics. Kidney cancer has, therefore, been aptly labelled a
­metabolic disease4,10,11.
The most common form of kidney cancer, clear cell
renal cell carcinoma (ccRCC) (BOX 1), is an aggressive
cancer that arises from the proximal tubular epithelium
and, in its metastatic form, is associated with high mor‑
tality12. In addition to the well-known and continually
validated Warburg effect, reductive carboxylation occurs
in many ccRCC cells13,14. This glutamine-­dependent
pathway involves ‘backwards flow’ of the TCA cycle.
Such unexpected aberrations of metabolism in ccRCC
have provided new opportunities for imaging and new
targets for therapeutic intervention. In this Review, we
discuss the advantages of metabolic reprogramming for
ccRCC cells and examine how exploitation of repro‑
grammed metabolism lends itself to novel opportu‑
nities for biomarkers, imaging and particularly new
­therapeutic paradigms.
Advantages of metabolic reprogramming
Independent of any proliferative advantage, cancer
cells with metabolic characteristics that enable them to
outcompete normal cells for the resources that support
their reprogrammed metabolism have a clear survival
advantage, and hence such properties become propa­
gated. For example, the initially puzzling increase in
glucose uptake and glycolysis that characterizes the

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Key points building components21. Although metabolic reprogram‑

• The incidence of kidney cancer, particularly clear cell renal cell carcinoma, is
increasing and knowledge of its pathophysiology is essential for nephrologists
• Reprogramming of metabolic pathways enables cancer cells to rapidly proliferate,
survive in conditions of nutrient depletion and hypoxia, and evade the immune system
• Most forms of kidney cancer are associated with reprogramming of metabolic
pathways including oxygen sensing, the tricarboxylic acid cycle and the metabolism
of tryptophan, fatty acids, glucose, glutamine and arginine
• Metabolic reprogramming provides opportunities for functional imaging approaches
based on the altered pathways
• Novel therapies for kidney cancers that target critical proteins or enzymes that are
involved in dysregulated metabolic pathways are being developed
Warburg effect might enable tumour cells to thrive in
a nutrient-depleted state, while at the same time ena‑
bling accelerated production of lipids and nucleotides
through the pentose phosphate pathway15, and providing
tumour-intrinsic antioxidant activity through a switch to
glutamine metabolism9,16,17 (FIG. 1). In addition, activa‑
tion of the hypoxia pathway armamentarium, including
neoangiogenesis, even in the absence of hypoxia, ena‑
bles cancer cells to thrive as their surroundings become
progressively more deprived of oxygen18. Such activa‑
tion is seen in the majority of ccRCCs with mutations
in VHL, which encodes the Von Hippel-Lindau disease
tumour suppressor (VHL)19. The driver of the evolution
of dependence of some ccRCCs on extracellular amino
acids, such as arginine20, is not obvious but it might
be linked to enhanced synthesis of essential cellular
ming is advantageous for tumour cells, altered metabolic
pathways can be exploited as a therapeutic strategy, for
example by limiting the supply of nutrients on which the
cells depend22 or by devising compounds that modulate
the altered pathways23,24.
Reprogrammed metabolic pathways in ccRCC
Metabolic reprogramming in ccRCC is most commonly
related to mutations in VHL, which occur in ~90% of
cases25. VHL is involved in oxygen and iron sensing
through the transcription factors hypoxia-inducible
factor 1‑α (HIF‑1α) and HIF‑2α. In VHL-mutant dis‑
ease, constitutive activation of HIF-mediated metabolic
pathways leads to the activation of pathways that coun‑
teract the effects of hypoxia in the normoxic (though
progressively hypoxic) environment of ccRCC26. In addi‑
tion, research involving genomic27, proteomic20,28 and
metabo­lomic8,9 studies has identified a profound meta‑
bolic shift in aggressive ccRCCs that involves the TCA,
pentose phosphate, and phosphoinositide 3‑kinase
(PI3K) ­pathways among others.
Tryptophan pathways
Tryptophan is an essential amino acid with three pri‑
mary downstream pathways: the serotonin, indole­
acetate and kynurenine pathways29,30. The majority of
tryptophan is catabolized through the kynurenine path‑
way via the rate-limited enzyme activity of indoleam‑
ine 2,3‑dioxygenase (IDO)31. One of the most reported
effects of tryptophan metabolism is immunosuppression

Warburg effect
The phenomenon of cells
producing energy primarily by
glycolysis followed by lactate
fermentation, rather than by
glycolysis followed by the
tricarboxylic acid (TCA) cycle
in mitochondria.
Table 1 | Selected oncogenes and tumour suppressor genes that regulate metabolism
Gene Effects on metabolic pathways Relevance to RCC Refs
PTEN Inhibition of glycolysis through inactivation of AKT • Among patients with RCC, 2.6% have biallelic 117,118
loss and 16.6% have monoallelic loss of PTEN
• Loss of PTEN is associated with high stage and
grade of RCC
TSC1/2 Deficiency leads to the Warburg effect and Mutation is a risk factor for RCC 119,120
glutamine addiction through activation of mTOR
AKT Upregulation of glycolysis through activation of • AKT mutations are rare in RCC but AKT is 121–124
enzymes including hexokinase activated owing to loss of PTEN
• AKT inhibitors are being tested in clinical trials
for RCC
VHL Inhibition of the Warburg effect through Loss‑of‑function mutations found in >90% of 25,125
deactivation of HIF patients with RCC
p53 • Downregulation of glycolysis via deactivation p53 mutations are rare in RCC 126–129
of GLUT‑1/4 and upregulation of TIGAR
• Upregulation of glutamine metabolism via
increased transcription of glutaminase 2
LKB1 Upregulation of glycolysis and β‑oxidation and LKB1 activity is compromised in RCC (in vitro, 130–132
downregulation of lipid synthesis via activation in vivo and in patients)
of AMPK
Myc • Upregulation of the Warburg effect through • Often mutated and overexpressed in RCC 133–137
activation of hexokinase, LDHA and PDK1 • Activated by HIF‑2α
• Upregulation of glutamine metabolism through • Myc overexpression induces RCC in mice
activation of glutaminase 1
• Upregulation of lipid synthesis through activation
of FAS and SCD1
APMK, AMP-activated protein kinase; FAS, fatty acid synthase; GLUT, glucose transporter; HIF, hypoxia-inducible factor; LDHA,
lactate dehydrogenase A; PDK1, pyruvate dehydrogenase kinase 1; RCC, renal cell carcinoma; SCD1, stearoyl-CoA desaturase 1;
TIGAR, p53‑inducible glycolysis and apoptosis regulator.

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Box 1 | Renal cell carcinoma Abnormalities of lipid metabolism in ccRCC were

• Diagnosed in approximately 64,000 patients in the USA annually113
• One of the relatively few malignancies with an increasing incidence114
• Five histologic subtypes exist: clear cell, papillary type 1, papillary type 2,
chromophobe and oncocytoma
• Clear cell renal cell carcinoma is the most common histologic subtype
• The disease is frequently asymptomatic115 and, in the nephrology clinic, is commonly
diagnosed incidentally during workup of acute kidney injury or haematuria4
• Associated with paraneoplastic syndromes, most of which are related to
reprogrammed metabolism
• Early immunomodulating therapies showed minimal success, but newer targeted
therapies and checkpoint inhibitors have improved survival116
as a result of tryptophan depletion32 and an increase in
immunosuppressive metabolites in the kynurenine
pathway30.
In ccRCC, the level of tryptophan is reduced, sug‑
gesting increased utilization9. Tissue levels of kynure‑
nine and quinolinate are increased in ccRCC, whereas
the ­levels of enzymes that feed the serotonin and
indoleacetate pathways, including DOPA decarboxylase,
mono­amine oxidase and aldehyde dehydrogenase 2,
are decreased, suggesting activation of the kynurenine
pathway9 (FIG. 2). Moreover, immunohistochemistry
studies have shown that levels of IDO1 are increased in
the endothelial cells of ccRCC tumour tissues compared
to those in normal kidney tissues33,34, and a non-targeted
urine metabolomics analysis showed that quinolinate
was the most increased urinary metabolite (of those
identified) in patients with ccRCC compared to healthy
individuals35. Given the immunosuppressive effects of
kynurenine and quinolinate, these studies suggest that
increased utilization of tryptophan to produce these
metabolites in ccRCC cells results in immunosuppres‑
sion that might enable enhanced tumour growth and
contribute to the low success rate of interferon‑α-based
immuno­therapies in this disease34. Despite these find‑
ings, extant studies lack definitive evidence to support
the i­ mmunosuppressive effect of tryptophan metabolism
in ccRCC.
Fatty acid oxidation and synthesis
Metabolism of fatty acids is regulated by their
­β‑oxidation and by their synthesis via fatty acid syn‑
thase (FAS) (FIG. 3). When utilized for the TCA cycle,
fatty acids are first converted into fatty acyl-CoA and
then into fatty acyl-carnitine, which is transferred into
mitochondria by carnitine palmitoyltransferase. In mito‑
chondria, fatty acyl-carnitine is converted back into
fatty acyl-CoA, which undergoes β‑oxidation to form
acetyl-coenzyme A (acetyl-CoA). This lengthy process is
regulated by various enzymes, including acyl-CoA dehy‑
drogenase, hydroxyacyl-CoA dehydrogenase and enoyl-
CoA hydratase36. Acetyl-CoA is converted back into fatty
acyl-CoA and then into fatty acids by FAS37. Fatty acids
are elongated and desaturated by stearoyl-CoA desat‑
urase (SCD1) to make unsaturated fatty acids as well
as triglycerides and phospholipids that are required for
membrane synthesis38.
reported as early as 1987 (REF. 39). A study using gas
chromatographic methods found increased cholesterol
ester storage in the tumour tissues of patients with ccRCC
compared with normal kidney tissues39. Consistent
with this finding, mRNA and protein levels of SCD1
are increased in ccRCC tissues and are required for the
growth and survival of ccRCC cells40, and increased l­ evels
of FAS correlate with tumour aggressiveness and poor
patient survival41. Furthermore, a metabolomics study
showed increased levels of long-chain fatty acids8 and a
proteomics study showed decreased levels of enzymes
involved in β‑oxidation in ccRCC tissues9,20. Together,
these findings suggest upregulation of lipid storage and
utilization of lipids for membrane synthesis in ccRCC.
Interestingly, urinary and tissue metabolomics ­studies
found increased levels of fatty acyl carnitines and carni‑
tine in samples from patients with ccRCC compared with
normal controls, and these alterations correlated
with kidney cancer grade9,42. The possibility exists that
the increase in carnitine levels is due to down­regulation
of β‑oxidation enzymes; however, precisely how acyl-­
carnitines and carnitine affect the ccRCC phenotype
and cellular activity is not yet known. Given the lack of
biomarkers for detection of ccRCC and the non-invasive
procedure of urine collection, an increase in urinary car‑
nitines could (with further validation) potentially be a
novel biomarker for ccRCC screening. Such a biomarker
would be particularly useful for patients who have risk
factors for ccRCC, such as smoking or obesity.
Glucose metabolism and HIF
In normal cells, glucose is a major source of pyruvate,
which feeds the TCA cycle for energy production under
normoxia. Under hypoxia, normal cells switch their
energy production from the TCA cycle to lactate fer‑
mentation; increased levels of HIF-1α lead to induction
of lactate dehydrogenase (LDH), which catalyses the
conversion of pyruvate to lactate43. By contrast, cancer
cells predominantly produce energy by lactic acid fer‑
mentation, regardless of the oxygen level; this change in
metabolism is known as the Warburg effect or aero­bic
glycolysis44,45. Interestingly, several studies have shown
that pluripotent stem cells have higher levels of aero‑
bic glycolysis than somatic cells46, indicating that the
Warburg effect is not unique to cancer cells but might be
a common phenomenon among undifferentiated cells.
The Warburg effect was among the first demonstra‑
tions of metabolic reprogramming in cancer but is not
universal to all malignancies. For example, lung cancer
cells do not rely on the Warburg effect, indicating the
complexity and heterogeneity of cancer metabolism47.
ccRCC does, however, seem to follow the classic Warburg
effect20,28 (FIG. 3). The levels of glucose transporter 1
(GLUT‑1) are increased in ccRCC tumours compared
to normal control tissues, suggesting increased uptake
of glucose48. Moreover, metabolomic8,9, proteomic9,20 and
transcriptomic8 studies have shown increased levels of
glycolysis metabolites and enzymes, including phos‑
phoglycerate kinase, hexokinase, pyruvate kinase 2,
and LDH‑A in ccRCC cells and tissues, suggesting

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↑ Lipid synthesis
↑ Tryptophan
metabolism Carnitine Fatty acid Cholesterol
ROS inhibition
Tryptophan
↓ β-oxidation
↑ Reductive GSH or GSSG
• Kynurenine carboxylation
• Quinolinate ↑ Glycolysis Glucose

TCA Urea
Immunosuppression Lactate Pyruvate cycle Glutamine cycle Arginine

Increased Decreased Unknown Levels increased Levels decreased Levels unknown

Figure 1 | Metabolic reprogramming in clear cell renal cell carcinoma (ccRCC). In ccRCC, aerobic glycolysis, carnitine
and lipid synthesis, reductive carboxylation, the glutathione/oxidized glutathione (GSH/GSSG) pathway, and tryptophan
Nature Reviews | Nephrology
metabolism are upregulated, whereas the urea cycle and energy production through the tricarboxylic acid (TCA) cycle is
downregulated. These changes are advantageous for ccRCC cells as they enable them to survive in conditions of nutrient
depletion and hypoxia, provide the cellular building blocks that are required for proliferation, and result in the production of
immunosuppressive (kynurenine and quinolinate) and antioxidant (GSH and GSSG) metabolites. ROS, reactive oxygen species.

Oncometabolite
A small molecule component
of normal metabolism that
on accumulation, results in
metabolic dysregulation and
consequently primes cells for
progression to malignancy.
upregu­lation of glucose utilization for lactate fermenta‑
tion, the sine qua non of the Warburg effect. On the other
hand, fructose‑1,6‑bisphosphatase 1 (FBP1), which
antagonizes glycolysis, is depleted in ccRCC tumours,
and ectopic expression of FBP1 inhibited ccRCC tumour
growth in a xenograft model49. The levels of pyruvate
carboxylase and pyruvate dehydrogenase, the enzymes
that catabolize pyruvate to feed the TCA cycle, are also
significantly decreased in ccRCC9, further suggesting
that these tumours rely on lactate fermentation.
Interestingly, the increase in GLUT‑1 expression in
ccRCC tumours correlates with a decrease in the num‑
bers of infiltrating CD8+ T cells50, suggesting an additional
mechanism by which ccRCC might suppress the immune
system. This decrease in CD8+ T cells might be the result
of increased lactate levels owing to GLUT‑1 induction as
lactate has been reported to inhibit T‑cell activity51.
As VHL loss is a common occurrence in ccRCC,
a substantial proportion of the current understanding of
this tumour type has been derived from the study of HIF
biology. HIF‑α has profound effects on tumour metabo‑
lism and is the apparent driving force behind the Warburg
effect in RCC. In VHL-deficient ccRCC, HIF-1α increases
the expression of GLUT‑1, which promotes cellular glu‑
cose uptake52. HIF-1α also transcriptionally upregulates
genes that encode enzymes involved in glycolysis, such
as hexokinase 1 and 2 and glyceraldehyde 3‑phosphate
dehydrogenase53,54. In addition, HIF-1α upregulates LDH
expression and thus promotes the conversion of pyruvate
to lactate and shifts cellular metabolism away from the
TCA cycle through the regulation of pyruvate dehydro‑
genase55,56. HIF‑1α also regulates the expression of several
microRNAs, including miR‑210 (REF. 57), which is over‑
expressed in ccRCC58,59 and has been shown to down­
regulate mitochondrial respiration60. Selected antagonists
of HIF‑2α have been developed24,61 and their therapeutic
potential in ccRCC is discussed below.
TCA cycle and the electron transport chain
In ccRCC tissues, the TCA cycle is downregulated
between succinate and malate and upregulated between
citrate and α‑ketoglutarate compared to normal kidney
tissues8,9,20,28,62 (FIG. 3). Non-targeted metabolomic ana­lyses
have shown increased levels of citrate and cis-­aconitate
in ccRCC tissue, whereas levels of fumarate and malate
are decreased8,9,20,62. The increase in levels of citrate
and cis-aconitate might be the result of upregulation of
reductive carboxylation for fatty acid synthesis. Tracing
of 13C-labelled glutamine showed utilization of glutamine
for reductive carboxylation in VHL-deficient ccRCC cell
lines and xenografts; HIF‑2α was sufficient to promote
this reductive TCA cycle and glutamine addiction63.
The decrease in levels of fumarate and malate in
ccRCC tissue is likely due to a reduction in levels of suc‑
cinate dehydrogenase8,9, which catabolizes succinate to
form fumarate. The levels of isocitrate dehydrogenase
(IDH), which makes α‑ketoglutarate from isocitrate,
were also decreased in some grades of ccRCC tissues
compared to adjacent normal tissues8,9. Gain‑of‑function
mutations in IDH1 and IDH2 result in increases in the
levels of an enantiomer of l-2‑hydroxyglutarate that is
an oncometabolite in ccRCC64.
Glutamine metabolism
Glutamine has various physiological functions, includ‑
ing as a building block for protein synthesis, as a major
source for lipid synthesis and energy production, and as
a precursor to the antioxidant molecule, glutathione65–67.
In the normal renal cortex, glutamine also regulates uri‑
nary pH by producing ammonia68. Several independent
studies have shown that glutamine utilization is increased
in ccRCC compared to normal kidney tissues8,9,63,69.
Although glutamine can be utilized in the reductive
carboxylation pathway to generate fatty acids and l-2‑­
hydroxyglutarate13,64, another function of glutamine
in ccRCC seems to be to feed the glutathione/oxidized
­glutathione pathway8,9 (FIG. 3).
Glutathione is an antioxidant that converts hydrogen
peroxide into water. Reduced glutathione is converted
to oxidized glutathione via a reaction that is regulated
by glutathione peroxidase. A combined proteomics and
metabolomics study in ccRCC showed increased levels
of metabolites in the glutamine and glutathione/oxidized
glutathione pathways, including glutamine, glutamate,

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Semi-essential amino acid glutathione, and oxidized glutathione 9. The  ­l evels
An amino acid that can only be of enzymes that inhibit use of glutamine for  the
synthesized under specific glutathione/oxidized glutathione pathway (glutathione
metabolic conditions. Also S‑transferase and γ‑glutamyl transpeptidase) were
known as a conditionally
essential amino acid.
decreased, whereas levels of glutathione peroxidase 1 were
increased, suggesting that ccRCC cells utilize glutamine in
this pathway to scavenge reactive oxygen species (ROS),
essentially acting as an intrinsic antioxidant system that
enables cell survival. Indeed, upregulation of the gluta­
mine and glutathione/oxidized glutathione pathways
correlates with high-grade, high-stage and metastasis
of ccRCC8,9. In some tumours and cancer cell lines23,70,71
including a human ccRCC cell line9,72, inhibition of gluta­
minase (which catalyses the conversion of glutamine
to glutamate) or removal of glutamine from the culture
media resulted in a decrease in cell survival in vitro, sug‑
gesting a dependence on exogenous glutamine (termed
glutamine addiction) in these malignancies.
Arginine reprogramming
The semi-essential amino acid arginine has a vital role in
multiple metabolic pathways, including protein syn‑
thesis and the production of nitric oxide, polyamines,
urea, creatine, nucleotides, proline, and glutamate73,74.
Arginine is synthesized from citrulline in two steps of the
urea cycle: citrulline and aspartate are first converted to
argininosuccinate via the enzyme argininosuccinate syn‑
thase‑1 (ASS1), and argininosuccinate is then converted
into arginine and fumarate by argininosuccinate lyase
(FIG. 4). ASS1 is the rate-limiting enzyme for the conver‑
sion of citrulline to arginine for ammonia detoxification
through the urea cycle in the liver and kidney cortex75.
Regeneration of arginine from citrulline is, therefore,
dependent on an adequate supply of active ASS1.
The loss of ASS1 or its absence during oncogenesis
makes cells dependent on extracellular sources of argi‑
nine for survival, a state known as arginine auxotrophy76.
Several studies have reported that ASS1 is not expressed
in a variety of epithelial and lymphoid tumours, and
5-hydroxy-L-tryptophan Tryptophan Tryptamine
DDC
MAOA or
Epacadostat IDO*
MAOB
DDC N-formyl-kynurenine Indole-3-acetaldehyde
ALDH2
KN QN
Serotonin Immunosuppressors Indoleacetate
Increased Decreased Unknown
Levels increased Levels decreased Levels unknown
Figure 2 | Altered tryptophan metabolism in clear cell renal cell carcinoma (ccRCC).
Nature Reviews | Nephrology
In ccRCC, upregulation of tryptophan metabolism through the kynurenine (KN) pathway
results in increased production of the immunosuppressive metabolites KN and
quinolinate (QN). This pathway can be inhibited using the indoleamine 2,3‑dioxygenase
(IDO) inhibitor epacadostat. The levels of enzymes that feed the serotonin and
indoleacetate pathways of tryptophan metabolism, including DOPA decarboxylase
(DDC), monoamine oxidase A (MAOA) or MAOB and aldehyde dehydrogenase 2
(ALDH2), are decreased in ccRCC. *Upregulated in tumour endothelial cells.
hence these cells are auxotrophic for arginine77–79.
In biopsy samples from patients with ccRCC, ASS1 was
not expressed or was downregulated in tumour cells
but was highly expressed in normal proximal tubule
cells22. This finding was confirmed in all ccRCC grades
in a proteomic study20. The reason why some tumours
become arginine auxotrophic is not well understood.
A possible explanation for the loss of ASS1 activity
in some tumours might be cellular dedifferentiation
during tumorigenesis22. Alternatively the lack of ASS1
might be a result of accumulation of aspartate, which
is directed into pyrimidine and nucleotide synthesis in
these tumours21. Consistent with this model, arginine
deprivation inhibited tumour growth in the RENCA
mouse model of RCC22. This finding suggests a new
therapeutic strategy aimed at depletion of extracellular
arginine, which is discussed below.
Functional imaging
Glucose
The current standard staging procedure for RCC
employs computed tomography (CT) scanning. The
high uptake of glucose by cancer cells (a signature of the
Warburg effect) can be visualized in vivo using positron
emission tomography (PET) imaging with the glucose
analogue 18F-fluorodeoxyglucose (18F-FDG)80. This
technique has revolutionized imaging for some malig‑
nancies81–83, but is problematic in RCC owing to variable
tumour uptake of 18F-FDG84 and its secretion into the
urinary system85, so is not commonly used for routine
staging of kidney tumours.
A meta-analysis of 158 articles published between
2004 and 2015 suggested that in RCC, 18F-FDG PET
has lower sensitivity for diagnosis of primary renal
masses but higher sensitivity for diagnosis of metasta‑
ses86 than enhanced CT. 18F-FDG PET could, therefore,
potentially be used as a noninvasive pharmacodynamic
marker for the response to novel targeted anticancer
agents in patients with advanced (metastatic) RCC. To
improve the effectiveness of 18F-FDG tracer utilization in
advanced RCC, the relationship between the molecular
features of RCC and standard uptake values obtained by
18
F-FDG PET was evaluated87–90. These studies showed
that many RCC targeted therapies disrupt transcription
of GLUT‑1 and its translocation to the plasma mem‑
brane to promote glucose utilization89. 18F-FDG PET
has also been evaluated as an indicator of prognosis and
of treatment response in patients with advanced RCC
receiving targeted therapies, such as inhibitors of PI3K,
AKT and mTOR90,91. The results suggest that ­18F-FDG
PET is a useful pharmacodynamics biomarker for
­assessing the efficacy of these therapies.
Glutamine
As many ccRCCs are glutamine avid and glutamine
reprogramming has been identified in ccRCC, this
amino acid is now being exploited for novel PET-based
imaging techniques. A series of publications suggest that
18
F-FDG negative tumours might utilize glutaminolysis
preferentially to glycolysis92–95. Concomitantly, we and
others have found that RCC is strongly glutamine avid

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Glucose

GLUT-1

• Triglycerides
Glucose Cholesterol Unsaturated FA
↑ Glycolysis • Phopholipids
Mitochondria
HK
• Elongation
SCD1
• Desaturation
G6P
Carnitine ↓ β-oxidation
GPI
Short chain FA
Fatty acyl-CoA Acylcarnitines Fatty acyl-CoA VLCAD
F6P Long chain FA
PDK1 • HADH • MCAD
• GAPDH • PGK
• PFKP • ENO • SCEH • ACAT1 Fatty acid
TVB-2640 FAS
• ALDO • PKM2 synthesis
PDH Acetyl-CoA
Acetyl-CoA Fatty acyl-CoA
Pyruvate

PC Oxaloacetate Citrate Citrate

HIF-α LDH-A
Malate Cis-aconitate
PT2385 Lactate TCA CB-839
cycle ↑ Reductive
Fumarate Isocitrate carboxylation
↑ Lactate fermentation
SDHA or IDH GLS
SDHB
Succinate α-KG α-KG Glutamate Glutamine

Increased Levels increased • GST

• GGT
Decreased Levels decreased GPX1
Unknown Levels unknown ROS inhibition GSSG GSH

Figure 3 | Altered energy and glutamine metabolism in clear cell renal cell carcinoma (ccRCC). In ccRCC, aerobic
Nature Reviews | Nephrology
glycolysis, lactate fermentation, carnitine and lipid synthesis, reductive carboxylation and the glutathione/oxidized
glutathione (GSH/GSSG) pathway are upregulated, whereas energy production through the tricarboxylic acid (TCA) cycle
is downregulated. These altered metabolic pathways provide opportunities for therapy: increased lactate fermentation
can be targeted using the hypoxia-inducible factor α (HIF‑α) inhibitor PT2385; fatty acid synthesis can be inhibited using
the fatty acid synthase (FAS) inhibitor TVB‑2640; and glutamine metabolism can be inhibited using the glutaminase (GLS)
inhibitor CB‑839. ACAT1, acetyl-CoA acetyltransferase 1; α‑KG, α‑ketoglutarate; ALDO, aldolase; ENO, enolase; FA, fatty
acid; F6P, fructose 6‑phosphate; GAPDH, glyceraldehyde 3‑phosphate dehydrogenase; GGT, γ‑glutamyl transpeptidase;
GLUT‑1, glucose transporter 1; GPI, glucose-6‑phosphate isomerase; GPX1, glutathione peroxidase; GST, glutathione
S‑transferase; G6P, glucose-6‑phosphate; HADH, hydroxyacyl-CoA dehydrogenase; HK, hexokinase; IDH, isocitrate
dehydrogenase; LDH‑A, lactate dehydrogenase A; MCAD, medium-chain specific acyl-CoA dehydrogenase; PC, pyruvate
carboxylase; PDH, pyruvate dehydrogenase; PDK1, pyruvate dehydrogenase kinase 1; PFKP, phosphofructokinase;
PGK, phosphoglycerate kinase; PKM2, pyruvate kinase 2; ROS, reactive oxygen species; SCD1, stearoyl-CoA desaturase‑1;
SCEH, short-chain enoyl-CoA hydratase; SDH, succinate dehydrogenase; VLCAD, very long-chain specific acyl-CoA
dehydrogenase.

and possibly even glutamine addicted9,17. As a result HIF pathway

of this work, the glutamine analogue 4-18F-(2S,4R)-
fluoroglutamine was developed and shown to be taken
up by cancer cells96.
PET imaging has been used to show glutamine uptake
in animal models and in patients with glioma97. Moreover,
glutamine uptake correlated with disease progression in
these patients. In ccRCC, we used PET scanning to show
glutamine uptake in vitro and in several mouse xenograft
models (O.A.A. and R.H.W, unpublished observations).
Imaging based on the glutamine reprogramming of RCC
could potentially be used for RCC staging, patient selec‑
tion, and real-time monitoring of glutaminase inhibition
as a novel therapy for this disease.
Utilization of the HIF pathway for imaging has also
been investigated, capitalizing on HIF-1α stabilization
and degradation as well as its interaction with VHL98,99.
These efforts as well as the first‑in‑kind use of glutamine
metabolic reprogramming for real-time patient imaging
sets the stage for further exploitation of reprogrammed
metabolic pathways in patient care.
Therapeutic approaches
Disruption of VHL through mutation, deletion or methy­
lation is widely recognized as the most fundamental and
critical molecular alteration in ccRCC19. This disruption
leads to deregulation of downstream oxygen-sensing

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Extracellular Mitochondria to resistance owing to the development of binding site

Ornithine Citruline mutations in HIF‑2α and second site suppressor muta‑
OCT tions in HIF‑1β. The study investigators also identi­
fied a gene signature of HIF‑2α‑driven tumours that
could potentially be used to select patients who might
Urea cycle bene­it from HIF‑2α–targeted therapy24. Clinical trials
Ornithine Citruline of the PT2399 analogue, PT2385 (an orally bioavailable
ASL inhibitors ­formulation), are ongoing in patients with ccRCC102.
Urea Aspartate
Arginase ASS1
H20 Glutaminase inhibitors
ASL
Arginine Arginine Argininoscuccinate Another promising approach is direct targeting of
enzymes involved in tumour metabolism, such as
Increased
glutaminase (FIG. 3). In ccRCC, glutaminase activity is
ADI-PEG20

Fumarate
Decreased
Unknown
• Polyamines • Nitric oxide
Levels increased
• Proline and • Nucleotides
glutamate • Urea Levels decreased
Citruline • Creatine Levels unknown
Cytosol
Figure 4 | Altered arginine metabolism in clear cell renal cell carcinoma (ccRCC).
Nature Reviews | Nephrology
Arginine is synthesized from citrulline in two steps of the urea cycle. Argininosuccinate
synthase‑1 (ASS1) and argininosuccinate lyase (ASL) regulate intracellular arginine
levels. As ASS1 levels are markedly decreased in all grades of ccRCC, the tumour cells are
dependent on extracellular sources of arginine for their survival. Extracellular arginine
can be depleted using the pegylated form of arginine deaminase enzyme (ADI‑PEG20),
which converts arginine to citruline. ASL inhibitors can also be used for targeted therapy
of ccRCC. OCT, ornithine carbamoyl transferase.
pathways, causing accumulation of HIF‑1α and sub‑
sequent upregulation of hypoxia-response genes100,
resulting in a clinical phenotype characterized by florid
vasculature principally modulated by vascular endothe‑
lial growth factor (VEGF) signalling pathways. In the
past decade, remarkable advances have been made in
ccRCC drug development, primarily focusing on tar‑
geting either VEGF receptors (VEGFR) using kinase
inhibitors or the VEGF ligand using mono­clonal anti‑
bodies. These advances led to FDA approval of several
inhibitors of VEGFR (sunitinib, pazopanib, sorafenib,
axitinib, cabozantinib and lenvantinib) and VEGF
(bevacizumab). These angiogenesis inhibitors were
only modestly effective in ccRCC, however, and often
characterized by off-target effects and chronic irrita­
tive toxicities such as fatigue and rash101. Furthermore,
the metabolic basis of ccRCC is only partly addressed
by targeting the terminal phenotype driven by VEGF.
Subsequent encouraging efforts in drug development
have attempted to exploit ccRCC metabolic reprogram‑
ming by targeting critical proteins or enzymes involved
in dysregulated metabolic pathways.
HIF‑2α antagonists
Among the most promising approaches to target meta­
bolic reprogramming in ccRCC is the development of
selective HIF‑2α antagonists24,61 such as the small mol‑
ecule inhibitor, PT2399, which was identified using a
structure-based design approach24. In preclinical stud‑
ies, PT2399 was found to dissociate the HIF‑2 hetero­
dimer (HIF-2α–HIF-1β) in ccRCC cells, resulting in
inhibition of tumour growth in the majority of cell lines
tested24. Interestingly, prolonged PT2399 treatment led
thought to restore the TCA cycle in the context of the
Warburg effect23,70. This restored pathway provides cellu‑
lar building blocks for rapidly proliferating ccRCC cells.
In a clinical trial, the small molecule inhibitor of glu‑
taminase, CB‑839, either alone or in combination with
the mTOR inhibitor everolimus, showed encouraging
clinical activity in patients with RCC; nine of 15 (60%)
evaluable patients who received twice-daily therapy
showed radiographic partial response or stable disease
at a median follow-up of 4.6 months72.
FAS inhibitors
FAS is another metabolic enzyme for which drug devel‑
opment efforts are coalescing. In RCC, FAS overexpres‑
sion is associated with tumour aggressiveness and poor
prognosis41. Interestingly, reports suggest that among
patients with metastatic RCC, those who are obese
have lower FAS expression in their tumours and this
reduction potentially contributes to an overall better
prognosis for obese patients compared to those who are
not obese103. In lung, ovarian, prostate, and pancreatic
tumour xenografts, FAS inhibition in combination with
paclitaxel or docetaxel promoted cell death, disrupted
lipid rafts in cell membranes, and abrogated key signal‑
ling pathways104. A clinical trial of the novel FAS inhibi­
tor TVB‑2640 in patients with advanced stage solid
tumours is underway105.
IDO inhibitors
Immunotherapy provides another avenue through
which inhibitors of metabolic pathways have poten‑
tial clinical applications106. Among the most clinically
advanced approaches are inhibitors of IDO, which
has a role in one of many T‑cell immune checkpoints
relevant to cancer biology. As mentioned above, IDO
serves in the rate-limiting step of tryptophan catabolism
through the kynurenine pathway. This pathway leads to
tryptophan depletion in the local tumour microenviron‑
ment, resulting in suppression of antitumour T cells34.
Inhibition of IDO prevents this immunosuppressive
effect and e­ nables T‑cell activation34.
One of the IDO inhibitors currently being tested in
RCC is the selective IDO1‑targeted inhibitor epacadostat
(FIG. 2). This orally bioavailable formulation enhances the
lytic ability of tumour-antigen-specific T cells in preclin‑
ical models107. A clinical trial combining epacadostat
with the PD‑1 inhibitor pembrolizumab is ongoing in
patients with several types of malignancies, including

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ccRCC108. Early results from a cohort of patients with
melanoma in this trial showed encouraging activity; in
those with treatment-naive advanced melanoma (n = 19)
the disease control rate was 74%, whereas the overall
Response Evaluation Criteria In Solid Tumours response
rate was 58%.
Arginine depletion
The pegylated form of arginine deaminase (ADI‑PEG20)
can be used to deplete arginine through catalytic deam‑
ination of arginine to citrulline22,109 (FIG. 4). Cells that
express normal levels of ASS1, such as normal kidney
parenchyma cells, can recycle citrulline back to arginine,
whereas cells that lack ASS1, such as ccRCC cells, are not
able produce arginine from citrulline. ADI‑PEG20 can,
therefore, exert antitumour activity by limiting arginine
availability in tumour cells without any adverse effect
on the surrounding renal parenchyma. Clinical trials of
ADI‑PEG20 are underway in hepatocellular carcinoma,
acute myeloid leukaemia, non-small cell lung cancer,
non-Hodgkin lymphoma, breast carcinoma, melanoma
and mesothelioma110. Although arginine deprivation
using ADI‑PEG20 seems to be a promising strategy
for treating ASS1‑deficient tumours such as ccRCC,
the effectiveness of this therapy could potentially be
limited by the ability of some tumours to re‑express
ASS1 (REF. 22).
Conclusions and future perspectives
Kidney cancer is a disease of aberrant cell cycle progres‑
sion that critically involves reprogramming of classical
metabolic pathways that are important for the produc‑
tion of energy and cellular components as well as for the
control of immune surveillance. For this reason, RCC can
be described as a metabolic disease, and all components
of clinical management, from imaging to pathology to
therapeutics can in theory capitalize on these repro‑
grammed pathways. Such new approaches are currently
being ­evaluated and are close to fruition.
In the future, we foresee an era in which malignancies,
including RCC, will be classified on the basis of enhance‑
ment or alteration of metabolic pathways in addition
to the site of occurrence or microscopic pathology111.
Tumour heterogeneity must be considered, however, and
is particularly relevant in RCC112. Separate regions of indi‑
vidual tumours likely have distinct metabolic reprogram‑
ming and understanding of this variation is required to
enable the development of successful treatments. Despite
this heterogeneity, therapeutics specifically targeted to
tumour metabolism, rather than toxic to all proliferating
cells, are highly likely to be more effective, and have far
fewer adverse effects than existing therapies. Metabolic
reprogramming is rapidly being translated into clinical
advances and we anticipate the development of additional
novel therapies for renal cancer in the near future.

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Author contributions
All authors researched the data for the article, made substan-
tial contributions to discussions of the content, wrote the
article and reviewed or edited the manuscript before
submission.
Competing interests statement
The authors declare no competing interests.
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