Pediatric Nephrology (2021) 36:479–489

https://doi.org/10.1007/s00467-020-04496-5

REVIEW

Renin-angiotensin system in mammalian kidney development

Ihor V. Yosypiv 1

Received: 26 December 2019 / Revised: 30 January 2020 / Accepted: 31 January 2020 / Published online: 18 February 2020
# IPNA 2020

Abstract
Mutations in the genes of the renin-angiotensin system result in congenital anomalies of the kidney and urinary tract (CAKUT),
the main cause of end-stage renal disease in children. The molecular mechanisms that cause CAKUT are unclear in most cases.
To improve the care of children with CAKUT, it is critical to determine the underlying mechanisms of CAKUT. In this review, we
discuss recent advances that have helped to better understand how disruption of the renin-angiotensin system during kidney
development contributes to CAKUT.

Keywords Kidney development . Renin-angiotensin . Prorenin receptor . Ureteric bud . Mesenchyme

Introduction Synopsis of kidney development

The renin-angiotensin system is essential for normal kid-
ney development [1–9]. Dysregulation of the renin-
angiotensin system during embryogenesis results in di-
verse forms of congenital anomalies of the kidney and
urinary tract (CAKUT) in mammals [1–9]. Mutations of
the renin-angiotensin system genes in humans are associ-
ated with renal tubular dysgenesis (RTD, OMIM 267430)
[10]. Affected patients exhibit severe hypotension, and
most children with RTD die in the perinatal period, most
likely due to pulmonary hypoplasia (a consequence of
oligohydramnios). Recent advances in the kidney and uri-
nary tract development field have expanded our under-
standing of the molecular mechanisms through which
renin-angiotensin system regulates normal kidney devel-
opment. Here, we provide a comprehensive overview of
the molecular and cellular mechanisms by which intact
renin-angiotensin system directs renal morphogenesis
and outline lineage-specific roles of how aberrations of
the renin-angiotensin system during kidney development
contribute to CAKUT.
* Ihor V. Yosypiv
iiosipi@tulane.edu
1
Section of Pediatric Nephrology, Department of Pediatrics,
Hypertension and Renal Center of Excellence, Tulane University
Health Sciences Center, 1430 Tulane Avenue, New
Orleans, LA 70112, USA
Development of the permanent (metanephric) kidney in mam-
mals begins during the fifth week of gestation in humans and
on embryonic (E) day E10.5 in mice (of a 19-day gestation)
from the outgrowth of the ureteric bud (UB) from the Wolffian
(nephric) duct (WD) which invades the surrounding group of
cells within the metanephric mesenchyme (MM) [11].
Nascent UB tips interact reciprocally with self-renewing
nephron progenitor cells (NPCs) of the MM and undergo suc-
cessive branching to form the renal collecting system, whereas
MM cells condense around UB tips and differentiate into
nephrons. Stromal mesenchyme, which surrounds the MM
and the UB, interacts with these compartments and gives rise
to different types of cells that include glomerular mesangial
cells, fibroblasts, vascular smooth muscle cells, renin cells,
pericytes, and mesenchyme surrounding the ureter [11, 12].
The urinary bladder development begins during the fifth week
of gestation in humans and at E11.5 in the developing mouse
fetus from the superior region of the urogenital sinus. UB-
derived ureters initially join the bladder indirectly, via the
portions of WD (common WDs). Later in gestation, the ure-
ters detach from the WDs and fuse with the bladder to estab-
lish urine flow. Separation of ureters from the Wolffian duct
followed by ureter-bladder fusion is achieved through spatio-
temporally regulated apoptosis of common WDs [13, 14].
Developmental defects that disrupt normal kidney or bladder
development result in a diverse array of congenital anomalies
of the kidney and urinary tract (CAKUT) which include renal
agenesis, kidney hypodysplasia, and ureter anomalies that can
cause reflux of the urine or urinary tract obstruction [11].
480
Expression, activity, and signaling
of the renin-angiotensin system during mammalian
kidney development
In the rodent kidney, angiotensinogen (ATG), the substrate for
enzyme renin which generates angiotensin I (Ang I) from
ATG, is detected in the UB, proximal tubules, and renal stro-
ma [15] (Table 1). In humans, ATG mRNA is localized in the
proximal tubule on the eighth week of pregnancy and remains
expressed thereafter [17]. Expression of renin mRNA in the
embryonic mouse kidney is detected at E14.5 in a small num-
ber of cells scattered throughout the kidney [18]. On E15.5,
renin becomes abundantly expressed in the renal arteries, as
well as in the arcuate and interlobar arteries. Later in gestation,
renin localizes in the juxtaglomerular cells [18]. Renin mRNA
is expressed in the human metanephros at the glomerular vas-
cular pole and in arteries adjacent to glomeruli on the sixth
week of gestation [17]. Aside from cleaving ATG to produce
Ang I, renin acts via the prorenin receptor (PRR (also called
ATP6AP2)) that triggers several intracellular signaling path-
ways, including p38 kinase in kidney mesangial and vascular
smooth muscle (VSMC) cells, extracellular signal-regulated
kinases 1 and 2 (Erk1/2), and phosphatidylinositol 3-kinase/
Akt (PI3K/Akt) in human embryonic kidney cells grown
in vitro [28, 29]. The PRR is a single trans-membrane domain
receptor encoded by the Atp6ap2 (ATPase-associated
protein2) gene located on the X chromosome in humans
(ATP6AP2) and rodents (Atp6Aap2) [30]. In addition to being
a receptor for renin/prorenin, PRR co-purifies with the vacu-
olar proton pump V-ATPase and is considered to be its acces-
sory protein [31]. Atp6ap2 mRNA and protein are expressed
in the mouse metanephros on E12.5 [24]. PRR immunoreac-
tivity is detected in the UB and developing nephrons on E13.5
[24]. Later during gestation (on E16.5 and E18.5), PRR is
most abundantly present in the tubules which resemble
collecting ducts (CDs) as well as in the glomerular mesangium
[24]. Kidney PRR protein expression is high during gestation
and declines gradually after birth in the mouse [24]. In the
neonatal human kidney, PRR localizes mainly in the glomer-
uli, proximal tubules, collecting ducts, and arteries [27]. PRR
expression in neonatal kidneys is correlated inversely with
gestational age and is increased in neonates compared to older
children. These data are consistent with the hypothesis that
PRR plays a role in nephrogenesis in humans.
Ang I is converted to Ang II, the major effector peptide of
the renin-angiotensin system, by angiotensin-converting en-
zyme (ACE). In the rat kidney, Ace mRNA is present on
E16 in the developing glomeruli and proximal tubule [20].
During invasion of the S-shaped bodies by capillaries, which
occurs around 20 weeks of gestation in humans, ACE immu-
nostaining is present in glomerular endothelial cells [17].
Later during gestation, at E30-E35, ACE immunoreactivity
is localized in proximal tubules and CDs [32]. Angiotensin
Pediatr Nephrol (2021) 36:479–489
II (Ang II), the major effector peptide of the renin-
angiotensin system, acts via the Agtr1 and Agtr2 receptors.
In rodent kidney, Agtr2 is detected earlier than Agtr1, peaks
early during gestation, and rapidly declines after birth [23, 33].
Unlike the Agtr2, Agtr1 levels are low in early gestation, in-
crease during gestation, peak perinatally, and decline gradual-
ly thereafter [23, 33]. On E12, AGTR1 protein expression in
the mouse kidney is low in the UB and the adjacent metaneph-
ric mesenchyme [15]. In the E14 and E15 mouse kidney,
AGTR1 immunoreactivity becomes localized on the
basolateral and luminal sides of UBs and their derivatives.
At E16, AGTR1 is detected in UB branches, glomeruli,
microvessels, stromal mesenchyme, and proximal tubules.
AGTR2 protein and mRNA are detected in the mouse embry-
onic kidney from E11.5 and are confined to the mesenchyme
adjacent to UB tips and in the UB [22]. At E14, AGTR2
immunostaining is present in the developing nephrons, med-
ullary stroma, and branching UB. On E16, AGTR2 is abun-
dantly expressed in tubules localized in the inner cortex and
look like proximal tubules [22]. In the human embryonic kid-
ney, AGTR1 and AGTR2 mRNAs are expressed on E30-E35
of gestation [17]. At this time, AGTR1 mRNA is expressed in
glomeruli and proximal tubules, whereas AGTR2 mRNA is
present in the mesenchyme [17]. Similar to temporal trends of
Agtr2 mRNA expression in rodents, AGTR2 mRNA levels
decrease after 20 weeks of gestation in humans. In contrast
to AGTR2 mRNA expression profile, AGTR1 mRNA is
expressed for the whole duration of metanephric kidney de-
velopment [17]. Immunoreactive kidney tissue Ang II con-
tents are higher in the developing rodent kidney compared to
the adult kidney (rat kidney: P1 667 ± 75, adult 103 ± 6 fmol/g
tissue; mouse kidney: E17.0 800 ± 60, P1 975 ± 136, adult
200 ± 50 pg/g tissue) [6, 34]. In summary, ATG, renin, ACE,
Agtr1, and Agtr2 are expressed during early metanephric kid-
ney development in humans and rodents, indicating a role for
kidney tissue Ang II in normal kidney organogenesis.
Lineage-specific requirement of renin-angiotensin
system signaling during murine kidney development
Studies utilizing knockout mouse models have revealed a crit-
ical role of the renin-angiotensin system during kidney devel-
opment and greatly amplified our understanding of how dis-
ruptions in the renin-angiotensin system result in CAKUT.
Genetic inactivation of the Atg, renin, Atp6ap2, Ace,
Agtr1a;Agtr1b, or Agtr2 in mice is either lethal (Atp6ap2),
indicating an essential role of the PRR in embryonic develop-
ment or leads to a spectrum of abnormalities in the develop-
ment of the metanephros [1–9] (Table 2). Complete deletion
of renin (Ren1c), Atg, Ace, or Agtr1a;Agtr1b in mice leads to
hypoplastic inner medulla and hydronephrosis that become
apparent and progress following birth. Agtr1a; Agtr1b-defi-
cient mice (lacking genes encoding both Agtr1 and Agtr2
Pediatr Nephrol (2021) 36:479–489 481

Table 1 Expression of the renin-angiotensin system components during metanephric kidney development

E12 E14 E15 E16 E19 References

ATG
Mouse UB, SM UB, SM, PT PT, UB, SM PT, UB, SM [15]
Rat UB, SM PT, UB, SM PT [16]
Human From 8 weeks and throughout gestation [17]
PT
Renin
Mouse Precursor cells M of entire M of entire M close to V, G V, G [18]
present in M/SM kidney kidney
Rat V V V [19]
Human E30-E35
At the vascular pole of the glomerulus and [17]
arteries located next to glomeruli
ACE
Rat PT, G, CD PT, G, CD [20]
Human E30-E35 until birth
PT, CD [17]
AGTR1
Mouse UB, M UB, G UB, V PT, UB, SM, G PT, DT [15, 26]
Rat G, UB, SM SM PT, CD, G [21]
Human E30-E35 until birth [17]
G, PT, JG cells
AGTR2
Mouse UB, M UB, M, SM UB, SM Inner cortical [22]
tubules
M M, under renal M between M between [23]
capsule CDs CDs
Under renal Under renal
capsule capsule
Rat M Condensed M Medulla, G, V [21]
Human E30-E35 until birth [17]
M
PRR/ATP6AP2
Mouse UB, CM, SM UB, G CDs CDs, G [24–26]
Human From E33
G, PT, CD, arteries [27]

ATG angiotensinogen, ACE angiotensin-converting enzyme, AGTR1/AGTR2 angiotensin II receptors, PRR/ATP6AP2 prorenin receptor, UB ureteric
bud, M mesenchyme, CM cap mesenchyme, SM stromal mesenchyme, PT proximal tubule, G glomeruli, V renal vessels, CD collecting duct

receptors) exhibit hypoplasia of the ureteral smooth muscle,
resulting in impaired ureteral peristalsis and increased pres-
sure within the renal pelvis [6]. Thus, small medulla and
hydronephrosis seen in Ren1c-, Atg-, Ace-, or Agtr1a;
Agtr1b-knockout mice may result from functional urinary
tract obstruction causing increased backward pressure to the
renal tissue. Given that activation of the Agtr1 by Ang II
counteracts shrinkage of the developing papillas grown
in vitro, Agtr1 signaling may also promote structural develop-
ment of the medulla by induction of medullary CD elongation
[44]. In addition, Agtr1 signaling may contribute to structural
development of the medulla by promoting vasa recta forma-
tion [45]. A total of 3.1% of Agtr2-knockout mice have duplex
renal collecting systems, vesicoureteral reflux, and
hydronephrosis [41]. The number of UB tips is decreased in
Agtr2-null compared with Agtr2+/+ mouse kidneys, indicating
that Agtr2 signaling promotes early UB branching morpho-
genesis [44]. Inductive effects of the Agtr2 on UB branching
are mediated by increased UB cell proliferation and survival
[44]. In terms of the effect of the global deletion of Ren1c-,
Atg-, Ace-, or Agtr1a; Agtr1b genes on renal function, mutant
mice have polyuria and a decreased urine concentrating ability
482
Table 2 Renin-angiotensin
system gene mutations associated Gene/model
with murine and human CAKUT
Murine models
Atg−/−
Ren1−/−
Hoxb7Cre;Renflox/flox
Foxd1Cre;Renflox/flox
Atp6ap2−/−
Hoxb7Cre;Atp6ap2flox/flox
Aqp2Cre;Atp6ap2flox/flox
V-ATPaseB1Cre;Atp6ap2flox/flox
Six2Cre;Atp6ap2flox/flo
Nphs2Cre;Atp6ap2flox/flox
Foxd1Cre;Atp6ap2flox/flox
Ace−/−
Agtr1a;Agtr1b−/−
Hoxb7Cre;Agtr1aflox/flox
Aqp2Cre;Agtr1aflox/flox
Foxd1Cre;Agtr1flox/flox
Agtr2−/−
Human CAKUT
ATG−/−
AGTR1−/−
AGTR2−/−
ACE−/−
REN−/−
Agtr1/AGTR1 angiotensin II receptor type 1, Agtr2/AGTR2 angiotensin II receptor type 2, Ace/ACE angiotensin-
converting enzyme, Aqp2 aquaporin 2, PUV posterior urethral valves, CAKUT congenital anomalies of the kidney
and urinary tract, UPJ uretero-pelvic junction, RTD renal tubular dysgenesis, Ren1 renin 1, Atg/ATG
angiotensinogen, Ang angiotensin, Atp6ap2 gene that encodes prorenin receptor (PRR), UB ureteric bud, CD
collecting duct, PC principal cell of collecting duct, IC intercalated cell of collecting duct
[3, 4, 7]. AGTR1a subtype is a murine homolog to the human
AGTR1. Complete deletion of the Agtr1a subtype in mice
results in normal renal tissue structure, low blood pressure,
polyuria, and impaired capability to concentrate the urine
[46]. Reduced ability to concentrate the urine in Agtr1a-null
mice may result from decreased expression of solute trans-
porters that are important for salt reabsorption along the
Pediatr Nephrol (2021) 36:479–489
Renal phenotype Reference
Vascular thickening, interstitial fibrosis, delayed glomerular [1, 2]
maturation, hypoplastic papilla hydronephrosis, reduced
ability to concentrate urine
Arterial wall thickening, interstitial fibrosis, [3]
glomerulosclerosis, hypoplastic papilla hydronephrosis
No structural renal phenotype [35]
Absence of renin, hypertrophic arteries, hydronephrosis
Embryonic lethal [36]
Kidney hypoplasia, thin cortex, reduced UB tip and nephron [37]
number, polyuria impaired urine-concentrating ability
No structural renal phenotype, polyuria, reduced urine [38]
osmolality
No structural renal phenotype
Reduced developing nephron volume and size, delayed [25]
nephrogenesis, small cystic kidneys, podocyte foot
process effacement
Foot process effacement, early postnatal death from kidney [8, 9]
failure, severe proteinuria
Decreased number of glomeruli, expansion of Six2+ nephron [26]
progenitors, marked decrease in arterial and arteriolar
development
Arterial wall thickening, hypoplastic papilla and medulla, [4]
hydronephrosis, reduced ability to concentrate urine
Decreased kidney weight, hypoplastic papilla and medulla, [5, 7]
hydronephrosis, delayed glomerular maturation, arterial
wall thickening, interstitial fibrosis, tubular atrophy
reduced ability to concentrate urine
No structural abnormalities, reduced Aqp2 levels and urine [39]
concentrating
ability after water deprivation
No structural or functional abnormalities [40]
Duplicated ureters, hydronephrosis, decreased UB branching [22, 41]
RTD: Reduced number of proximal tubules, short proximal [10, 42]
tubules without brush border, atrophic loops of Henle and
collecting ducts, closely packed glomeruli, marked
thickening and disorganization of interlobular and
preglomerular arteries
RTD, similar to AGT phenotype, PUV [10, 42]
UPJ obstruction, megaureter, MCDK, hydronephrosis, PUV [43]
RTD, similar to AGT phenotype, renal hypodysplasia, PUV [10, 42]
RTD, similar to AGT phenotype [10, 42]
nephron or impaired water reabsorption. In this regard, re-
duced expression of the thiazide-sensitive sodium-chloride
cotransporter and the alpha-subunit of the amiloride-
sensitive epithelial Na+ channel are observed in Agtr1a-
knockout compared with wild-type mice [47]. In addition,
Agtr1a−/− mice have reduced expression of AQP2 protein in
the inner medulla and decreased vasopressin levels in the
Pediatr Nephrol (2021) 36:479–489
circulation [48]. Thus, decreased urine concentrating ability in
Agtr1a−/− mice may be due to impaired interactions between
AGTR1a and arginine vasopressin (AVP) receptor in the inner
medulla. Targeted inactivation of the individual components
of the renin-angiotensin system in mice has allowed circum-
vention of embryonic lethality and determination of renin-
angiotensin system functions in the UB, nephrogenic, and
stromal compartments (Table 2).
UB lineage
Targeted deletion of the Ang II Agtr1a subtype A (Agtr1a−/−)
in the UB lineage in mice using Hoxb7Cre (in all UB-derived
CD cells) or aquaporin 2 (Aqp2) Aqp2Cre (in principal cells
(PC)) allows determination of the role of the AGTR1 in the
regulation of urine-concentrating ability in the absence of sys-
temic AGTR1A-mediated effects observed in mice with com-
plete inactivation of the Agtr1a. Deletion of the Agtr1a in
either all CD cells or in PC does not alter systemic blood
pressure, kidney morphology, or baseline urinary concentrat-
ing ability [39]. However, both strains of mutant mice exhibit
dampened increase in osmolality of the urine following ad-
ministration of desmopressin, a synthetic analogue of the
antidiuretic hormone arginine vasopressin, or after water dep-
rivation [39]. These changes may result from reduced expres-
sion of AQP2 in the medulla and not from changes in salt
delivery into renal tubules or altered expression of the vaso-
pressin V2 receptor mRNA in the renal medulla [39].
Activation of the AGTR1 is also reported to induce alkalini-
zation of the CD lumen in the rabbit [49, 50]. These findings
indicate that AGTR1 activation by Ang II may facilitate func-
tional maturation of CD cells that regulate acid-base and water
balance.
Renin is detected in the developing mouse CD on E15.5
[18]. Global deletion of the Ren1c gene in mice results in
hydronephrosis and inability to concentrate the urine, suggest-
ing that CD renin might be responsible for this phenotype [3].
Sequeira-Lopez et al. examined whether UB/CD renin plays a
role in the development of the CD derivatives during kidney
development [35]. Conditional Ren1c deletion in the UB/CD
lineage was achieved using Hoxb7-cre mice, which were
crossed to Ren1c flox/flox mice. However, lack of renin in the
UB/CD did not affect kidney or renal vascular morphology,
expression, and distribution of renin in the kidney. The authors
conclude that renin is dispensable in the renal collecting sys-
tem for kidney development.
As UB-derived CD is the predominant nephron site of PRR
expression, we used a cre-lox conditional targeting approach
to delete Atp6ap2 (gene that encodes PRR protein) specifical-
ly in the UB lineage using Hoxb7Cre driver and examine the
role of the UB PRR on kidney development in mice
(Hoxb7Cre+;Atp6ap2flox/flox) [37]. Knockout
Hoxb7Cre+;Atp6ap2flox/flox metanephroi have decreased UB
483
branching and increased UB cell apoptosis [37].
Hoxb7Cre+;Atp6ap2flox/flox mice have reduced expression of
genes crucial for nephrogenesis and UB branching morpho-
genesis. Genes with reduced expression include glial cell-
derived neurotrophic factor (GDNF), its receptor rearranged
during transfection (Ret), and genes known to be downstream
targets of Ret such as Wnt11, Etv4, and Etv5 (Fig. 1).
Following birth, Hoxb7Cre+;Atp6ap2flox/flox mice have small
dysplastic kidneys with thin cortex and reduced number of
nephrons. Reduced nephron endowment in this model is like-
ly due to decreased UB tip number. Later in life,
Hoxb7Cre+;Atp6ap2flox/flox mice have increased levels of se-
rum creatinine and develop chronic kidney disease. In addi-
tion to renal structural anomalies, Hoxb7Cre+;Atp6ap2flox/flox
mice exhibit reduced expression of winged helix transcription
factor Foxi1 (a transcription factor that promotes differentia-
tion of the CD intercalated cells (IC) from precursor UB cells),
basolateral membrane chloride-bicarbonate transporter anion
exchanger 1 (AE1), V-ATPase α4 subunit, and Aqp2 mRNA
[37]. Functionally, Hoxb7Cre+ ;Atp6ap2 flox/flox mice are
polyuric, have reduced capacity to concentrate, and acidify
the urine after 48 h of NH4Cl administration in drinking water
despite no difference in water intake compared with control
wild-type mice [37]. To explore in-depth the underlying
mechanisms by which UB PRR regulates UB branching and
CD morphogenesis, we performed a whole-genome analysis
of RNA expressed in UB cells FACS-isolated from kidneys of
Hoxb7Cre+;Atp6ap2flox/flox and control mice on day of birth
(P0) and carried out gene ontology analysis to identify func-
tional groups of genes that are differentially expressed [51].
Expression of several genes expressed specifically in the UB
cells and previously demonstrated to regulate UB branching
was altered in mutants. Genes with decreased expression in-
cluded Wnt11, Bmp7, Etv4, and Gfrα1, whereas levels of
Wnt9b, β-catenin, and Fgfr2 mRNA were increased.
Because intact β-catenin activity in the UB lineage is critical
for normal UB branching, we next determined β-catenin sig-
naling in UB cells in vitro and in vivo. Infection of immortal-
ized UB cells with adenovirus-driven short hairpin (sh) anti-
sense shPRR in vitro increased levels of active form of β-
catenin as well as the expression of direct β-catenin target,
axin2. The same effect of disrupted PRR signaling in the
UB on β-catenin activity in UB epithelia was observed
in vivo in double-transgenic Hoxb7Cre+;Atp6ap2flox/flox/
BatGal+ mice. In BatGal+ transgenic mice, activation of β-
catenin-responsive promoter by endogenous β-catenin in-
creases expression of nuclear β-galactosidase (BatGal) [51].
In addition to genes known to regulate UB branching morpho-
genesis, the functional groups of genes with decreased expres-
sion in Hoxb7Cre+;Atp6ap2flox/flox UB cells included genes
that regulate metabolism of amino acids, molecular transport,
and production of energy. These findings show that UB PRR
directs UB branching and modulates CD function by
484
a b UB lineage
Gdnf, Ret, Wnt11,
Six2+ NP Gdnf Etv4/5
Ret
Wnt11 Foxi1, AE1,
V-ATPase α4
Hoxb7+
RV
UB
Hoxb7Cre+;Atp6ap2flox/flox
Foxd1+ Stroma
c MM lineage
Lef1,Jag1, Wnt4, P0: Reduced nephron number,
Lhx1, Fgf8, Six2, block in nephrogenesis after RV
Cited1, Sall1, Notch1 stage, small cystic kidneys, early
postnatal death
Six2Cre;Atp6ap2flox/+:
Six2Cre+;Atp6ap2flox/flox P60: Focal glomerulosclerosis,
proteinuria, reduced renal funcon
d Stromal lineage
E16.5: Absence of renin
Absence of renal P0: Neonatal mortality
renin, expanded renal
P14: Thickened renal arteries and
α-SMA expression arterioles
P60: Hydronephrosis, reduced renal
function and urine osmilality
Foxd1Cre+;Renflox/flox
Fig. 1 Lineage-specific roles of the renin-angiotensin system signaling in
the developing kidney. a Schematic of major lineages and select lineage-
specific molecular markers in the developing kidney. NP nephron pro-
genitors, UB ureteric bud, RV renal vesicle, GDNF glial cell-derived
neurotrophic factor. b In the UB lineage, absence of the UB prorenin
receptor (ATP6AP2) signaling causes a reduction of Gdnf-Ret-Wnt11
pathway gene expression, causing decreased UB branching. Foxi1,
AE1 (chloride-bicarbonate anion exchanger 1), and V-ATPase direct ter-
minal differentiation and function of UB-derived collecting duct cells. c
In the metanephric mesenchyme (MM) lineage, ATP6AP2 promotes
regulating the expression of genes that guide UB branching
and determine terminal differentiation of the CD cells.
Moreover, UB/CD PRR is important for the function of CD
cells involved in acid-base and water homeostasis.
Ramkumar et al. investigated how deletion of Atp6ap2 in
IC or in PC of the CD affected renal morphology and water
and Na+ handling in mice [38]. IC- or PC-targeted Atp6ap2
knockout (KO) was achieved by crossing mice expressing Cre
recombinase under the control of the B1 subunit of the V-
ATPase (Atp6v1b1) or Aqp2 promoters, respectively, with
Atp6ap2-floxed mice. No gross alterations in kidney tissue
histology or anatomy were found in IC- or PC-mutant mice
at 21 days of age [38]. Expression of the renal epithelial med-
ullary channel ENaC-α was reduced in PC-mutant mice. This
was accompanied by an increased loss of Na+ in the urine in
PC-mutant compared to control mice. In addition, expression
of renal medullary AQP2 and urine osmolality was reduced,
whereas urine volume was increased in PC-KO compared
with control mice. In contrast, ENaC or AQP2 expression,
Na+ balance, urine volume, and osmolality did not differ in
IC-KO compared with control mice. Thus, PC PRR regulates
ENaC activity, water transport, and urinary Na+ excretion.
One possible explanation for a discrepancy in the impact of
Pediatr Nephrol (2021) 36:479–489
E12.5: Reduced number of UB tips and
nephrons
E18.5: Small kidneys
P30: Polyuria, reduced capacity to
concentrate and acidify the urine
Nephrin, podocin, P7: Podocyte foot process
WT1, V-ATPase C effacement
P21: Proteinuria, reduced
renal function
Nphs2Cre+;Atp6ap2flox/flox
Sall1, Jag1, WT1, E18.5: Decreased RV and
expansion of Six2+ NPs
glomerular number, decre-
ase in arterial and arteriolar
Foxd1, Meis1, development
α-SMA, renin
Foxd1Cre+;Atp6ap2flox/flox
nephrogenesis by maintaining appropriate balance between NP mainte-
nance and induction of nephron differentiation. Podocyte ATP6AP2 di-
rects normal podocyte development and function via maintenance of
normal V-ATPase expression and function in podocytes. Lef1, Jag1,
Wnt4, Lhx1, Fgf8, Notch1, WT1—nephron differentiation markers.
Cited1, Six2, Sall1—NP markers. d In the Foxd1+ stromal lineage, renin
and ATP6AP2 are critical for normal renal arterial tree development.
ATP6AP2 promotes arterial development by maintaining expression of
stromal markers Foxd1 and Meis1. ATP6AP2 also facilitates normal
nephron differentiation by inhibiting excessive expansion of Six2+ NPs
renin vs. PRR deficiency in the UB/CD lineage for kidney
development may result from the difference in signaling path-
ways downstream of renin and PRR, where UB PRR affects
renal development primarily as a subunit of V-ATPase [30].
An additional possibility is that lack of renal structural pheno-
type in Hoxb7Cre+;Ren1c flox/flox mice may be due to a rescue
by renin-independent Ang peptide generation from AGT by
proteases [52].
Nephrogenic lineage
During renal morphogenesis, PRR expression is prominent
within the metanephric mesenchyme and its derivatives. To
determine the role of the PRR (ATP6AP2) within Six2+
nephrogenic progenitor population, we deleted Atp6ap2 in
Six2+ nephron progenitors and their epithelial derivatives in
mice using Six2 Cre -mediated ablation of the Atp6ap2
(Six2Cre+;Atp6ap2flox/flox) [25]. We did not observe changes
in UB tree volume or in the number of UB tips in
Atp6ap2-mutant compared with control mice on E12.5. In
contrast, average size of developing glomeruli and glomerular
volume were reduced in Six2Cre+;Atp6ap2flox/flox kidneys at
E12.5. The number of renal vesicles (RV) did not differ
Pediatr Nephrol (2021) 36:479–489
between mutant and control kidneys on E12.5. In contrast, the
number of comma- and S-shaped bodies was reduced in
Six2Cre+;Atp6ap2flox/flox mice at this stage. We conclude that
glomerular structure volume is reduced in
Six2Cre+;Atp6ap2flox/flox mutants on E12.5 due to a block in
nephrogenesis that occurs after the RV phase. Detailed analy-
sis showed that the expression of genes critical for nephron
induction, such as Wnt4, Fgf8, Pax8, Lhx1, Lef1, Jag1, and
Fgf20, is decreased in Six2Cre+;Atp6ap2flox/flox mutants (Fig.
1) [25]. To determine whether reduced nephrogenesis in
Six2Cre+;Atp6ap2flox/flox mice results from early depletion of
nephron progenitor cells, we examined the expression of mo-
lecular markers of CM cells with self-perpetuating ability such
as Six2, Cited1, and Sall1 [53]. Reduced expression of neph-
ron progenitor markers Six2, Cited1, and Sall1 was noted in
mutant compared to control kidneys, suggesting that reduced
nephron induction in Six2Cre+;Atp6ap2flox/flox mice may be
due to premature depletion of nephron progenitors with pre-
cocious propensity of nephron progenitors to differentiation
[25]. Following birth, Six2Cre+;Atp6ap2flox/flox kidneys are re-
duced in size, lack a well-developed nephrogenic zone, have
reduced number of nephrons, and contain cysts in the outer
medulla and cortex. Ultrastructural changes observed in
Six Cre+ ;Atp6ap2 flox/flox kidneys include effacement of
podocyte foot processes, a characteristic finding observed in
renal glomerular proteinuric disease. At 2 months of age, plas-
ma creatinine and urinary excretion of albumin were increased
in heterozygous Six2Cre+;Atp6ap2flox/+ compared with control
mice. Premature cessation of nephrogenesis results in de-
creased number of nephrons and is linked to kidney hypopla-
sia, proteinuria, increased risk of hypertension, and chronic
kidney disease in later life [54, 55]. To investigate in-depth
the molecular and cellular mechanisms through which neph-
ron progenitor cell (NPC) PRR regulates nephrogenesis, we
searched for genes regulated by PRR in Six2+ NPCs FACS-
isolated from control and Six2Cre+;Atp6ap2flox/flox kidneys on
E15.5 utilizing microarray analysis. The expression of β-ca-
tenin, Notch1, Jag1, Lhx1, Lef1, and p53, genes known to
regulate kidney development, was reduced in mutant com-
pared with control kidneys [56]. The groups of downregulated
genes include genes that control cell and embryo develop-
ment, regeneration of the kidney tissue, cell organization and
assembly, cell structure, proliferation, and apoptosis. Because
Six2Cre+;Atp6ap2flox/flox mice did not survive beyond the first
2 days after birth, we investigated the effect of Atp6ap2 gene
dosage reduction in Six2Cre+;Atp6ap2flox/+ (Het) mice on the
number of nephrons, ultrastructure of the glomerular base-
ment membrane (GBM), and systemic blood pressure. Het
mice had a reduced number of glomeruli, GBM with irregular
thickening and focal effacement of podocyte foot processes.
In addition, Het mice had elevated systemic blood pressure
and increased urinary excretion of soluble form of PRR
(sPRR). sPRR is formed by protease-mediated cleavage of
485
the extracellular domain of the full-length PRR and is secreted
into the plasma where it is able to bind renin [57]. Increased
urinary sPRR contents in Het mice may result from renal
tissue damage (decreased glomerular number, segmental
thickening of the glomerular basement membrane) [56]. In
turn, increased levels of sPRR in the urine may induce
prorenin/reninactivity in the collecting duct, causing increased
local formation of Ang II which may contribute to increased
blood pressure in Het mice. Collectively, these findings indi-
cate that NPC PRR plays a critical role in nephrogenesis by
regulating the expression of genes important in directing di-
verse cellular activities. It is likely that decreased nephron
number and increased excretion of sPRR in the urine play a
role in developmental programming of hypertension in
Six2Cre+;Atp6ap2flox/+ mice.
Our observations on the role of NPC PRR in podocyte
morphology and function are in line with data by Oshima
et al. and Riediger et al., showing that PRR is critical in
podocytes. Deletion of Atp6ap2 in mouse podocytes with
Cre-recombinase driven by the podocyte-specific promoter
of the Nphs2 (Nphs2Cre+;Atp6ap2flox/flox) mice causes efface-
ment of the podocyte foot processes, decreased expression,
and altered subcellular distribution podocin and nephrin, crit-
ical constituents of the podocyte slit-diaphragm, massive pro-
teinuria, and early death following birth from kidney injury
(Table 1) [8, 9]. Additional changes demonstrated in
Nphs2Cre+;Atp6ap2flox/flox podocytes include decreased ex-
pression of the V0 c-subunit (Atp6v0c) of the V-ATPase.
Reduced V0 c levels are associated with decreased ability to
acidify lysosomes, increased expression of lysosomal and
autophagosomal markers. Observed alterations are consistent
with reduced ability of lysosomes and autophagosomes to
process intracellular cargo [8, 9]. Autophagy represents an
important physiological mechanism for intracellular recycling
of proteins and damaged organelles to maintain homeostasis.
Normal autophagy relies on appropriate pH within the lyso-
somes and autophagosomes. Given reduced lysosomal acidi-
fication and increased expression of lysosomal and
autophagosomal markers in Nphs2 Cre+ ;Atp6ap2 flox/flox
podocytes, the authors conclude that PRR controls acidifica-
tion of lysosomes and phagosomes to protect podocytes from
decreased protein recycling resulting from compromised au-
tophagy. Lineage-specific effects of other renin-angiotensin
system components within the Six2+ nephrogenic or forkhead
transcription factor 1 (Foxd1+) stromal precursor populations
have not been defined. Additional studies are required to de-
termine the role of renin-angiotensin system actions via the
AT2R within these lineages.
Stromal lineage
Renin-secreting juxtaglomerular (JG) cells, which originate
from Foxd1-expressing stromal cells, differentiate into
486
pericytes, glomerular mesangium, and mural cells of the kid-
ney arterioles [35]. To determine the role of the stromal renin
in kidney development, Sequeira-Lopez et al. deleted renin in
Foxd1+ stromal cells and all their descendants by crossing
Ren1c flox/flox mice with Foxd1-cre mice
(Foxd1Cre+;Ren1cflox/flox) [35]. It remains controversial
whether Foxd1+ cells can form renal endothelial cells [35,
58]. Removal of renin in the Foxd1+ cells resulted in neonatal
mortality. The kidneys of mice that survived immediately after
birth showed a marked decrease in renin expression, thick
arteries, reduced plasma renin levels, and hydronephrosis.
Thus, renin generated in the Foxd1+ stromal compartment is
crucial for normal kidney and renal vasculature development
and that main source of circulating renin is the kidney
vasculature.
We recently investigated the role of the stromal PRR in
kidney development in mice using conditional deletion of
the Atp6ap2 in Foxd1+ stromal progenitors by crossing
Atp6ap2 flox/flox mice with Foxd1-cre mice
(Foxd1Cre+;Atp6ap2flox/flox) [26]. Similar to
Foxd1Cre+;Ren1cflox/flox mice, removal of PRR in the Foxd1+
cells resulted in death within several days after birth. The
kidneys of living mice showed decreased number of renal
arteries and arterioles, as evidenced from decreased expres-
sion of α smooth muscle actin (α-SMA), in the developing
interstitium. Expression of renin in the renal arterioles and
arteries was markedly reduced in Foxd1Cre+;Atp6ap2flox/flox
compared with control mice. These data indicate that PRR
plays a critical role in the development of cells that express
renin and that renin-expressing cells are required for the cor-
rect formation of the kidney arteries. Expression levels of
Foxd1 and Meis1, molecular markers of renal stroma, were
also reduced in Foxd1 Cre+ ;Atp6ap2 flo x/flox kidneys.
Subsequently, expanded expression of Six2+ nephron progen-
itor population accompanied by slower differentiation of the
developing nephrons was observed in mutants (Fig. 1) [26].
These findings demonstrate that PRR present in renal stromal
mesenchyme is critical for normal differentiation of the renal
arteries. In turn, deficient arterial development in
Foxd1Cre+;Atp6ap2flox/flox mice may cause excessive expan-
sion of nephron progenitors to impede proper formation of the
kidney.
Schrankl el al. studied the role of the stromal Ang II AT1R
in kidney development in mice with targeted inactivation of
the Agtr1a;Agtr1b receptor subtypes in the Foxd1+ cells
(Foxd1 Cre+/Agtr1flox/flox) [40]. The major AT1A receptor sub-
type was expressed in vascular smooth muscle cells, renin,
mesangial, and interstitial cells, which all derive from
Foxd1+ stromal progenitors. The kidneys showed neither
structural nor functional (blood pressure and glomerular filtra-
tion rate) abnormalities in comparison with wild-type mice.
These findings suggest that targeted deletion of the
Agtr1a;Agtr1b in renal stromal progenitors and their
Pediatr Nephrol (2021) 36:479–489
descendants, in contrast to characteristic renal structural and
functional consequences observed in mice with global
Agtr1a;Agtr1b inactivation, does not disturb normal kidney
development [7, 40]. It is conceivable that normal kidney
development in Foxd1 Cre+/Agtr1flox/flox mice is compensated
by AT1R activity in compartments beyond the stromal lineage,
i.e., in cells expressing renin, renal mesangial cells, interstitial,
or vascular smooth muscle cells.
Renin-angiotensin system inhibitor fetopathy
Use of renin-angiotensin system inhibitors (RASi) such as
ACE inhibitors (ACEi), Ang II receptor blockers (ARBs),
and direct renin inhibitors (DRI) is associated with an in-
creased risk of fetopathy in humans. The severity of fetopathy
appears to be related to the timing of exposure to renin-
angiotensin system-inhibiting drugs during gestation and to
the drug type taken by pregnant women. Pulmonary hypopla-
sia requiring mechanical ventilation and renal injury that need
renal replacement therapy occur more frequently in children
with RASi exposure after the first trimester compared to chil-
dren exposed during the first trimester [59]. A recent study
reports that fetopathy was not observed when RASi were
discontinued before 20 weeks of gestational [60]. In contrast,
90% of pregnancies had oligohydramnios and 31% had signs
of RASi fetopathy when exposed to RASi after the first tri-
mester [60]. The rate of fetopathy was higher for ARBs
(29.2%) than for ACEi (3.2%). Considering a broad-
spectrum of significant adverse effects of RASi on fetal
wellbeing, use of all drugs that block the renin-angiotensin
system should be avoided during all trimesters of pregnancy.
All patients of potential childbearing age should be counseled
about the potential fetal risks associated with RASi and the
importance of contraception when taking these drugs.
Conclusion
Mutations in the renin-angiotensin system genes are associat-
ed with renal malformations in mammals and humans. These
observations indicate an important role for the renin-
angiotensin system in normal kidney development. Recent
studies in mice have demonstrated lineage-specific roles for
discrete components of the renin-angiotensin system in the
UB, nephrogenic mesenchyme, and stromal lineages during
embryonic development. The role of the PRR signaling in
cell-specific lineages (e.g., in PCs and ICs of the CD, in
podocytes) has helped to define the cell-autonomous and
non-cell autonomous mechanisms underlying CAKUT and
renal functional derangements. As aberrant renin-angiotensin
system impairs normal kidney development, these findings
further underscore a need to avoid the use of inhibitors of
the renin-angiotensin system during pregnancy and advocate
Pediatr Nephrol (2021) 36:479–489
caution for their use in early infancy. Opportunities for pre-
vention and education of healthcare providers and women
about the use of RASi during pregnancy and in early infancy
should be optimized.
State of the field
Recent studies have expanded our knowledge of the role of
the renin-angiotensin system in kidney development and in
the pathogenesis of CAKUT. However, a better understanding
of the time course of developmental origins of renal anomalies
and diseases linked to renin-angiotensin system gene muta-
tions or its drug-induced inhibition is needed. This will poten-
tially identify new biomarkers to more precisely predict affect-
ed offspring and ensure early initiation of monitoring, genetic
counseling, and discontinuation of nephrotoxic drugs. More
detail has to be uncovered regarding the specific signaling
pathways affected, which could drive the development of nov-
el treatment strategies. A greater understanding of differences
in the responses of each sex to renin-angiotensin system ab-
errations during embryonic development is needed. As the
postnatal kidney is composed of > 25 distinct cell types, fur-
ther work is needed to explore how disruptions in the renin-
angiotensin system signaling during renal organogenesis im-
pact specific renal cell identity and plasticity. As induced plu-
ripotent stem cells (iPSCs) represent a valuable tool to inves-
tigate mechanisms underlying human disease, iPSC-derived
kidney organoids can be used to model human CAKUT asso-
ciated with renin-angiotensin system gene mutations or RASi-
induced toxicity [61]. In addition, gene-editing tools such as
clustered regularly interspaced short palindromic repeat
(CRISPR)/CRISPR-associated protein 9 (Cas9)) can be uti-
lized to generate mutated control iPSC lines or correct poten-
tially pathogenic mutations in iPSCs derived from patients
with CAKUT associated with renin-angiotensin system gene
mutations.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
References
1. Nagata M, Tanimoto K, Fukamizu A, Kon Y, Sugiyama F, Yagami
K, Murakami K, Watanabe T (1996) Nephrogenesis and renovas-
cular development in angiotensinogen-deficient mice. Lab Investig
75:745–753
2. Niimura F, Labosky PA, Kakuchi J, Okubo S, Yoshida H, Oikawa
T, Ichiki T, Naftilan AJ, Fogo A, Inagami T (1995) Gene targeting
in mice reveals a requirement for angiotensin in the development
and maintenance of kidney morphology and growth factor regula-
tion. J Clin Invest 96:2947–2954
487
3. Takahashi N, Lopez ML, Co Whig JE Jr, Taylor MA, Hatada T,
Riggs E, Lee G, Gomez RA, Kim HS, Smithies O (2005) Ren1c
homozygous null mice are hypotensive and polyuric, but heterozy-
gotes are indistinguishable from wild-type. J Am Soc Nephrol 16:
125–132
4. Esther CR Jr, Howard TE, Marino EM, Goddard JM, Capecchi
MR, Bernstein KE (1996) Mice lacking angiotensin-converting en-
zyme have low blood pressure, renal pathology, and reduced male
fertility. Lab Investig 7:953–965
5. Oliverio MI, Kim HS, Ito M, Le T, Audoly L, Best CF, Hiller S,
Kluckman K, Maeda N, Smithies O, Coffman TM (1998) Reduced
growth, abnormal kidney structure, and type 2 (AT2) angiotensin
receptor-mediated blood pressure regulation in mice lacking both
AT1A and AT1B receptors for angiotensin II. Proc Natl Acad Sci U S
A 95:15496–15501
6. Miyazaki Y, Tsuchida S, Nishimura H, Pope JC IV, Harris RC,
McKanna JM, Inagami T, Hogan BL, Fogo A, Ichikawa I (1998)
Angiotensin induces the urinary peristaltic machinery during the
perinatal period. J Clin Invest 102:1489–1497
7. Tsuchida S, Matsusaka T, Chen X, Okubo S, Niimura F, Nishimura
H, Fogo A, Utsunomiya H, Inagami T, Ichikawa I (1998) Murine
double nullizygotes of the angiotensin type 1A and 1B receptor
genes duplicate severe abnormal phenotypes of angiotensinogen
nullizygotes. J Clin Invest 101:755–760
8. Oshima Y, Kinouchi K, Ichihara A, Sakoda M, Kurauchi-Mito A,
Bokuda K, Narita T, Kurosawa H, Sun-Wada GH, Wada Y, Yamada
T, Takemoto M, Saleem MA, Quaggin SE, Itoh H (2011) Prorenin
receptor is essential for normal podocyte structure and function. J
Am Soc Nephrol 22:2203–2212
9. Riediger F, Quack I, Qadri F, Hartleben B, Park JK, Potthoff SA,
Sohn D, Sihn G, Rousselle A, Fokuhl V, Maschke U, Purfürst B,
Schneider W, Rump LC, Luft FC, Dechend R, Bader M, Huber TB,
Nguyen G, Muller DN (2011) Prorenin receptor is essential for
podocyte autophagy and survival. J Am Soc Nephrol 22:2193–
2202
10. Gribouval O, Gonzales M, Neuhaus T (2005) Mutations in genes in
the renin-angiotensin system are associated with autosomal reces-
sive renal tubular dysgenesis. Nat Genet 37:964–968
11. Costantini F, Kopan R (2010) Patterning a complex organ:
branching morphogenesis and nephron segmentation in kidney de-
velopment. Dev Cell 18:698–712
12. Li W, Hartwig S, Rosenblum ND (2014) Developmental origins
and functions of stromal cells in the normal and diseased mamma-
lian kidney. Dev Dyn 243:853–863
13. Batourina E, Tsai S, Lambert S, Sprenkle P, Viana R, Dutta S,
Hensle T, Wang F, Niederreither K, McMahon AP, Carroll TJ,
Mendelsohn CL (2005) Apoptosis induced by vitamin A signaling
is crucial for connecting the ureters to the bladder. Nat Genet 37:
1082–1089
14. Hoshi M, Reginensi A, Joens MS, Fitzpatrick JAJ, McNeill H, Jain
S (2018) Reciprocal spatiotemporally controlled apoptosis regu-
lates Wolffian duct cloaca fusion. J Am Soc Nephrol 29:775–783
15. Iosipiv IV, Schroeder M (2003) A role for angiotensin II AT1 re-
ceptors in ureteric bud cell branching. Am J Phys 285:F199–F207
16. Prieto M, Dipp S, Meleg-Smith S, El-Dahr SS (2001) Ureteric bud
derivatives express angiotensinogen and AT1 receptors. Physiol
Genomics 6:29–37
17. Schutz S, Le Moullec J-M, Corvol P, Gasc JM (1996) Early expres-
sion of all the components of the renin–angiotensin system in hu-
man development. Am J Pathol 149:2067–2079
18. Jones CA, Sigmund CD, McGowan RA, Kane-Haas CM, Gross
KW (1990) Expression of murine renin genes during fetal develop-
ment. Mol Endocrinol 4:375–383
19. Gomez RA, Lynch KR, Sturgill BC, Elwood JP, Chevalier RL,
Carey RM, Peach MJ (1989) Distribution of renin mRNA and its
protein in the developing kidney. Am J Phys 257:F850–F858
488
20. Jung FF, Bouyounes B, Barrio R, Tang SS, Diamant D, Ingelfinger
JR (1993) Angiotensin converting enzyme in renal ontogeny: hy-
pothesis for multiple roles. Pediatr Nephrol 7:834–840
21. Norwood VF, Craig MR, Harris JM, Gomez RA (1997) Differential
expression of angiotensin II receptors during early renal morpho-
genesis. Am J Phys 272:R662–R668
22. Song R, Spera M, Garrett C, El-Dahr SS, Yosypiv IV (2010)
Angiotensin II AT2 receptor regulates ureteric bud morphogenesis.
Am J Phys 298:F807–F817
23. Kakuchi J, Ichiki T, Kiyama S, Hogan BL, Fogo A, Inagami T,
Ichikawa I (1995) Developmental expression of renal angiotensin
II receptor genes in the mouse. Kidney Int 47:140–147
24. Song R, Preston G, Yosypiv IV (2013) Ontogeny of the (pro)renin
receptor. Pediatr Res 74:5–10
25. Song R, Preston G, Kidd L, Bushnell D, Sims-Lucas S, Bates CM,
Yosypiv IV (2016) Prorenin receptor is critical for nephron progen-
itors. Dev Biol 409:382–391
26. Yosypiv IV, Lopez M, Song R, Goes Martini A (2019) Stromal
prorenin receptor is critical for normal kidney development. Am J
Phys Regul Integr Comp Phys 316:R640–R650
27. Terada T, Urushihara M, Saijo T, Nakagawa R, Kagami S (2017)
(Pro)renin and (pro)renin receptor expression during kidney devel-
opment in neonates. Eur J Pediatr 176:183–189
28. Huang Y, Noble NA, Zhang J, Xu C, Border WA (2007) Renin-
stimulated TGF-beta1 expression is regulated by a mitogen-
activated protein kinase in mesangial cells. Kidney Int 72:45–52
29. Sakoda M, Ichihara A, Kaneshiro Y, Takemitsu T, Nakazato Y, Nabi
AH, Nakagawa T, Suzuki F, Inagami T, Itoh H (2007) (Pro)renin
receptor-mediated activation of mitogen-activated protein kinases
in human vascular smooth muscle cells. Hypertens Res 30:1139–
1146
30. Nguyen G, Delarue F, Burcklé C, Bouzhir L, Giller T, Sraer JD
(2002) Pivotal role of the renin/prorenin receptor in angiotensin II
production and cellular responses to renin. J Clin Invest 109:1417–
1427
31. Ludwig J, Kerscher S, Brandt U, Pfeiffer K, Getlawi F, Apps DK,
Schägger H (1998) Identification and characterization of a novel
9.2-kDa membrane sector-associated protein of vacuolar proton-
ATPase from chromaffin granules. J Biol Chem 273:10939–10947
32. Mounier F, Hinglais N, Sich M, Gros F, Lacoste M, Deris Y,
Alhenc-Gelas F, Gubler MC (1987) Ontogenesis of angiotensin-I
converting enzyme in human kidney. Kidney Int 32:684–690
33. Garcia-Villalba P, Denkers ND, Wittwer CT, Hoff C, Nelson RD,
Mauch TJ (2003) Real-time PCR quantification of AT1 and AT2
angiotensin receptor mRNA expression in the developing rat kid-
ney. Nephron Exp Nephrol 94:e154–e159
34. Yosipiv IV, Dipp S, El-Dahr SS (1994) Ontogeny of somatic
angiotensin-converting enzyme. Hypertension 23:369–374
35. Sequeira-Lopez ML, Nagalakshmi VK, Li M, Sigmund CD,
Gomez RA (2015) Vascular versus tubular renin: role in kidney
development. Am J Phys Regul Integr Comp Phys 309:R650–
R657
36. Sihn G, Burckle C, Rousselle A, Reimer T, Bader M (2013)
(Pro)renin receptor: subcellular localizations and functions. Front
Biosci 5:500–508
37. Song R, Preston G, Ichihara A, Yosypiv IV (2013) Deletion of the
prorenin receptor from the ureteric bud causes renal hypodysplasia.
PLoS One 8:e63835
38. Ramkumar N, Stuart D, Mironova E, Abraham N, Gao Y, Wang S,
Lakshmipathi J, Stockand JD, Kohan DE (2018) Collecting duct
principal, but not intercalated, cell prorenin receptor regulates renal
sodium and water excretion. Am J Physiol Ren Physiol 315:F607–
F617
39. Stegbauer J, Gurley SB, Sparks MA, Woznowski M, Kohan DE,
Yan M, Lehrich RW, Coffman TM (2011) AT1 receptors in the
Pediatr Nephrol (2021) 36:479–489
collecting duct directly modulate the concentration of urine. J Am
Soc Nephrol 22:2237–2246
40. Schrankl J, Neubauer B, Fuchs M, Gerl K, Wagner C, Kurtz A
(2019) Apparently normal kidney development in mice with con-
ditional disruption of ANGII-AT1 receptor genes in FoxD1 positive
stroma cell precursors. Am J Physiol Ren Physiol 16:F1191–F1200
41. Oshima K, Miyazaki Y, Brock JW, Adams MC, Ichikawa I, Pope
JC (2001) Angiotensin type II receptor expression and ureteral bud-
ding. J Urol 166:1848–1852
42. Lacoste M, Cai Y, Guicharnaud L, Mounier F, Dumez Y, Bouvier
R, Dijoud F, Gonzales M, Chatten J, Delezoide AL, Daniel L,
Joubert M, Laurent N, Aziza J, Sellami T, Amar HB, Jarnet C,
Frances AM, Daïkha-Dahmane F, Coulomb A, Neuhaus TJ,
Foliguet B, Chenal P, Marcorelles P, Gasc JM, Corvol P, Gubler
MC (2006) Renal tubular dysgenesis, a not uncommon autosomal
recessive disorder leading to oligohydramnios: role of the renin-
angiotensin system. J Am Soc Nephrol 17:2253–2263
43. Nishimura H, Yerkes E, Hohenfellner K, Miyazaki Y, Ma J, Hunley
TE, Yoshida H, Ichiki T, Threadgill D, Phillips JA 3rd, Hogan BM,
Fogo A, Brock JW 3rd, Inagami T, Ichikawa I (1999) Role of the
angiotensin type 2 receptor gene in congenital anomalies of the
kidney and urinary tract, CAKUT, of mice and men. Mol Cell 3:
1–10
44. Song R, Preston G, Khalili A, El-Dahr SS, Yosypiv IV (2012)
Angiotensin II regulates growth of the developing papillas
ex vivo. Am J Physiol Ren Physiol 302:F1112–F1120
45. Madsen K, Marcussen N, Pedersen M, Kjaersgaard G, Facemire C,
Coffman TM, Jensen BL (2010) Angiotensin II promotes develop-
ment of the renal microcirculation through AT1 receptors. J Am Soc
Nephrol 21:448–459
46. Oliverio MI, Delnomdedieu M, Best CF, Li P, Morris M, Callahan
MF, Johnson GA, Smithies O, Coffman TM (2000) Abnormal wa-
ter metabolism in mice lacking the type 1A receptor for ANG II.
Am J Phys 278:F75–F82
47. Brooks HL, Allred AJ, Beutler KT, Coffman TM, Knepper MA
(2002) Targeted proteomic profiling of renal Na(+) transporter
and channel abundances in angiotensin II type 1a receptor knockout
mice. Hypertension 39:470–473
48. Li XC, Shao Y, Zhuo JL (2012) AT1a receptor signaling is required
for basal and water deprivation-induced urine concentration in
AT1a receptor-deficient mice. Am J Physiol Ren Physiol 303:
F746–F756
49. Weiner ID, New AR, Milton AE, Tisher CC (1995) Regulation of
luminal alkalinization and acidification in the cortical collecting
duct by angiotensin II. Am J Phys 269:F730–F738
50. Tojo A, Tisher CC, Madsen KM (1994) Angiotensin II regulates
H+-ATPase activity in rat cortical collecting duct. Am J Phys 267:
F1045–F1051
51. Song R, Janssen A, Li Y, El-Dahr SS, Yosypiv IV (2017) Prorenin
receptor controls renal branching morphogenesis via Wnt/β-catenin
signaling. Am J Physiol Ren Physiol 312:F407–F417
52. Yosipiv I, El-Dahr SS (1996) Activation of angiotensin-generating
systems in the developing rat kidney. Hypertension 27:281–286
53. Kopan R, Chen S, Little M (2014) Nephron progenitor cells:
shifting the balance of self-renewal and differentiation. Curr Top
Dev Biol 107:293–331
54. Barker DJ, Osmond C, Golding J, Kuh D, Wadsworth ME (1989)
Growth in utero, blood pressure in childhood and adult life, and
mortality from cardiovascular disease. BMJ 298:564–567
55. Brenner BM, Garcia DL, Anderson S (1988) Glomeruli and blood
pressure. Less of one, more the other? Am J Hypertens 1:335–347
56. Song R, Kidd L, Janssen A, Yosypiv IV (2018) Conditional abla-
tion of the prorenin receptor in nephron progenitor cells results in
developmental programming of hypertension. Phys Rep 6:e13644
57. Cousin C, Bracquart D, Contrepas A, Corvol P, Muller L, Nguyen
G (2009) Soluble form of the (pro)renin receptor generated by
Pediatr Nephrol (2021) 36:479–489
intracellular cleavage by furin is secreted in plasma. Hypertension
53:1077–108250
58. Sims-Lucas S, Schaefer C, Bushnell D, Ho J, Logar A, Prochownik
E, Gittes G, Bates CM (2013) Endothelial progenitors exist within
the kidney and lung mesenchyme. PLoS One 8:e65993
59. Nadeem S, Hashmat S, Defreitas MJ, Westreich KD, Shatat IF,
Selewski DT, Onder AM, Chiang M, Weaver DJ Jr, Steinke J,
Barcia J, Hernandez J, Hidalgo G, Ingraham SE, Abitbol CL, Pan
C, Greenbaum LA (2015) Renin angiotensin system blocker
fetopathy: a midwest pediatric nephrology consortium report. J
Pediatr 167:881–885
489
60. Weber-Schoendorfer C, Kayser A, Tissen-Diabaté T, Winterfeld U,
Eleftheriou G, Te Winkel B, Diav-Citrin O, Greenall A,
Hoeltzenbein M, Schaefer C (2020) Fetotoxic risk of AT1 blockers
exceeds that of angiotensin-converting enzyme inhibitors: an obser-
vational study. J Hypertens 38:133–141
61. Takahashi K, Tanabe K, Ohnuki M, Narita M, Ichisaka T, Tomoda
K, Yamanaka S (2007) Induction of pluripotent stem cells from
adult human fibroblasts by defined factors. Cell 131:861–872
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