Diabetes & Metabolism 36 (2010) 1–10

Review

Advanced glycation end-products: Implications for diabetic

and non-diabetic nephropathies
M. Daroux a,b , G. Prévost a,c , H. Maillard-Lefebvre a,d , C. Gaxatte a,e ,
V.D. D’Agati f , A.M. Schmidt g , É. Boulanger a,e,∗
a EA2693, Vascular Aging Biology, Research Division, Lille Medical School, 1, place de Verdun, 59045 Lille, France
b Department of Nephrology, Regional University Hospital of Lille, Lille, France
c Department of Endocrinology and Diabetology, Regional University Hospital of Lille, Lille, France
d Department of Internal Medicine, Regional University Hospital of Lille, Lille, France
e Department of Gerontology, Regional University Hospital of Lille, Lille, France
f Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
g Department of Surgical Science, College of Physicians and Surgeons, Columbia University, New York, NY, USA

Received 10 January 2009; accepted 23 June 2009

Available online 22 November 2009

Abstract
Glycation is the process whereby sugars bind to the free amine residues of proteins. These newly formed modified molecular species are known
as ‘advanced glycation end-products’, or AGEs. AGE toxicity may occur through at least three mechanisms: interaction with the receptor for AGEs
(RAGE); tissue deposition; and in situ glycation. AGEs trigger proinflammatory, profibrotic and procoagulant cellular responses that are capable
of damaging tissues, often targeting particular organs. In diabetic patients, the conditions needed to promote AGE formation are all present, and
are further accentuated by accompanying renal failure. The aim of this review is to outline the involvement of AGEs in the various forms of renal
pathology associated with diabetic and non-diabetic nephropathies. AGEs are present in all renal compartments in diabetic patients, including the
vessels, glomeruli, tubules and interstitium. Many cell types may be activated—specifically, endothelial, tubular and mesangial cells, and podocytes.
AGEs play a major role in the accumulation of extracellular matrix, as occurs in diabetic glomerulosclerosis, and are also involved in most diabetic
(renovascular, microangiopathic and glomerular) and non-diabetic renal injury associated with progressive glomerulosclerosis and ageing.
© 2009 Elsevier Masson SAS. All rights reserved.

Keywords: Advanced glycation end-products; Diabetic nephropathy; Glomerulosclerosis; Fibrosis; RAGE; Review

Résumé
Produits de la glycation avancée : implication au cours de la néphropathie diabétique et des autres néphropathies.
La glycation est une réaction non enzymatique définie par la fixation d’un sucre à un résidu amine libre d’une protéine. Ces molécules néoformées
ont des effets délétères et constituent une nouvelle famille nommée « produits de glycation avancée » ou AGE (advanced glycation end-products).
La toxicité des AGE est fondée sur trois mécanismes : l’interaction avec le récepteur des AGE (RAGE), les dépôts tissulaires et la glycation in
situ. Les AGE entraînent une réponse cellulaire néfaste, pro-inflammatoire, profibrosante et procoagulante, tant au niveau tissulaire qu’au niveau
de certains organes cibles. Au cours du diabète, toutes les conditions sont réunies pour promouvoir la formation des AGE, notamment en cas
d’insuffisance rénale associée. L’objectif de cette revue est de décrire l’implication des AGE dans les diverses pathologies rénales associées ou
non au diabète. Les AGE sont présents, chez le diabétique, dans toutes les structures rénales incluant les vaisseaux, les glomérules, les tubules et
l’interstitium. De nombreux types cellulaires peuvent ainsi être activés : les cellules endothéliales, tubulaires, mésangiales ainsi que les podocytes.
Les AGE jouent également un rôle majeur dans l’accumulation de la matrice extracellulaire mise en évidence au cours du diabète et participent aux
autres complications rénales liées au diabète (néphroangiosclérose et glomérulopathie). Les AGE sont également impliqués dans les néphropathies
non diabétiques et au cours du vieillissement rénal.
© 2009 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Produits de glycation avancée ; Néphropathie diabétique ; Glomérulosclerose ; Fibrose ; RAGE ; Revue générale

∗ Corresponding author. Tel.: +33 0 6 62 70 05 67; fax: +33 0 3 20 44 64 87.

E-mail address: eric.boulanger@chru-lille.fr (É. Boulanger).

1262-3636/$ – see front matter © 2009 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.diabet.2009.06.005
2 M. Daroux et al. / Diabetes & Metabolism 36 (2010) 1–10
1. Introduction
Diabetes-induced renal disorders can affect multiple com-
partments of the kidney, as implied by the term ‘diabetic
nephropathies’, including: the large vessels, with the subse-
quent development of atherosclerosis and renovascular disease;
the microvessels, in the form of arterio- and arteriolosclerosis;
and, in particular, the glomeruli, leading to nodular or dif-
fuse glomerulosclerosis, generally considered the quintessential
lesion of diabetic nephropathy (DN) [1]. These pathological
changes arise in part from the adverse effects of hyperglycaemia,
leading to the formation of advanced glycation end-products
(AGEs) [2,3]. AGEs are also implicated in the pathophysiol-
ogy of non-diabetic renal diseases and ageing. They have been
found in renal tissues in IgA and lupus nephritis, hyperten-
sive nephropathy, renal fibrosis and chronic transplant rejection
[4–6], and are also implicated in physiological ageing as well as
age-related disorders such as Alzheimer’s disease and macular
degeneration [7]. Diabetologists, along with nephrologists and
geriatricians, need to be familiar with the deleterious effects of
AGE formation and resulting organ damage. The present review
is an update of recent advances in our understanding of the roles
of AGEs in the development of DN, non-diabetic renal disease
and renal ageing.
2. AGEs and their interaction with receptors
Chronic hyperglycaemia promotes the formation of modified
molecular species such as AGEs. AGEs result from the binding
of free lysine or arginine NH2 residues on proteins to a sugar with
an ‘ose’, such as glucose, fructose or glucose-6-phosphate. The
formation of AGEs can occur through three major biochemical
mechanisms: glycation; the polyol pathway and glycoxidation.
The first, glycation, directly depends on glucose concentra-
tions, time and temperature, and requires several stages before
an AGE can be formed. First described in 1912 by Louis-Camille
Maillard at the Paris Academy of Sciences, glycation is a non-
enzymatic process in which glucose binds to a protein in a
high-glucose-concentration environment [8]. Glycation of pro-
teins involves the formation of a Schiff base, which is then
transformed into Amadori products that, in turn, are subject
to further molecular modifications before becoming an AGE.
The most familiar intermediary glycation product measured in
routine clinical practice is glycated haemoglobin (HbA1c ).
The second mechanism, the polyol pathway, is enzymatic in
nature. Glucose is transformed by aldolase reductase or sorbitol
dehydrogenase into an intermediary product that, after binding
to a protein, becomes an AGE.
The glycoxidation pathway is based on oxidative stress,
whereby the oxidation of glucose leads to the formation of gly-
oxal and methylglyoxal. These oxidized sugars are extremely
unstable and can quickly react with different proteins to form
AGEs (Fig. 1).
Although there is no precise AGE classification, these
molecules can be differentiated according to the type of
binding, the nature of the glycated protein or the particular
sugar that is bound. So far, two AGEs have been especially
Fig. 1. Diagrammatic representation of advanced glycation end-product (AGE)
formation.
widely studied, as they are antigenic and easy to analyze:
N␧ -(carboxylmethyl)lysine (CML), which is mainly present in
biological fluids and has a short half-life; and pentosidine, which
is mostly found in the extracellular matrix (ECM) and, thus, has
a longer half-life. AGE toxicity is linked to three mechanisms:
deposition; in situ glycation and receptor interaction.
2.1. AGE receptors
At least five types of AGE receptors have been identified
so far: the macrophage scavenger receptor 1 (MSR1 or CD36)
[9]; the AGE receptor R1 (AGE-R1 or p60), corresponding to
oligosaccharyl transferase 48; the AGE receptor R2 (AGE-R2
or p90), which corresponds to phosphoprotein 80K-H; the AGE
receptor R3 (AGE-R3 or galactin-3), a scavenger receptor that
recognizes galactoside residues; and RAGE, commonly referred
to as the ‘receptor for AGEs’ and the most widely studied type
[10].
RAGE, a transmembrane receptor of the immunoglobulin
superfamily [11], is a multiligand receptor with the capability
of interacting with several types of proteins, including AGEs,
the S100 proteins or calgranulins (belonging to the proinflam-
matory cytokines), the high-mobility group B1 (HMGB1) also
known as ‘amphoterin’, and the proteins with a ␤ fibrillary
structure [12,13]. In humans, the RAGE gene is located on chro-
mosome 6 in the major histocompatibility complex (MHC) class
III region [14]. RAGE consists of an intracellular domain, a short
transmembrane domain and an extracellular domain. Genetic
variants of the RAGE gene (AGER in HUGO nomenclature)
have been associated with vascular disease and risk of renal
disorders [15]. The association between the RAGE -374 T/A
homozygous AA genotype and cardiovascular disease as well as
albumin excretion in type 1 diabetic patients with poor metabolic
control suggests a gene–environment interaction in the develop-
ment of DN and cardiovascular complications [16]. The 82 Ser
allele of the RAGE gene is a risk allele for developing advanced
nephropathy in Caucasian type 1 diabetic patients [17].
 M. Daroux et al. / Diabetes & Metabolism 36 (2010) 1–10
Fig. 2. A. Soluble RAGE (sRAGE) cleavage and splicing: RAGE: recep-
tor of advanced glycation end-products (AGEs); cRAGE: cleaved RAGE;
esRAGE: endogenous secretory RAGE. B. Cell response after RAGE activation:
ICAM-1: intercellular adhesion molecule-1; VCAM-1: vascular cellular adhe-
sion molecule-1; IL-6: interleukin-6, TNF-␣: tumour necrosis factor-␣; NFk B:
nuclear factor-kappa B.
Soluble RAGE (sRAGE) corresponds to the extracellu-
lar domain of RAGE. As the N-terminal ‘V’-type domain
is also included, sRAGE has the same ligand-binding speci-
ficity as RAGE and may act as a decoy by binding with
proinflammatory ligands and preventing them from reaching
membrane-associated RAGE. sRAGE comprises two forms:
endogenous secretory RAGE (esRAGE) and cleaved RAGE
(cRAGE; Fig. 2A) [18,19]. The former occurs via alternative
splicing of intron 9/exon 10 of the RAGE gene [18]. Another
mechanism responsible for the circulating pool of sRAGE is
based on proteolytic processing (by ADAM10) from the full-
length membrane-bound RAGE that produces cRAGE [19]. The
formation of cRAGE can be inhibited with matrix metallopro-
3
tease (MMP) inhibitors. Cells deficient in ADAM10 produce
only a small amount of sRAGE, suggesting that it is responsible
for RAGE cleavage. Both esRAGE and cRAGE are functionally
equivalent and able to interact with RAGE ligands.
RAGE is particularly found in the vascular compartment
(endothelial cells, vascular smooth muscle cells, mononuclear
leukocytes, macrophages), the nervous system, and in the lungs,
muscles and peritoneum [20–22]. In the kidneys, RAGE has
been identified on the surface of endothelial cells, podocytes,
tubular cells and mesangial cells [23,24].
2.2. Interaction of AGE and RAGE
The AGE/RAGE interaction activates a series of intra-
cellular signalling pathways, including nicotinamide adenine
dinucleotide phosphate (NADPH) oxidase and nuclear fac-
tor kappa-B (NF␬-B), with production of reactive oxygen
species (ROS) [25]. The cellular response can involve sev-
eral types—proinflammatory, profibrotic, procoagulant and/or
angiogenic—with overexpression of cell adhesion molecules
such as vascular cell adhesion molecule-1 (VCAM-1), and the
production of cytokines [interleukin-2 (IL-2), IL-6 and tumour
necrosis factor-␣ (TNF-␣)], tissue factor (TF) and vascular
endothelial growth factor (VEGF; Fig. 2B) [22,26–28].
3. AGEs in diabetic nephropathies
3.1. Where are AGEs located in the diabetic kidney?
AGEs can be identified in many renal structures. In arteries,
AGE deposits are mainly found in atheromatous plaques. Their
presence has been reported in the carotid, aortic, femoral, radial
and iliac arteries. However, there are no reports in the literature
of the presence of AGEs in the renal artery, although such a
finding appears to be reasonable [29,30]. The AGE concentration
in plaques is correlated with the degree of atherosclerosis, and
is even higher in diabetic patients with renal failure [25,31]. An
ultrastructural study carried out in rats with DN demonstrated
the presence of AGEs in the glomerular basement membrane,
mesangium, podocytes, tubules and endothelial cells [23,32].
The extent of AGE concentration is proportional to the severity
of mesangial expansion in the course of DN [33] (Table 1).
3.2. Cellular effects of AGEs
Endothelial cells express RAGE, where interaction with
AGEs can mediate numerous negative effects leading to macro-
and microvascular endothelial dysfunction. Both in vitro and in
vivo, endothelial RAGE activation leads to increased expres-
sion of VCAM-1 (blood cell–endothelium interactions) and
E-cadherin (homotype adhesion) [34–36]. The glycation of
endothelial intracellular proteins has also been described. In
vitro, glycation of fibroblast growth factor-␤ (FGF-␤) is accom-
panied by a significant decrease in binding of heparin, its natural
ligand, and by a reduction in its mitogenic activity [37]. AGEs
directly lower the level of nitric oxide synthase (NOS) expres-
sion [38]. They can also directly interact with NO and inactivate
4 M. Daroux et al. / Diabetes & Metabolism 36 (2010) 1–10
Table 1
AGE deposits in diabetic kidneys, as reflected by the percentage of AGE-positive staining in type 2 diabetic renal biopsies.
Mesangium Glomerular basement membrane
HSA-CML (%) 96 4 85
Pentosidine (%) 77 4 31
Data are based on a study of 26 human PBR [27]. HSA-CML: human serum albumin-carboxymethyl-lysine.
it [39], and disrupt endothelial anticoagulant activities by reduc-
ing levels of the anticoagulant thrombomodulin and increasing
levels of procoagulant TF [40]. Endothelial RAGE activation
by AGEs stimulates the synthesis of ROS through activation of
the NADPH-oxidase pathway, with activation of superoxide ion
(O2 – ) and hydrogen peroxide (H2 O2 ). These factors all promote
endothelial dysfunction through perturbations of coagulation,
permeability, vasomotor function and cell adhesion, leading to
the development of renal macro- and microvascular diabetic
lesions [41,42].
Mesangial cell RAGE activation has effects on the cell cycle
and maintains mesangial cells in a quiescent state. In turn, this
inhibition of cell proliferation promotes mesangial cell apoptosis
and hypertrophy [43,44]. AGEs increase mesangial synthesis of
fibronectin as well as collagen types I and IV. Following RAGE
activation, mesangial cells secrete monocyte chemoattractant
protein-1 (MCP-1), which participates in the inflammatory pro-
cess [44,45]. Mesangial cells also express other receptors for
AGE, such as AGE-R1 and AGE-R2, the activation of which
may contribute to the damaging effects of AGEs by promoting
mesangial cell apoptosis [46,47].
Podocyte RAGE activation is strongly implicated in the
development of DN [48,49]. AGEs interfere with the podocyte
cell cycle and inhibit cell proliferation, causing cytoplasmic
hypertrophy followed by apoptosis. This effect can be pre-
vented by RAGE small interfering RNA (siRNA) [50]. Glycated
albumin, through the engagement of RAGE, inhibits nephrin
synthesis by podocytes, and alters the slit diaphragm that forms
the glomerular filtration barrier [51]. AGEs also interact with
podocyte cytoskeletal protein ␣-actinin-4 (ACTN-4), a key com-
ponent of the slit diaphragm [52]. In the presence of AGEs,
ACTN-4 gene transcription and expression by podocytes is sig-
nificantly diminished [53]. This alteration is an initial step in the
development of proteinuria, and diminution of ACTN-4 expres-
sion has been correlated with the degree of albuminuria and renal
failure [54].
AGE engagement with RAGE on tubular cells leads to
TGF-␤ pathway activation. In vitro, RAGE activation by cul-
tured epithelial tubular cells is followed by an increase of
TGF-␤ concentration in the culture medium, and by enhance-
ment of transcription and expression of small mothers against
decapentaplegic-2 and -3 (SMAD-2 and SMAD-3). These two
molecules, which are activated early in the process, affect
the transcription of numerous genes [55]. TGF-␤ induces the
epithelial-to-mesenchymal transition (EMT) process, which
involves phenotype modification of epithelial tubular cells into
myofibroblastic cells, a transformation that is accompanied by
altered cell function favouring profibrotic activity. EMT results
in phenotype changes, with a decrease in epithelial markers and
Tubular basement membrane Interstitium Vessel walls
19 96
90 54
the presence of mesenchymal markers such as ␣-smooth muscle
actin, and plays a key role in the development of renal fibrosis
by stimulating the secretion of ECM proteins such as collagen
and fibronectin [3]. In vitro, tubular epithelial cell RAGE acti-
vation by AGEs induces EMT via the TGF-␤ pathway, whereas
EMT may be totally inhibited by anti-RAGE antibodies and par-
tially inhibited by anti-TGF-␤ antibodies [56]. In diabetic rats,
0.5–5% of tubular cells express myofibroblast markers. Renal
biopsies from patients with DN also demonstrate the presence
of EMT [56].
3.3. Effects of AGEs on ECM
Glycated proteins can modify ECM structure by cross-linking
proteins such as collagen and elastin. This process increases
ECM rigidity, reduces its turnover and might, at least partly,
explain the vascular rigidity and hypertension that typically
develop during diabetes and ageing [57].
DN progression is accompanied by significant mesangial
expansion that is partly linked to a decrease in ECM degra-
dation and reversible in the presence of aminoguanidine, an
inhibitor of AGE formation [58]. Modification in matrix turnover
includes regulation of MMP, and of their activators [membrane-
type MMP (MT-MMP)] and inhibitors [tissue inhibitor MMP
(TIMP)]. The collagen affinity for MMP-3 is clearly diminished
when the latter is glycated [59]. While MMP-2 gene expression
augments this activity, the presence of AGEs in the mesangium
reduces the activity of MT1-MMP (an MMP-2 activator) by
45%. Also, there is a parallel augmentation of the activity of
inhibitors TIMP-1 and TIMP-2, although these effects can be
prevented by aminoguanidine, further emphasizing the impor-
tant role of AGEs in disease progression [60]. MMP activity in
non-collagen proteins such as MMP-7 is also lowered in the pres-
ence of AGEs [61] (Fig. 3). ECM glycation leads to alterations in
the cell–matrix interaction. In vitro, the culture of podocytes on
a glycated matrix is accompanied by a reduction in cell attach-
ment and proliferation [62]. AGEs also regulate ECM protein
and protease expression by human mesangial cells [8].
3.4. From animal models to humans
The presence of AGEs in the kidney is the result of different
mechanisms: trapping; in situ glycation and tubular reabsorp-
tion. Compared with control animals, intravenous injection
of AGEs over a 5-month period in normal rats led to a 50%
increase in renal accumulation of AGEs [63]. AGE distribution
was comparable to that observed in DN and mimicked the
histological changes of DN, including hypertrophy and sclerosis
of glomeruli, mesangial matrix hypertrophy, thickening of
 M. Daroux et al. / Diabetes & Metabolism 36 (2010) 1–10
Fig. 3. Double effects of advanced glycation end-products (AGEs) on matrix
metalloproteinases (MMPs). MT-MMPs: membrane-type MMPs; TIMPs: tissue
inhibitors of MMPs; ECM: extracellular matrix.
tubular and glomerular basement membranes, and effacement of
podocyte foot processes. AGE renal accumulation was accom-
panied by increased excretion of both total urinary protein (2.5
times that of the controls) and urinary AGE. Injection of AGEs
into non-diabetic rats that had undergone subtotal nephrectomy
led to glomerulosclerosis and tubulointerstitial damage [63,64].
A study of rats given radioactive pentosidine confirmed the
key role of the kidney in AGE metabolism, with 83% of the
total radioactivity eliminated via the urine, and a large residual
quantity of AGEs trapped in the kidneys—35% compared with
only 2% in the liver [65]. Urinary elimination of AGE is directly
dependent on dietary intake. Indeed, a reduced AGE intake was
followed by lower circulating and tissue AGE levels in mice. In
healthy volunteers, a low-AGE diet was followed by a decrease
in pyrraline urinary concentration [66]. These findings have also
been reported in patients with chronic renal failure (CRF) and
diabetes [67,68]. In addition, tubular reabsorption plays a key
role in renal AGE accumulation. Epithelial cells in the proximal
tubules express an apical membrane receptor called ‘megalin’,
which can reabsorb filtered low-molecular-weight (LMW)
proteins, including LMW AGEs. After megalin-binding, AGEs
undergo endocytosis, and are then directed towards lysosomes
through a mechanism that is both limited and saturable [65,69].
Table 2
Localization of advanced glycation end-products (AGEs) in renal biopsies from diabetic and non-diabetic nephropathy patients.
Mesangium Glomerular basement membrane
Diabetic nephropathy (n = 26) CML CML
Focal segmental glomerulosclerosis (n = 18) Pentosidine CML
Hypertensive nephropathy (n = 7) CML CML
IgA nephropathy (n = 15) MDA-lysine ND
Lupus nephritis (n = 11) CML CML
CML: carboxymethyl-lysine; MDA-lysine: malondialdehyde-lysine; ND: no determination; main localizations are shown in bold [27,33,63].
5
4. AGEs and diabetic nephropathy: similarities with
other nephropathies and ageing
DN is not the only kidney condition involving AGEs. Renal
disorders linked with AGEs are also reported during CRF,
chronic inflammatory diseases, high dietary AGE and ageing,
although the precise role of AGEs in these different kidney
pathologies has yet to be elucidated. During diabetes, AGEs
are a consequence of chronic hyperglycaemia and precede dia-
betic complications [70]. In non-diabetic patients, their presence
could disrupt the equilibrium between dietary intake, oxidation
(glycoxidation), in situ glycation and renal elimination. Exces-
sive kidney AGE deposition is found in arterionephrosclerosis,
IgA nephropathy, lupus nephritis, uraemia and the experimental
murine model of focal sclerosis mediated by adriamycin [23,71].
Compared with DN, AGEs and their distribution often differ in
these diverse pathological settings (Table 2).
All biopsies preformed in patients with arterionephrosclero-
sis have been strongly positive for CML levels in the glomeruli
and vascular structures, with pentosidine being mostly present
in the interstitium [23]. AGEs are known to be important in
atherosclerosis progression and are positively correlated with
cardiovascular mortality in non-diabetic women [72]. Dur-
ing IgA nephropathy, CML and pentosidine staining in the
mesangium and interstitium is particularly mild, whereas these
two types of AGEs are found in excess in the tubules. Also, there
are high levels of pyrraline in the interstitium, while vascular
staining for AGEs is faint [33,73]. In lupus nephritis, patho-
logical lesions are present in the glomeruli and, in some cases,
the vessels, too, with a similar distribution, but weaker intensity
of staining of AGEs compared with DN. The increased AGEs
found in lupus glomerulonephritis could be the consequence of
chronic inflammation that leads to oxidative stress and glycox-
idation [74]. In vitro, RAGE activation of mesangial cells by
DNA antibody induces a proinflammatory response and may
contribute to renal changes [75].
It is uncertain to what extent kidney AGE accumulation is
a cause or consequence of kidney disease, and AGEs could
even exert effects through a sort of vicious circle. During CRF,
uraemia itself promotes blood and tissue AGE accumulation.
Reduction of AGE clearance and permanent oxidative (car-
bonyl) stress are responsible for such AGE excess [65]. Also, in
CRF, the presence of AGEs increases endothelial dysfunction
associated with an imbalance between relaxation and vasocon-
striction: endothelial reactivity is decreased, and the response to
ischaemia and hyperthermia is not adaptative [76]. In 51 non-
diabetic uraemic patients, blood levels of AGEs and mRNA of
Tubular basement membrane Interstitium Vessel walls
CML Pentosidine CML
Pentosidine Pentosidine CML
CML/Pentosidine Pentosidine CML
Pyrraline Pyrraline MDA-lysine
Pentosidine Pentosidine CML
6 M. Daroux et al. / Diabetes & Metabolism 36 (2010) 1–10
RAGE correlated with the glomerular filtration rate and endothe-
lial dysfunction. AGEs accelerate degradation of renal function
by promoting fibrosis at least in part through EMT, which itself
has been correlated with the extent and severity of intersti-
tial fibrosis and renal failure [77]. The postulated mechanisms
of senescence and ageing in organisms, ranging from yeast to
mammals, include environmental and genetic factors, elevated
oxidative stress, cumulative DNA damage, altered gene expres-
sion, telomere shortening and energy utilization. As AGEs are
implicated in physiological ageing, diabetes might be consid-
ered the equivalent of accelerated ageing, particularly at the
level of the vascular tree [7]. AGE blood levels and tissue accu-
mulation are increased in organs (blood vessels, brain, eyes
and kidneys) in healthy elderly people [21,78–80], and AGEs
also accumulate in various tissues with ageing. In Alzheimer’s
disease, AGEs have been found in neurofibrillary tangles and ␤-
amyloid plaques [81,82]. AGEs also have direct cellular toxicity
and are able to induce apoptosis through the caspase pathway
[83,84]. As glycation of tau is followed by reduction of its sol-
ubility and ability to be degraded, this may represent one of
the first steps in the development of Alzheimer’s [85]. Also, as
many cells and tissues of the eye are profoundly influenced by
glycation, AGEs are now receiving considerable attention as a
possible pathogenic factor in vision disorders. AGEs accumulate
in the macula in age-related macular degeneration, and RAGE
activation in retinal pigment epithelial cells may contribute to
the up-regulation of VEGF, thereby potentially inciting or prop-
agating neovascular macular disease [86]. In addition, numerous
factors, including AGEs, can contribute to renal ageing. Through
AGE accumulation, in situ glycation and RAGE activation, gly-
cation could promote the physiological and pathological effects
of renal ageing. It has recently been shown that AGEs in the
diet correlate with serum AGE levels, oxidative stress, lifespan
and renal dysfunction. Indeed, exogenous (dietary) AGEs are
reported to accelerate ageing in mice, while the addition of a
chemically defined AGE to low-AGE mouse chow can predis-
pose to the development of cardiovascular and chronic kidney
diseases [87].
5. Prevention and treatment
Diet may play a key role in the prevention of AGE-linked
pathologies. Food acts as a dietary source of variable amounts
of exogenous AGE, depending on its sugar and protein compo-
sition, and how it is cooked. The richer in proteins and sugars
a food is, and the more it is heated, the more AGEs it will con-
tain. In murine models, food restriction or a diet low in AGE
protects against the development of renal lesions [87,88]. Main-
taining optimal glycaemic balance provides a way of limiting
endogenous AGE neoformation.
Several targeted molecules have been tested as AGE
inhibitors. Aminoguanidine interacts with glucose-derived
products obtained from glycoxidation and the polyol pathway.
Its beneficial effect has, to a great extent, been demonstrated
in vitro and in vivo in animal models, with significant reduction
of AGE levels in blood and tissues [89,90]. In diabetic mice,
aminoguanidine not only prevents DN, but also diabetic
retinopathy and neuropathy, and improves endothelial dys-
function [91,92]. ACTION 1 (Aminoguanidine Clinical Trial
in Overt Type 1 Diabetic Nephropathy), a phase-III clinical
trial, failed to demonstrate any significant differences between
placebo and aminoguanidine-treated groups, and only a trend
towards lower serum creatinine and lower urinary protein was
observed with the treatment. The study was stopped because
of severe adverse effects such as abnormal liver function tests,
gastrointestinal disturbances, flu-like symptoms and vasculitis
or lupus-like phenomena [91].
Another AGE inhibitor has also been studied—namely,
2-isopropylidenehydrazono-4-oxo-thiazolidin-5-ylacetalinide
(OPB-9195), an ROS chelator that prevents the formation
of glucose derivatives such as methylglyoxal, glyoxal and 3-
deoxyglucosone, intermediaries that are indispensable for AGE
formation [93,94]. OPB-9195 is able to slow the progression
of glomerulosclerosis through a reduction in glycated collagen.
However, clinical studies were stopped because of vitamin B6
deficiency induced by OPB-9195 (pyridoxal chelator).
Of the aromatic ‘LR’ group, LR-90, LR-9 and LR-74 all
inhibit glycation of Amadori products and block glycoxidation.
Their in vivo effects are comparable to those of aminoguani-
dine and OPB-9195 [95]. Pyridoxamine, a vitamin B6 derivative,
inhibits the transformation of intermediary glycation products
[96]. Following injection of pyridoxamine in diabetic rats, a
decrease in the progression of DN has been observed [97]. Pyri-
doxamine has also been used in phase-II clinical trials without
major side-effects [98,99]. Furthermore, benfotiamine, a liposol-
uble vitamin B1 derivative, acts on glucose-derived products and
reduces the glycation of albumin [100]. Benfotiamine can reduce
AGE formation in endothelial cells and prevent the development
of DN lesions [101]. In type 2 diabetic patients, oral benfoti-
amine prevents endothelial dysfunction induced by a rich AGE
diet [102].
There are several possible ways to limit tissue AGE accu-
mulation and reduce their deleterious effects. Alagebrium
(ALT-711) is an AGE cross-link breaker (sugar/protein cross-
link) that can reduce AGE accumulation and improve endothelial
dysfunction [103]. ALT-711 administration in diabetic mice pre-
vented the biological and histological changes of DN [104].
Several clinical trials have also demonstrated beneficial effects
of ALT-711 on blood pressure, arterial stiffness, left ventricular
mass and diastolic filling [105–107].
In addition, a number of treatments currently in use as tar-
geted therapies for various disorders have recently been reported
to have ‘anti-AGE’ properties, including renin–angiotensin–
aldosterone system blockers [angiotensin-converting enzyme
(ACE) inhibitors, angiotensin II receptor blockers (ARBs)],
statins, some oral antidiabetics and antioxidative molecules. In
vitro, ACE inhibitors and ARBs are able to block the secretion
of AGE-induced TGF-␤ and reduce the formation of ROS [108].
These agents can also increase blood concentrations of sRAGE,
which can bind AGEs, thereby reducing renal AGE deposits and
DN progression [109,110], and have beneficial effects on oxida-
tive stress, reducing the glycoxidation pathway [111]. Statins can
reduce RAGE expression in diabetic patients, leading to effects
on MCP-1 production [112]. In vitro, metformin and piogli-
 M. Daroux et al. / Diabetes & Metabolism 36 (2010) 1–10
tazone were able to reduce AGE formation, but these effects
are yet to be confirmed in vivo [113–115]. Furthermore, some
antioxidants have demonstrated antiglycation effects [116].
Other compounds that are currently only used for basic
research may be developed for therapeutic purposes. The most
promising candidates are sRAGE and anti-RAGE antibody.
sRAGE acts as a decoy by binding AGEs and blocking RAGE
activation and, when injected intraperitoneally into db/db mice,
prevents albuminuria, glomerulosclerosis and glomerular base-
ment membrane (GBM) thickening [49]. Administration of
sRAGE also reduces inflammatory factors such as VCAM-1, TF
and TGF-␤1, and stabilizes atherosclerotic lesions [117,118].
Anti-RAGE antibody specifically blocks RAGE activation. In
vitro, RAGE antibodies reduce ECM remodelling [6]. Admin-
istration of anti-RAGE antibody over a 2-week period reduced
serum creatinine, albuminuria, GBM thickness and mesangial
volume in db/db and type 1 diabetic mice [119,120].
6. Conclusion
AGEs have numerous implications in ‘diabetic
nephropathies’. However, although they play a major role
in the development of DN itself, their presence has also
been demonstrated in other renal diseases and in ageing. The
battle against AGEs constitutes an integral part of the current
recommendations for renoprotective and ‘future’ anti-ageing
strategies. Nevertheless, while awaiting the development of a
patient-specific, targeted therapeutic approach, there is still a
need for strict glycaemic control, a suitably adapted diet, and
vascular protection through the use of ACE inhibitors or ARBs,
statins and certain oral antidiabetic agents.
7. Conflicts of interest
No potential conflicts of interest relevant to this article have
been reported.
Acknowledgments
Pr Éric Boulanger has held a post-doctoral position in the
laboratory of Dr Ann Marie Schmidt at Columbia University in
NY, USA, and would like to thank ALFEDIAM (Association
de langue française pour l’étude du diabète et des maladies
métaboliques) for kindly providing him with a grant.
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