1. Drug-Induced Nephrotoxicity
Chronic kidney disease affects 8–16% of the global population
[1]. It is characterized by the gradual loss of key functions over time, eventually leading to kidney failure requiring dialysis or kidney transplantation to maintain life
[2]. Moreover, recent studies further reveal that acute kidney injury (AKI) is positively associated with the risk of chronic kidney disease, and patients with chronic kidney disease complicated with AKI have a higher mortality rate
[3]. Even with the advancement of medical technology, the incidence of AKI has gradually increased in recent years, leading to an increase in patient mortality
[4]. A variety of risk factors may contribute to the occurrence of AKI, including food preparations, drugs, infection, ischemia, sepsis, and intravenous contrast agents
[5][6]. In particular, drug-induced nephrotoxicity is a major contributing factor in approximately 60% of AKI cases in hospitalized patients
[7].
Drug-induced nephrotoxicity causes more than 1.5 million adverse events in the United States each year, affecting approximately 20% of the adult population
[8][9]. Although kidney damage is usually reversible, it is estimated that the annual management cost is approximately $3.5 billion
[8]. Drug-induced nephrotoxicity is driven by multiple mechanisms, including renal tubular cytotoxicity, altered glomerular hemodynamics, inflammation, crystal nephropathy, and thrombotic microangiopathy
[10][11][12].
Direct nephron-toxicant mechanisms have been most extensively studied on the renal proximal tubule epithelial cells (RPTEC) (
Table 1). However, renal tubular epithelial cells express a wide range of transporters, many of which are unique to specific segments of renal tubules. Consequently, drugs with an affinity for these transporters cause cell apoptosis or death in specific nephron fractions
[13][14][15]. In contrast, some drugs, such as amphotericin B, cause renal tubular toxicity by non-specifically destroying the entire tubular epithelial cell membrane. In addition, renal tubular epithelial cells may be damaged by drug penetration, resulting in drug-induced kidney stones or drug-induced ischemic events. For example, contrast agents used in radiographic procedures such as angiography cause nephropathy by inducing oxidative stress and osmosis as well as hemodynamic changes
[16].
Table 1. Methods used for in vitro nephrotoxicity assessment in 3D models and in vivo renal tissues.
| Methods |
Renal Tubule Epithelia Cells |
Podocytes Stromal Cells |
| Drugs |
Targeted Cells |
Drugs |
Drugs |
| Drugs, chemicals, or toxic agents with different doses |
Gentamicin [17][18][19][20] Citrinin [17][21] Cisplatin [17][18][19][22][23][24][25][26][27][28][29] Rifampicin [17][30] Acetone [25][28][31] Aspirin [24][27][32] Penicillin G [24][27][33] Tenofovir [26][34] Cyclosporin A [26][35][36] Adriamycin [19][25][37] 4-aminophenol (PAP) [25][38] Colchicine [25][39] Cadmium chloride [40][41] |
Brush border membrane of the proximal tubules S2 proximal tubular segment Basolateral membrane of proximal tubules Apical membrane of renal proximal tubules S1 and S2 proximal tubular segment Loop of Henle Brush border membrane of the proximal tubules Basolateral mem-brane of proximal tubules Brush border membrane of the proximal tubules/Thick ascending limb of the loop of Henle Brush border membrane of the proximal tubules Loop of Henle S3 proximal tubular segment S1 proximal tubular segment |
Doxorubicin [17][42][43] Aspirin [27] Penicillin G [27] Puromycin-aminonucleoside [17][44] Adriamycin [42][43] |
Doxorubicin [17][43] Puromycin-aminonucleoside [17] |
| Time-frames |
24 h [17][18][22][26] 48 h [18][24][27][40] 72 h [19][25][28] 2 wks [19 |
[60][61], the validity of 2D in vitro studies is still questionable. Except for culture conditions that are far from the highly complex in vivo conditions, the measurable toxicity endpoints in these reflect a low-complexity system, but they faithfully reflect cell viability and proliferation, have poor physiological or clinical relevance, and there is no predictable in vivo drug response
[62].
2.2. Rodent Experiments
The use and outcome of animal models is essential to bridge the translational gap from the in vitro to the clinic. However, animal models are expensive to use, are time-consuming, require expertise, have low throughput potential, and have ethical issues, but most importantly, these models are usually less relevant to human systems
[63]. This mismatch between animal and human results is mainly due to the many differences in the expression of drug transporters and metabolic enzymes between species.
Rodents and rabbits are most used as animal models to test nephrotoxicity. However, the expression levels of organic cation transporter 1 (OCT1) and OCT2 are comparable in rodent kidneys, while OCT2 is dominant in human kidneys. The advantage of rabbit is that it is a suitable animal model between rodents and larger animal models (such as primates). The rabbit size allows off-the-shelf blood sampling and makes it easier to obtain many cells and tissues from a single animal. In addition, rabbits live longer than rodents. Genetically, the rabbit immune system and human immune system are significantly more similar than rodent genomes
[64]. The differences in the expression of transporters between animals and humans and between different non-human species limit the utility of animal models to study adverse drug reactions. Although these issues are improved, the development of more appropriate in vitro 3D models is needed for preclinical and early-stage clinical development
[65].
3. Three-Dimensional Renal Culture Models for Predicting Nephrotoxicity
The perception of in vitro 3D renal models is based on the creation of renal structures mimicking the physical and biochemical features of in vivo renal tissue with multiple cell types contacted to renal extracellular matrix ECM. Thus, 3D renal models are often divided into spheroids, organoids, and tissue-engineered models, and organ-on-chip models used in drug development or renal cancer modeling, are presented in Figure 1.
Figure 1. In vitro 3D kidney models for predicting nephrotoxicity. (A) Renal spheroids are often considered as RPTEC embedded in hydrogel to form hollow spherical cysts with an apical membrane facing the renal tubular lumen. (B) Organoids consist of multiple cells, different types of renal tubular, endothelial, and interstitial cells that self-organize in response to developmental cues and overcome the cellular simplicity of 2D cultures. (C) Three-dimensional (3D)-engineered kidney tissue consists of various renal cells with ECM as a complex and highly charged network (i.e., collagen, elastin, laminin, and glycoproteins), providing a 3D structure for the spatial organization of cells. (D) A kidney-liver-on-a-chip that comprises a perfusable, convoluted 3D renal tubule, and liver cells within the ECM enable fluid flow and the administration of test compounds to the apical surface of the cells.
The average in vivo cell density is up to 7.5 × 10
7 cells/mL, with solute concentrations of 30–80 g/L. By contrast, an in vitro 2D culture can only provide a maximum density of 10
6 cells/mL with solute concentrations of about 1–10 g/L. Two-dimensional (2D) cell cultures lack in vivo features such as cell–cell and cell–ECM interactions, matrix chemical composition and mechanics, chemotaxis gradients of soluble cell signals, cell oxygenation, and 3D matrix structure. These limitations in 2D culture will affect cell proliferation, polarization, migration, signal transduction, and gene expression
[66].
The difference in the physical and physiological properties between 2D and 3D cultures makes 2D cells more susceptible to drugs than 3D cells, because 2D cells cannot maintain their normal morphology compared to 3D cells
[67]. Another reason that 2D cells respond differently to drugs than 3D cells is the cell surface receptor organization. Drugs usually target certain receptors on the cell surface. The difference in the structure and spatial arrangement of the surface receptors may affect the drug receptor binding efficiency, thereby triggering different responses
[68]. Third, cells cultured in 2D are usually at the same cell proliferation stage, while 3D cells are usually at a different cell proliferation stage, similar to cells in the body
[67]. In 3D cellular systems, the cell proliferation stage is limited, which is similar to the in vivo situation
[69].
Microfluidics, which is a study of fluid flow in micron-size domains, proves to be an effective technology in the study both in vivo and in vitro. The capability of microfluidic devices to integrate all the necessary components in a less than a 1-inch silicon chip along with the advances in micro-electro-mechanical systems (MEMS) led to highly efficient lab-on-a-chip devices
[70]. Other unique features of a microfluidic platform such as its perfect length scale fitting at cellular and tissue levels as well as a very small number of required agents make them an excellent choice for biological applications
[71]. The collaboration between engineers, biologists, and medical doctors led to the advent of the organ-on-a-chip
[72][73][74].
The initial design of a published kidney-on-a-chip has two compartments
[75][76]. A top channel mimics the urinary lumen with fluid flow, whereas the bottom chamber mimics interstitial space and is filled with media. Kidney cells are under much lower shear stress than the endothelial cells. This device used rat distal tubular cells or Madin-Darby Canine Kidney (MDCK) cells, and its shear stress was ≈1 dyn/cm
2 [75]. A second report
[76] showed a similar design but with human proximal tubular cells attached. In a human renal cell model, the authors reproduced cisplatin nephrotoxicity in this channel system. Proximal tubular epithelial cells have much lower shear stress: ≈0.2 dyn/cm
2 [76]. The foot processes of podocyte, a glomerular visceral epithelial cell, form a size- and charge-selective barrier to plasma protein, and derangement of the barrier causes podocyte injury and proteinuria
[77]. In addition, podocyte-on-a-chip has been tried with no success yet
[78]. The challenge is that podocytes are exposed under a very low shear stress in vivo and require a sophisticated culturing condition.
Although the obvious advantages of 3D culture have been demonstrated, 3D cell culture is not as widely accepted as 2D culture in the research field, which is predicated on the large structural deviation in cellular phenotypes in the 3D model. The inconsistency between the models hinders reproducible experimental data and proper system analysis. Another practical consideration hindering the widespread use of 3D models is the high price, which further limits the feasibility of large-scale experiments
[67].
Table 2 summarizes the characteristics of 2D cell culture and 3D cell culture models.
Table 2. In vitro 2D vs. 3D renal models of drug-induced nephrotoxicity.
| Models |
Advantages |
Disadvantages |
| Biomarkers |
References |
| |
Protein markers |
m-RNA markers |
|
| 2D culture |
-Robust model -Easy to assess, manipulate -Cost- and time-efficient -Large scale -Retention of key metabolic |
| Podocytes |
Wilms tumor-1 Nephrin Podocin Podocalyxin Synaptopodin | -Static model -Dedifferentiation -Lack of in vivo-like morphologic and phenotypic characteristics -Low complexity -Little predictive -Poor physiological or clinical relevance |
| NPHS1 |
| NPHS2 Synaptopodin Wilms tumor-1 Podocalyxin |
[18] [83] [84] [23] [85] |
3D culture |
-In vivo-like cell shape -More physiologic characteristics -Response to toxic insults with biomarkers found in vivo
|
| Proximal tubules | ] |
-3D paracrine and autocrine signaling; -Potential penetration gradients toward center -Cells of different stages (proliferating, hypoxic, quiescent, and necrotic) possible -More similar to in vivo expression profiles -Better predictive values to in vivo compound responses60 min [44] 24 h [17] |
Lotus tetragonolobus lectin Aquaporin-1 (AQP1) Cadherin 6 Jagged 1 Megalin Kidney injury molecule 1[22][42] 48 h [27] 5 days [43] |
-Cost-intensive -Simplified architecture -Can be variable -Less amenable to HTS/HCS -Hard to reach in vivo maturity -Complication in assay -Lack vasculature -May lack key cell types24 h [17] 5 days [43] |
| Biomarkers |
| ABCC1 |
| ABCC3 ABCC4 SLC22A3 SLC40A1 |
[18] [83] [84 |
Animal models |
-Physiological resemblance -Well established |
|
|
| -Physiological relevance | -Complete organism -Test drug metabolism |
-Species differences -Low throughput -Poor prediction -Ethical concerns -High costs |
Gene markers |
Kim-1 [17][18][23][24] HO-1 [17] |
NPHS1 [17][42] WT1 |