Identification of Glomerular and Plasma Apolipoprotein M as Novel Biomarkers in Glomerular Disease

Introduction: Dysregulation of sphingolipid and cholesterol metabolism contributes to the pathogenesis of glomerular diseases (GDs). Apolipoprotein M (ApoM) promotes cholesterol efflux and modulates the bioactive sphingolipid sphingosine-1-phosphate (S1P). Glomerular ApoM expression is decreased in patients with focal segmental glomerulosclerosis (FSGS). We hypothesized that glomerular ApoM deficiency occurs in GD and that ApoM expression and plasma ApoM correlate with outcomes. Methods: Patients with GD from the Nephrotic Syndrome Study Network (NEPTUNE) were studied. We compared glomerular mRNA expression of ApoM (gApoM), sphingosine kinase 1 (SPHK1), and S1P receptors 1 to 5 (S1PR1-5) in patients (n 84) and controls (n 6). We used correlation analyses to determine associations between gApoM, baseline plasma ApoM (pApoM), and urine ApoM (uApoM/Cr). We used linear regression to determine whether gApoM, pApoM, and uApoM/Cr were associated with baseline estimated glomerular filtration rate (eGFR) and proteinuria. Using Cox models, we determined whether gApoM, pApoM, and uApoM/Cr were associated with complete remission (CR) and the composite of end-stage kidney disease (ESKD) or 40% eGFR decline. Results: gApoM was reduced (P < 0. 01) and SPHK1 and S1PR1 to 5 expression was increased (P < 0. 05) in patients versus controls, consistent with ApoM/S1P pathway modulation. gApoM positively correlated with pApoM in the overall cohort (r 0. 34, P < 0. 01) and in the FSGS (r 0. 48, P < 0. 05) and minimal change disease (MCD) (r 0. 75, P < 0. 05) subgroups. Every unit decrease in gApoM and pApoM (log 2) was associated with a 9. 77 ml/min per 1. 73 m 2 (95% confidence interval CI: 3. 9615. 57) and 13. 26 ml/min per 1. 73 m 2 (95% CI: 3. 5722. 96) lower baseline eGFR, respectively (P < 0. 01). From Cox models adjusted for age, sex, or race, pApoM was a significant predictor of CR (hazard ratio HR: 1. 85; 95% CI: 1. 06-3. 23). Conclusions: pApoM is a potential noninvasive biomarker of gApoM deficiency and strongly associates with clinical outcomes in GD.