Free Deoxycholic Acid Exacerbates Vascular Calcification in CKD through ER Stress-Mediated ATF4 Activation
Shinobu Miyazaki‐Anzai, Masashi Masuda, Yuji Shiozaki, Audrey L. Keenan, Michel Chonchol, Claus Kremoser, Makoto Miyazaki
Abstract
Key Points CKD increases levels of DCA, which induces endoplasmic reticulum stress in vascular smooth muscle cells and vascular calcification. Inhibition of FXR selectively increases DCA, resulting in severe vascular calcification. Inhibition of ATF4 in vascular smooth muscle cells blocks DCA-induced vascular calcification in vitro and in vivo . Background Our metabolome approach found that levels of circulating, free deoxycholic acid (DCA) is associated with the severity of vascular calcification in patients with CKD. However, it is not known whether DCA directly causes vascular calcification in CKD. Methods Using various chemicals and animal and cell culture models, we investigated whether the modulation of DCA levels influences vascular calcification in CKD. Results CKD increased levels of DCA in mice and humans by decreasing urinary DCA excretion. Treatment of cultured VSMCs with DCA but no other bile acids (BAs) induced vascular calcification and osteogenic differentiation through endoplasmic reticulum (ER) stress–mediated activating transcription factor-4 (ATF4) activation. Treatment of mice with Farnesoid X receptor (FXR)–specific agonists selectively reduced levels of circulating cholic acid–derived BAs, such as DCA, protecting from CKD-dependent medial calcification and atherosclerotic calcification. Reciprocal FXR deficiency and DCA treatment induced vascular calcification by increasing levels of circulating DCA and activating the ER stress response. Conclusions This study demonstrates that DCA plays a causative role in regulating CKD-dependent vascular diseases through ER stress–mediated ATF4 activation.