Chronic Cyclosporine-A treatment is associated with serious side effects, including kidney toxicity and anemia. Although pathophysiology of Cyclosporine-A-induced kidney injury remains incompletely understood, hypoxia is likely involved. Here, we investigated the effect of the hypoxia inducible factor activator daprodustat on Cyclosporine-A -induced kidney toxicity. As Cyclosporine-A profoundly alters protein phosphorylation by inhibiting the phosphatase calcineurin, special attention was directed towards the kidney phospho-proteome. Mice received Cyclosporine-A with or without daprodustat for up to eight weeks. In kidney homogenates, 1360 selected proteins were analyzed at expression and phosphorylation levels. Of these, Cyclosporine-A changed the expression of 79 and the phosphorylation of 86 proteins. However, when Cyclosporine-A treatment was combined with daprodustat, the expression of 95 proteins and phosphorylation of only six proteins was altered suggesting that daprodustat prevented most protein phosphorylation brought about by Cyclosporine-A. Although daprodustat showed only marginal effect on its own, angiogenesis-related pathways were among the most profoundly impacted by daprodustat when given on top of Cyclosporine-A. Additionally, Cyclosporine-A lowered the blood hemoglobin concentration and caused kidney capillary rarefaction, which daprodustat prevented. Thus, combined daprodustat/Cyclosporine-A treatment prevented deleterious Cyclosporine-A effects on microcirculation and hemoglobin, and the protective action of daprodustat involves suppression of broad protein phosphorylation changes caused by Cyclosporine-A.

Osmotic stress represents a major challenge to cells, particularly in the kidney, where tonicity gradients are both physiologically relevant and pathologically altered. The transcription factor nuclear factor of activated T cells 5 (NFAT5) is a key regulator of the osmoadaptive response, yet its downstream metabolic effectors remain incompletely understood. In this study, we identify the glycolytic side-branch enzyme 2,3-bisphosphoglycerate mutase (BPGM) as a transcriptional NFAT5 target that is induced under hypertonic conditions. RNA-seq analysis revealed that Bpgm knockdown significantly alters gene expression under osmotic stress (450 mOsmol/kg), with substantial overlap between BPGM- and NFAT5-responsive transcriptional programs. Bpgm depletion impairs the induction of canonical NFAT5 target genes, suggesting a functional interplay between metabolic and transcriptional adaptation. Promoter enrichment analysis showed that genes regulated by both NFAT5 and BPGM under hypertonic conditions are associated with CpG islands and GC-rich elements, supporting a link to chromatin structure and transcriptional accessibility. Consistently, we show that HIF-1α expression is regulated downstream of NFAT5 and BPGM, indicating a hierarchical organization of osmotic and hypoxic stress responses. We propose that BPGM facilitates NFAT5 function through metabolic-epigenetic coupling, acting as an amplifier of protective gene expression. Notably, this axis is active in BPGM-expressing cells such as those of the distal convoluted tubule. Thus, our findings establish BPGM as a critical node in the osmoadaptive gene regulatory network and highlight how cell type-specific metabolic profiles influence the transcriptional response to hypertonic stress. Graphical abstract

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Clear cell renal cell carcinoma (ccRCC) is characterized by profound metabolic reprogramming and limited responsiveness to therapeutic stressors, including epigenetic modulation. How glycolytic enzymes contribute to metabolic stress tolerance in ccRCC remains incompletely understood. We investigated the role of the glycolytic enzyme 2,3-bisphosphoglycerate mutase (BPGM) using human tumor specimens, siRNA-mediated gene silencing, functional cell-based assays, and transcriptomic profiling. Epigenetic stress was induced using Vorinostat as a pan-histone deacetylase inhibitor. BPGM expression was consistently elevated in human ccRCC compared with adjacent normal kidney tissue. A498 cells exhibited high basal BPGM levels and limited sensitivity to Vorinostat, whereas BPGM depletion increased cellular stress responses and reduced proliferative capacity. Despite similar phenotypic outcomes, BPGM silencing and Vorinostat treatment triggered distinct transcriptional programs. While HDAC inhibition induced widespread transcriptional changes, BPGM loss elicited a focused stress-associated response, consistent with activation of the unfolded protein response, increased lipid peroxidation, and induction of ER stress-associated genes. Our data identify BPGM as a metabolic player contributing to stress-adaptive transcriptional states in ccRCC and suggest that targeting metabolic stress adaptation may complement epigenetic strategies in renal cancer.