Gag polyprotein is the precursor of HIV-1 structural proteins, required for correct assembly, budding and maturation of viral particle within HIV-1 life cycle. The process of maturation into an infectious virion is dependent on Gag and GagPol cleavage at nine predefined sites by HIV-1 proteinase. Its disruption is one of the main targets of HIV treatment. HIV-1, however, develops resistance to the proteinase inhibitors by creating mutations in both the proteinase and the substrate. The Gag processing by HIV-1 proteinase is a highly sequential process, that happens in specific order and rate. Previous biochemical studies determined the kinetic data of these processes using oligopeptides representing naturally occuring cleavage sites. This thesis describes the cleavage of the Gag polyprotein itself, which is the natural substrate of HIV-1 proteinase. For this purpose, the full-length Gag polyprotein was recombinantly prepared in bacterial expression system. The cleavage was carried out and its products were analyzed via SDS-PAGE and Western blotting. The substrate specificity of the wild-type and mutant HIV-1 proteinase with respect to the full-length wild-type Gag polyprotein was compared. Substantial differences were observed between the rates of individual steps of cleavage by the wild-type and mutant...

Master of Science / Division of Biology / Kristin Michel / To date malaria is the most important tropical disease, which is caused by Plasmodium sp. and vectored by anopheline mosquitoes. The mosquito’s immune system is one of the limiting factors of malaria transmission. Immune reactions, such as the prophenoloxidase (PPO) pathway result in the melanization of pathogens, and are effective at limiting parasite numbers. Novel strategies for malaria control aim to exploit the immune system to interrupt parasite transmission by boosting the immune responses in the mosquito vector. Serpins play a crucial role in regulating protease cascades involved in immunity of arthropods. In Anopheles gambiae, the major malaria vector in Sub-Saharan Africa, 18 SRPN genes encoding 23 distinct proteins have been identified. So far, two are identified as active inhibitors, and both affect parasite survival. This research aims to identify additional inhibitory serpins in An. gambiae and elucidate their potential function. Identification of such serpins will enhance our understanding of the immune system of this important vector species and may identify immunoregulators to be used in malaria control. SRPN7, 9, and 18 were tested for their ability to inhibit commercial proteases in vitro. Recombinant SRPN18 had no inhibitory activity, while SRPN7 and 9 inhibited several serine proteases. SRPN7, 9 and 18 were tested against two recombinant An. gambiae clip serine proteases (CLIPBs) that are required for activation of phenoloxidase and thus regulate melanization. Only SRPN9 strongly inhibited CLIPB9 in vitro, suggesting that this serpin is a potential negative regulator of melanization. This hypothesis is further supported by the finding that SRPN9 can inhibit PO activity in insect hemolymph, ex vivo. Taken together, this research identifies SRPN18 as the first non-inhibitory serpin described in mosquitoes. Additionally, this study describes the larval-specific SRPN7 as a functional inhibitor. Future studies on these proteins will elucidate their precise physiological functions. Finally, this thesis provides strong evidence that SRPN9 is a negative regulator of melanization in An. gambiae and may therefore affect pathogen survival within this important vector species.

Master of Science / Department of Entomology / Marcelo Ramalho-Ortigao / Sand flies (Diptera:Psychodidae) are vectors of parasites of the genus Leishmania transmitted to suitable vertebrate host during blood feeding. For blood feeding arthropods, including sand flies, blood meal digestion requires the secretion of inhibitory molecules, such as Kazal-type serine proteinase inhibitors that are involved in preventing the blood from coagulating within the mouthparts and the midgut. Previous studies have identified such molecules in mosquitoes, ticks, and triatomine bugs. Following studies of the midgut transcriptome of Phlebotomus papatasi, the principal vector of Leishmania major, two non-classical Kazal-type serine proteinase inhibitors were identified (PpKzl1 and PpKzl2). We are interested in the role of these proteins as inhibitors of coagulation cascades, in addition to their potential effects on blood digestion in P. papatasi. Ppkzl1 is similar to thrombin and trypsin inhibitors in triatomines and mosquitoes and Ppkzl2 is similar to Kazal-type inhibitors in mosquitoes with unknown function. Analyses of expression profiles indicated that although both transcripts are expressed prior to blood feeding in the midgut of P. papatasi they are tightly regulated by the blood meal. Reverse genetics studies using RNAi-targeted knockdown of PpKzl1 and PpKzl2 by dsRNA injection did not result in a detectable effect on mRNA expression levels. Thus, we expressed a recombinant PpKzl2 in a mammalian expression system (CHO-S free style cells) that was applied to in vitro studies to assess activity against various serine proteinases. Recombinant PpKzl2 inhibited chymotrypsin at nanomolar levels and also inhibited thrombin and trypsin at micromolar levels, suggesting that native PpKzl2 is an active serine proteinase inhibitor and may regulate digestive enzymes and thrombin in the midgut. Leishmania development within the sand fly midgut is faced with several barriers that can severely impact the parasites. For transmission to occur, parasites must be able to overcome these barriers including digestive proteinases, escape from the peritrophic matrix, and midgut attachment. Early stages of Leishmania are susceptible to killing by digestive proteinases in the sand fly midgut. Thus, targeting serine proteinase inhibitors may provide a new strategy to prevent transmission of Leishmania.

Azetidine is a four-membered nitrogen-containing heterocyclic ring that has recently received a great deal of attention as a molecular scaffold for the design and preparation of biologically active compounds. Structure-activity studies employing functionalized azetidines have led to the development of variety of drug molecules and clinical candidates encompassing a broad spectrum of biological activities. Herein, the synthesis a novel series of 3-aryl-3-arylmethoxyazetidines is described. Selected 3-aryl-3-arylmethoxyazetidines were evaluated for their binding affinity to multiple monoaminergic transporters for the potential treatment of methamphetamine addiction. It was discovered that this scaffold exhibits high binding affinity (nM) for both the serotonin and dopamine transporters. In addition, a new method was developed for the synthesis of 3,3-diarylazetidines. This new approach provides a facile and efficient method to synthesize a variety of diaryl heterocycles including 3,3-diarylazetidines, 3,3-diarylpyrrolidines, and 4,4-diarylpiperidines in moderate to good yields.

Dans le but d'obtenir des composés originaux ayant une activité inhibitrice envers la NE, des triazoles et des 2-aminofuranes diversement substitués ont été synthétisés. Une réaction de "click chemistry" catalysée par le cuivre entre un azide et un alcyne a été appliquée pour la synthèse des triazoles. La synthèse des composés de type 2-aminofuranes est basée sur l'attaque nucléophile d'un isonitrile sur un γ-oxo butynoate d'alkyle en présence d'un aldéhyde aromatique.Les tests biologiques ont été réalisés tout au long de la thèse. Les composés présentant les meilleures IC50 envers la NE ont été sélectionnées pour une évaluation en terme de sélectivité vs les autres sérines protéases du PN (la cathepsine G et la protéinase 3). Enfin, les meilleurs inhibiteurs ont subi une évaluation de leur activité anti-oxydante selon deux méthodes: méthode au DPPH (1,1-diphényl-2-picryl-hydrazyl) et méthode au thiocyanate ferrique. / To prepare new compounds with an inhibitory activity towards NE, diversely substituted triazoles and 2-aminofuranes were synthesized. Triazoles were obtained using the copper catalyzed "click chemistry" between an azide and an alkyne. The synthesis of 2-aminofuranes is based on the nucleophilic attack of an isonitrile on an alkyl γ-oxo-butynoate in the presence of an aromatic aldehyde.Biological assays were carried out throughout the thesis. Compounds owning the best IC50 towards NE were selected for evaluation in terms of selectivity vs the two other serine-proteases of the PN (cathepsin G and proteinase 3). Finally, evaluation of antioxidant activity of the best compounds was achieved using by two approachs: DPPH (1,1-diphenyl -2-picrylhydrazyl) method and ferric thiocyanate method.

Human tissue transglutaminase (TG2) is a calcium-dependent multifunctional enzyme that natively catalyzes the post-translational modification of proteins, namely by the formation of isopeptide bonds between protein- or peptide-bound glutamine and lysine residues. This ubiquitously expressed enzyme plays important roles in cellular differentiation, extracellular matrix stabilization, and apoptosis, to name a few. However, its unregulated activity has been associated with many pathologies such as fibrosis, cancer, neurodegenerative disorders and celiac disease. Most of these disorders are associated with unregulated acyl-transferase activity. As such, the Keillor group has directed its efforts towards the development of TG2 inhibitors. Over the years, the Keillor group has synthesized large libraries of targeted covalent inhibitors against TG2. These compounds have undergone pharmacodynamic testing in order to examine their kinetic parameters of inhibition. Having gained knowledge of their enzyme kinetics, the logical next step was to consider their pharmacokinetic profiles. In the context of this thesis, we considered two important pharmacokinetic properties: membrane permeability and off-target reactivity. Firstly, we aimed to evaluate our inhibitors for their ability to permeate the cell membrane. In efforts to do so, we were able to adapt, optimize, and validate a parallel artificial membrane permeability assay (PAMPA) utilizing hexadecane as our artificial membrane. We were able to test a few of our own inhibitors and found that compounds NC9, VA4 and AA9 possess Log Pe values of -5.26 ± 0.01, -4.66 ± 0.04 and -6.5 ± 0.5 respectively. Secondly, we sought to investigate the susceptibility of our inhibitors to glutathione addition reactions under physiological conditions. We adapted and optimized a colorimetric assay using Ellman’s reagent (DTNB) and found that our inhibitors are minimally reactive with glutathione. The methods developed over the course of this work provide protocols that can be adopted for the characterization of future inhibitors in the Keillor group, along the process of developing TG2 inhibitors into drug candidates.

Des mutations faux-sens au niveau du récepteur à activité tyrosine kinase FGFR3 (Fibroblast Growth Factor Receptor 3) entrainent sa suractivation qui apporte des dysfonctions biologiques dans plusieurs maladies. L’achondroplasie, la forme la plus commune de chondrodysplasie liée à Fgfr3, est une maladie génétique rare, touchant 1 nouveau-né sur 20 000, caractérisée par des signes cliniques spécifiques : nanisme rhizomélique, membres courts, macrocéphalie, hypoplasie de l’étage moyen de la face, compression cervico-médullaire. L’activité anormale du récepteur induit des défauts de l’ossification endochondrale responsables du phénotype pathologique. Pendant longtemps le seul traitement pour cette maladie a été l’allongement chirurgical des membres, cependant au cours des dernières années de nombreux chercheurs ont développé des potentielles stratégies thérapeutiques basées sur des études moléculaires. L’objectif de ma thèse était d’évaluer une nouvelle approche thérapeutique pour l’achondroplasie. Une stratégie thérapeutique prometteuse prévoit l’utilisation de petits inhibiteurs chimiques, connus sous le nom d’inhibiteurs de tyrosine kinases, qui sont capables d’arrêter l’activité de FGFR3. J’ai estimé les effets d’un de ces composés, NVP-BGJ398, dans un modèle murin mimant le nanisme achondroplase (Fgfr3Y367C/+). Des expérimentations effectuées ont montré une amélioration des caractéristiques pathologiques dans les souris traitées avec NVP-BGJ398. Nous avons également examiné l’impact de la mutation activatrice de FGFR3 sur le développement mandibulaire. L’étude a reconnu un défaut dans la croissance mandibulaire chez l’homme et la souris atteints. En outre nous avons pu investiguer la croissance osseuse de la mandibule et corriger le défaut pathologique avec NVP-BGJ398. Enfin j’ai participé à des analyses moléculaires pour décrire comment trois mutations de FGFR3 localisées à la même position (Lys650) peuvent induire trois différents nanismes avec sévérité croissante. Les résultats ont fourni une meilleure compréhension des mécanismes moléculaires pathologiques et pourront mener à des nouvelles cibles pour des approches thérapeutiques. / Missense mutations in the tyrosine kinase receptor FGFR3 (Fibroblast Growth Factor Receptor 3) lead to its overactivation causing biological dysfunctions in several diseases. Achondroplasia, the most common Fgfr3-related chondrodysplasia, is a rare genetic disorder, affecting 1 in 20000 live births, characterized by particular clinical features: rhizomelic dwarfism, short limbs, macrocephaly, midface hypoplasia, cervicomedullary compression. The abnormal activity of the receptor induces endochondral ossification defects that are responsible for the pathological phenotype. For a long time the only treatment for this disease was the limb lengthening surgery, however in recent years several researchers have developed potential therapeutic strategies based on molecular studies. The objective of my thesis was to evaluate a novel therapeutic approach for achondroplasia. A promising therapeutic strategy involved the use of small chemical inhibitors, known as tyrosine kinase inhibitors, that are able to arrest the FGFR3 activity. I have assessed the effects of one of these compounds, NVP-BGJ398, in a mouse model mimicking the acondroplastic dwarfism (Fgfr3Y367C/+). The experiments performed showed an improvement of all pathological hallmarks in NVP-BGJ398 treated mice. We have also inspected the impact of the activating FGFR3 mutation on the mandibular development. The study established a defect in mandibular growth in both affected patients and mice. Furthermore we could investigate the mandibular bone growth and correct the pathological defect with NVP-BGJ398. Finally I have participated in molecular analyses to describe how three FGFR3 mutations at the same position could lead to three different dwarfisms with increasing severity. The results provided a better understanding of FGFR3 pathological molecular mechanisms and could lead to new targets for therapeutic approaches.

Magister Pharmaceuticae - MPharm / Due to the contribution of hypertension to various cardiovascular diseases, many studies are currently focused on identifying efficient bioactive compounds with antihypertensive activity and thus reducing the levels of cardiovascular disease. ACE inhibitors are an important component of the therapeutic regimen for treating hypertension, but due to the increase in the prevalence of side effects of synthetic compounds, alternative and complementary medicines which may consist of pure bioactive compound or a combination of various compounds from natural sources are gaining importance in overcoming hypertension. Hypericum perforatum has been studied for various activities including anti-bacterial, anti-depressant, anti-oxidant properties, but studies on its cardiovascular effects specifically ACE inhibitory activity have not yet been explored. In this study, ACEI assay-guided fractionation of the ethanol extract of Hypericum perforatum was carried out other to isolate a compound with ACE inhibition. A compound – (3-hydroxy 4, 4 dimethyl-4-butyrolactone) was isolated from an active fraction of the plant extract and was tested for ACE inhibition and its chemical structure elucidated using 1HNMR and C13NMR spectrometry and further characterized using mass spectrometry and FTIR.

Echinococcus multilocularis verursacht die Alveoläre Echinokokkose (AE), eine lebendsbedrohliche Krankheit mit limitierten chemotherapeutischen Möglichkeiten. Die jetzige Anti-AE Chemotherapie basiert auf einer einzigen Wirkstoffklasse, den Benzimidazolen. Obwohl Benzimidazole in vitro parasitozid wirken, wirken sie in vivo bei AE-Behandlung lediglich parasitostatisch und rufen schwere Nebenwirkungen hervor. In Fällen operabler Läsionen erfordert die Resektion des Parasitengewebes über einen längeren Zeitraum eine chemotherapeutische Unterstützung. Damit sind die jetzigen Behandlungsmöglichkeiten inadäquat und benötigen Alternativen. In der vorliegenden Arbeit wurden die Signalwege von Plattwürmern analysiert, um potentielle Targets für neue therapeutische Ansätze zu identifizieren. Dabei konzentrierte ich mich unter Anwendung von molekularbiologischer, biochemischer und zellbiologischer Methoden auf Faktoren, die an Entwicklung und Proliferation von E. multilocularis beteiligt sind. Darunter waren die drei MAP kinases des Parasiten EmMPK1, ein Erk1/2-Ortholog, EmMPK2, ein p38-Ortholog und EmMPK3, ein Erk7/8-Ortholog. Des Weiteren identifizierte und charakterisierte ich EmMKK2, ein MEK1/2-Ortholog des Parasiten, welches zusammen mit den bekannten Kinasen EmRaf und EmMPK1 ein Erk1/2-ähnliches MAPK Modul bildet. Ich konnte zudem verschiedene Einflüsse von Wirtswachstumsfaktoren wie EGF (epidermal growth factor) und Insulin auf die Signalmechanismen des Parasiten und das Larvenwachstum zeigen, darunter die Phosphorylierung von Elp, ein Ezrin-Radixin-Moesin ähnliches Protein, die Aktivierung von EmMPK1 und EmMPK3 und eine gesteigerte mitotische Aktivität der Echinokokkenzellen. Zusätzlich wurden verschiedene Substanzen auf ihre letale Wirkung auf den Parasiten untersucht, darunter befanden sich (1.) generelle Inhibitoren von Tyrosinkinasen (PP2, Leflunamid), (2.) gegen die Aktivität von Rezeptor-Tyrosin-Kinasen gerichtete Präparate, (3.) ursprünglich anti-neoplastische Wirkstoffe wie Miltefosin und Perifosin, (4.) Inhibitoren von Serin/ Threonin-Kinasen, die die Erk1/2 MAPK Kaskade blockieren und (5.) Inhibitoren der p38 MAPK. In diesen Untersuchungen hat sich EmMPK2 aus den folgenden Gründen als vielversprechendes Target erwiesen. Aminosäuresequenz-Analysen offenbarten einige Unterschiede zu menschlichen p38 MAP Kinasen, welche sehr wahrscheinlich die beobachtete gesteigerte basale Aktivität des rekombinanten EmMPK2 verursachen, verglichen mit der Aktivität humaner p38 MAPK-α. Zusätzlich suggerieren die prominente Autophosphorylierungsaktivität von rekombinantem EmMPK2 und das Ausbleiben einer Interaktion mit den Echinococcus MKKs einen unterschiedlichen Regulierungsmechanismus im Vergleich zu den humanen Proteinen. Die Aktivität von EmMPK2 konnte sowohl in vitro als auch in kultivierten Metazestodenvesikeln durch die Behandlung mit SB202190 und ML3403, zwei ATP kompetitiven Pyridinylimidazolinhibitoren der p38 MAPK, in Konzentrations-abhängiger Weise inhibiert werden. Zudem verursachten beide Substanzen, insbesondere ML3403 die Inaktivierung von Parasitenvesikeln bei Konzentrationen, die kultivierte Säugerzellen nicht beeinträchtigten. Ebenso verhinderte die Anwesenheit von ML3403 die Generation von neuen Vesikeln während der Kultivierung von Echinococcus Primärzellen. Das Targeting von Mitgliedern des EGF-Signalwegs, insbesondere der Erk1/2-ähnlichen MAPK Kaskade mit Raf- und MEK- Inhibitoren verhinderte die Phosphorylierung von EmMPK1 in in vitro kultivierten Metazestoden. Obwohl das Parasitenwachstum unter diesen Konditionen verhindert wurde, blieb die strukturelle Integrität der Metazestodenvesikeln während der Langzeitkultivierung in Anwesenheit der MAPK Kaskade-Inhibitoren erhalten. Ähnliche Effekte wurden beobachtet nach Behandlung mit den anderen zuvor aufgeführten Inhibitoren. Zusammenfassend lässt sich festhalten, dass verschiedene Targets identifiziert werden konnten, die hoch sensibel auf die Anwesenheit der inhibitorischen Substanzen reagierten, aber nicht zum Absterben des Parasiten führten, mit Ausnahme der Pyridinylimidazolen. Die vorliegenden Daten zeigen, dass EmMPK2 ein Überlebendsignal vermittelnden Faktor darstellt und dessen Inhibierung zur Behandlung der AE benutzt werden könnte. Dabei erwiesen sich p38 MAPK Inhibitoren der Pyridinylimidazolklasse als potentielle neue Substanzklasse gegen Echinokokken. / Echinococcus multilocularis is the causative agent of alveolar echinococcosis (AE), a life-threatening disease with limited options of chemotherapeutic treatment. Anti-AE chemotherapy is currently based on a single class of drugs, the benzimidazoles. Although acting parasitocidic in vitro, benzimidazoles are merely parasitostatic during in vivo treatment of AE and cause severe site effects. In the case of operable lesions, the resection of parasite tissue needs to be supported by a prolonged chemotherapy. Thus, the current treatment options for AE are inadequate and require alternatives. In the present work, the flatworm signaling pathways were analyzed to establish potential targets for novel therapeutic approaches. I focused on factors that are involved in development and proliferation of E. multilocularis using molecular, biochemical and cell biological methods. Among the analysed factors were three MAP kinases of the parasite, EmMPK1, an Erk-1/2 orthologue, EmMPK2, a p38 orthologue and EmMPK3, an Erk7/8 orthologue. Further, I identified and characterized EmMKK2, a MEK1/2 orthologue of the parasite, which, together with the known kinases EmRaf and EmMPK1, forms an Erk1/2-like MAPK module. Moreover, I was able to demonstrate several influences of host growth factors such as EGF (epidermal growth factor) and insulin on worm signaling mechanisms and larval growth, including the phosphorylation of Elp, an ezrin-radixin-moesin like protein, EmMPK1, EmMPK3 and increased mitotic activity of Echinococcus cells. In addition, several substances were examined for their efficacy against the parasite including (i) general tyrosine kinase inhibitors (PP2, leflunamide), (ii) compounds designed to inhibit the activity of receptor tyrosine kinases, (iii) anti-neoplastic agents (miltefosine, perifosine), (iv) serine/threonine kinase inhibitors that have been designed to block the Erk1/2 MAPK cascade and (v) inhibitors of p38 MAPKs. In these studies, EmMPK2 proved to be a promising drug target for the following reasons. Amino acid sequence analysis disclosed several differences to human p38 MAPKs, which is likely to be the reason for the observed enhanced basal activity of recombinant EmMPK2 towards myelin basic protein in comparison to human recombinant p38 MAPK-α. In addition, the prominent auto-phosphorylation activity of the recombinant EmMPK2 protein together with the absence of an interaction with the Echinococcus MKKs suggest a different mechanism of regulation compared to the human enzyme. EmMPK2 activity could be effectively inhibited in vitro and in cultivated metacestode vesicles by treatment with SB202190 and ML3403, two ATP-competitive pyridinyl imidazole inhibitors of p38 MAPKs, in a concentration-dependent manner. Moreover, both compounds, in particular ML3403, caused parasite vesicle inactivation at concentrations which did not affect cultured mammalian cells. Likewise, during the cultivation of Echinococcus primary cells, the presence of ML3403 prevented the generation of new vesicles. Targeting members of the EGF signaling pathway, particulary of the Erk1/2-like MAPK cascade, with Raf and MEK inhibitors prevented the phosphorylation of EmMPK1 in metacestodes cultivated in vitro. However, although parasite growth was prevented under these conditions, the structural integrity of the metacestode vesicles maintained during long-term cultivation in the presence of the MAPK cascade inhibitors. Similar results were obtained when studying the effects of other drugs mentioned above. Taken together, several targets could be identified that reacted with high sensitivity to the presence of inhibitory substances, but did not cause the parasite’s death with one exception, the pyridinyl imidazoles. Based on the presented data, I suggest pyridinyl imidazoles as a novel class of anti-Echinococcus drugs and imply EmMPK2 as survival signal mediating factor, the inhibition of which could be used for the treatment of AE.

Chronic kidney disease (CKD), defined as a decrease in renal function, is a global issue. The treatment of CKD and its comorbidities imparts a costly burden on the American healthcare system, therefore the need for therapeutics that prevent the progression of chronic kidney disease is urgent. Microarray studies have shown that the serine protease inhibitor clade A member 3 (SERPINA3) is transcriptionally upregulated in kidney injury. SERPINA3 is an extracellular protease inhibitor that maintains the homeostasis of extracellular matrix proteins. Our lab hypothesizes that SERPINA3 might not only be a transcriptional biomarker for kidney injury, but the SERPINA3 protein might act as a key upstream regulator in the advancement of renal inflammation and fibrosis. Our research characterizes the expression patterns of SERPINA3 in models of acute and chronic kidney injury through immunoblotting and immunohistochemistry. Our unilateral ureteral obstruction (UUO) model of chronic renal injury displays significant glomerular localization of SERPINA3. The adenine diet model of chronic kidney injury and the renal ischemic reperfusion injury (RIRI) model of acute kidney injury both display tubular upregulation of SERPINA3. The DOCA-salt hypertension model of chronic kidney injury was imposed on two strains of mice, C57BL/6 and 129/sv, both of which display tubular and glomerular upregulation of SERPINA3. However, the C57BL/6 strain, which is known for its resistance to glomerular sclerosis, displays higher renal localization of SERPINA3 when exposed to DOCA-salt hypertension, than does the 129/sv strain. In conclusion, our data suggests that SERPINA3 protein is upregulated in both acute and chronic kidney injury. The role of SERPINA3 in these models remains unknown, however, our lab theorizes that SERPINA3 protein may be renoprotective in certain instances of kidney injury. Functional assays must be performed to elucidate the role of SERPINA3 in these models of kidney injury. Characterizing the function of SERPINA3 in chronic and acute kidney injury might aid in the development of novel therapeutics to prevent the advancement of CKD.