John Cijan He, MD, PhD, is a Professor of Medicine and Pharmacological Sciences and Chief of the Division of Nephrology at the Icahn School of Medicine at Mount Sinai.

John Cijan He, MD, PhD

APOL1-Mediated Kidney Disease: From Genetic Discovery to the Edge of Precision Medicine


A decade and a half after APOL1 was linked to kidney disease, clinicians are still grappling with misdiagnosis, unpredictable progression, and uneven access to genetic insight, just as targeted therapies begin to emerge.

Kirk Campbell, MD, Professor of Medicine and Chief of the Renal Division at the University of Pennsylvania Perelman School of Medicine.

Pranav Garimella, MD, Chief Medical Officer of the American Kidney Fund,

Kristin Meliambro, MD, is an Associate Professor in the Department of Medicine, Division of Nephrology at the Icahn School of Medicine at Mount Sinai.

Katalin Susztak, MD, PhD, is a Professor of Medicine and Genetics at the University of Pennsylvania

John Cijan He, MD, PhD, Professor of Medicine and Pharmacological Sciences and Chief of the Division of Nephrology at the Icahn School of Medicine at Mount Sinai

A Genetic Discovery That Reshaped Kidney Disease Risk

In the span of roughly 16 years, APOL1 has moved from evolutionary curiosity to one of the most important genetic risk factors in nephrology.

The G1 and G2 variants, enriched in populations with West and Central African ancestry, rose in frequency because they confer protection against 

 infection. Today, they are recognized as among the strongest common genetic risk factors for kidney disease.

Approximately one-third of African Americans carry at least one high-risk APOL1 variant, and about 14% carry the high-risk genotype—two risk alleles in combinations such as G1/G1, G2/G2, or G1/G2. Globally, more than 100 million people in sub-Saharan Africa are estimated to carry two risk variants, with frequencies reaching 37% in parts of Ghana and 50% in southeastern Nigeria.

“It is a long time,” said Campbell. “But the fact that it took 13 years from the discovery of APOL1 kidney disease genetic association to the first proof-of-concept APOL1 inhibitor efficacy report should be celebrated.”

At the same time, Campbell emphasized ongoing uncertainty:

“There are still no approved APOL1-specific therapies, no consensus on population screening, limited ability to predict who among carriers will progress, and unresolved questions about ‘second hits,’” he said.

Rethinking a Default Diagnosis: Hypertension as Explanation — or Misclassification

Before APOL1 can be treated, it must be recognized—and that remains a persistent challenge.

Hypertensive nephrosclerosis has long served as a default diagnosis for chronic kidney disease in patients with hypertension, particularly Black patients. But emerging evidence suggests this label often obscures more specific and potentially treatable disease.

One biopsy-based study found that clinical criteria for nephrosclerosis had a sensitivity of just 0.13. Even optimized algorithms only reached 0.19, and roughly 40% of clinically diagnosed cases were found to have alternative diagnoses such as glomerulonephritis or interstitial nephritis.

Clinicians increasingly caution against treating hypertension as the primary explanation by default. “Hypertensive nephrosclerosis is often a diagnosis of exclusion,” Garimella noted. “Some patients labeled that way actually have APOL1-associated kidney disease, FSGS, or another primary kidney disorder.”

The reframing has clinical and psychological implications. Elevated blood pressure may in some cases be a consequence rather than a cause of kidney disease.

“Sometimes patients feel that explanation doesn’t fully make sense, especially if their hypertension hasn’t seemed severe,” Meliambro observed. “Recognizing that there may have been more going on can be validating rather than implying they did something wrong.”

The data on blood pressure management remain nuanced. Some studies show intensive blood pressure control does not necessarily slow progression in high-risk APOL1 carriers, while other data suggest a survival benefit with more intensive control compared with standard targets.

The introduction of a dedicated ICD code for APOL1-mediated kidney disease represents an important structural shift, enabling more precise diagnosis, counseling, and trial referral.

The Core Problem: Risk Without Prediction

While identifying APOL1 risk variants is now straightforward, predicting outcomes remains the central clinical challenge.

Carriers of two high-risk alleles face an estimated 15%–20% lifetime risk of kidney disease—meaning roughly 80% will never develop kidney failure.

“This represents a major knowledge gap,” Susztak explained. “If you receive a genotype result, you start asking: should I be doing something specific to prevent disease?”

Traditional risk models have not resolved this. Polygenic risk scores have failed to improve prediction in APOL1 high-risk individuals. Clinical risk scores based on eGFR, proteinuria, age, and sex perform well in established disease but are not clinically meaningful in preserved kidney function, she said.

“Some work has suggested that the G1/G1 genotype might be associated with a higher risk of decline in GFR and also a younger age of developing kidney disease,” Meliambro noted, adding that this requires further validation. High-risk genotype is still defined as any two risk alleles.

To address this gap, researchers turned to proteomics.

In a study of approximately 1,400 African American individuals from the Penn Medicine Biobank—many with preserved kidney function and no proteinuria at baseline—researchers analyzed roughly 7,700 circulating proteins.

Using machine learning, they identified nine proteins that, combined with clinical variables, formed the APOL1 Proteomic Risk Score (APRS), achieving a time-dependent AUC of 86.5%.

Individuals in the highest-risk quintile had approximately a 60% probability of progressing to dialysis or transplant over 10 years, while those in the lowest-risk quintile had less than a 1% risk. The score outperformed both the Kidney Failure Risk Equation and polygenic risk scores.

“Some of these proteins are related to tissue damage in the kidney that is not reflected in creatinine levels or urinary protein,” Susztak said. “For example, markers like MMP7 and matrix proteins may reflect fibrosis or injury that isn’t detected with standard tests.”

Others reflect inflammatory and endothelial pathways.

The score has been validated in external cohorts, including UK Biobank and NIH-supported data, but remains a research tool.

“We need to incorporate this biomarker into clinical trials and demonstrate that it is actionable,” she said. “Currently, we can treat the disease but not cure it.”

What APOL1 Biology Is Revealing About Early Kidney Injury

Beyond prediction, APOL1 research is reshaping understanding of early disease biology.

“In African American patients, we know the APOL1 gene is a high-risk gene for what we call APOL1-mediated glomerular disease, which is essentially like FSGS,” said He. “When this gene is highly expressed, it can cause podocyte injury through specific cellular pathways.”

“Some of these proteins are related to tissue damage in the kidney that is not reflected in creatinine levels or urinary proteins,” Susztak said.

“Other proteins are linked to inflammation. APOL1 is strongly regulated by inflammation, so individuals with higher inflammatory states may be at greater risk.”

“And there are a few proteins related to endothelial injury that we are still working to understand.”

Together, these findings suggest injury may precede traditional clinical markers such as proteinuria or eGFR decline.

From Biology to Therapy: Precision Medicine Takes Shape

Mechanistic insight has enabled targeted drug development.

“Based on that mechanism, therapies have been developed to block the pathways activated by APOL1,” He said. “These inhibitors have shown promising results in reducing proteinuria in phase 2 studies, with ongoing phase 3 trials.”

Inaxaplin directly targets APOL1 pore formation in podocytes.

“This is a very specific, targeted therapy that inhibits the pore-forming function of the APOL1 protein,” Meliambro said. “It represents a true example of precision medicine in nephrology.”

Other approaches include antisense oligonucleotides and anti-inflammatory strategies.

Despite therapeutic advances, management remains standard CKD care.

“A two-risk-variant APOL1 genotype raises concern for progressive disease,” Garimella explained. “But the treatment backbone remains standard CKD care.”

That includes RAAS blockade, SGLT2 inhibitors when appropriate, blood pressure control, statins, and avoidance of nephrotoxins.

“APOL1 testing is worth considering when the result can change follow-up, trial eligibility, transplant donor counseling, or future targeted-treatment decisions,” Campbell said. “But it should come with counseling, and it should never replace a full kidney-disease workup.”

“Awareness only matters if it changes decisions such as diagnosis, counseling, testing, referral, or follow-up,” Garimella said.

The ICD code for APOL1-mediated kidney disease may help translate awareness into action.

Barriers to Integration and Uneven Adoption

Despite availability of testing, adoption remains inconsistent.

“It’s not necessarily ordering the test—it’s interpreting and explaining the results,” Meliambro said.

Barriers include lack of guidelines, limited genetic counseling infrastructure, and patient concerns about privacy and discrimination.

Equity Will Define the Impact of Precision Medicine

“Equitable access would require more than drug approval,” Campbell said. “It would require payer coverage for testing, counseling, nephrology referral, and medication.”

“Otherwise, we risk repeating the same inequities,” he said. “Patients with better access get tested and treated, while underserved populations remain underdiagnosed.”

The decision to hold a major consensus meeting in Accra reflects the field’s shifting center of gravity.

“This is a rapidly evolving field,” Meliambro said. “There has been substantial research progress. But there are still many unresolved questions—especially around predicting disease progression and translating this knowledge into improved patient outcomes.”

“There is significant investment and enthusiasm,” she added. “Hopefully that will lead to meaningful breakthroughs in the near future.”

Campbell reports relevant disclosures with NIH, National Kidney Foundation. Garimella reports relevant disclosures with NIH. Meliambro reports no relevant disclosures identified. Susztak reports relevant disclosures with NIH. He reports no relevant disclosures identified.

Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science. 2010;329(5993):841-845. doi:10.1126/science.1193032

Tzur S, Rosset S, Shemer R, et al. Missense mutations in the APOL1 gene are highly associated with end stage kidney disease risk previously attributed to the MYH9 gene. Hum Genet. 2010;128(3):345-350. doi:10.1007/s00439-010-0861-0

Friedman DJ, Pollak MR. APOL1 nephropathy: from genetics to clinical applications. Clin J Am Soc Nephrol. 2021;16(2):294-303. doi:10.2215/CJN.15161119

Gbadegesin RA, Ulasi I, Ajayi S, et al. APOL1 bi- and monoallelic variants and chronic kidney disease in West Africans. N Engl J Med. 2025;392:228-238. doi:10.1056/NEJMoa2403840

Hallan S, Øien CM, Garborg K, et al. Hypertensive nephrosclerosis: wider kidney biopsy indications may be needed to improve diagnostics. J Intern Med. 2021;289(4):527-540. doi:10.1111/joim.13146

Ojo A, Ulasi I, Freedman BI, et al. APOL1 kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. Published online June 23, 2025. doi:10.1016/j.kint.2025.04.029

Li C, et al. Proteomic risk score for early prediction of kidney disease progression in individuals with APOL1 high-risk genotypes. Nat Med. Published online April 15, 2026. doi:10.1038/s41591-026-04337-2

Egbuna O, Zimmerman B, Manos G, et al. Inaxaplin for proteinuric kidney disease in persons with two APOL1 variants. N Engl J Med. 2023;388(11):969-979. doi:10.1056/NEJMoa2202396

Vertex Pharmaceuticals Incorporated. Vertex advances inaxaplin (VX-147) into phase 3 portion of adaptive phase 2/3 clinical trial for the treatment of APOL1-mediated kidney disease. Press release. April 1, 2024. Accessed May 1, 2026. https://news.vrtx.com/news-releases/news-release-details/vertex-advances-inaxaplin-vx-147-phase-3-portion-adaptive-phase

Vertex Pharmaceuticals Incorporated. Vertex announces key advancements across kidney portfolio. Press release. September 25, 2025. Accessed May 1, 2026. https://news.vrtx.com/news-releases/news-release-details/vertex-announces-key-advancements-across-kidney-portfolio

Maze Therapeutics. Maze Therapeutics doses first patient in phase 2 HORIZON clinical trial evaluating MZE829 as a potential treatment for APOL1 kidney disease. Press release. February 7, 2025. Accessed May 1, 2026. https://ir.mazetx.com/news-releases/news-release-details/maze-therapeutics-doses-first-patient-phase-2-horizon-clinical

Maze Therapeutics. Maze Therapeutics announces positive topline data from phase 2 HORIZON trial of MZE829. Press release. March 25, 2026. Accessed May 1, 2026. https://ir.mazetx.com/news-releases/news-release-details/maze-therapeutics-announces-positive-topline-data-phase-2

Articles

APOL1 G1/G2 variants, selected for trypanosome resistance, are prevalent in people with West/Central African ancestry and drive substantial CKD and FSGS risk, yet progression remains poorly predictable. Hypertensive nephrosclerosis frequently misclassifies underlying glomerular or interstitial disease, prompting calls for more precise workups and use of the new APOL1-mediated kidney disease ICD code. A nine-protein APOL1 Proteomic Risk Score stratifies 10-year kidney failure risk far better than existing models. Targeted APOL1 inhibitors (eg, inaxaplin) and other modalities are advancing, while equitable access to testing, counseling, and therapy lags.

APOL1 research is driving precision nephrology, but prediction gaps and equity challenges still limit clinical impact.

APOL1-Mediated Kidney Disease: From Genetic Discovery to the Edge of Precision Medicine

Emerging Targets in Podocyte Injury Signal Shift in Glomerular Disease Treatment, With John Cijiang He, MD, PhD

An evolving understanding of podocyte injury in glomerular disease is being driven by advances in genetics, targeted therapeutics, and biomarker development, signaling a shift beyond traditional immunosuppression.

Recently, John Cijiang He, MD, PhD, Professor of Medicine and Pharmacological Sciences and Chief of the Division of Nephrology at the Icahn School of Medicine at Mount Sinai, spoke with 

he discussed the growing recognition of podocyte injury as a central mechanism in 

focal segmental glomerulosclerosis (FSGS)

Podocytes are highly specialized visceral epithelial cells that, along with glomerular endothelial cells and the glomerular basement membrane, form the glomerular filtration barrier. This structure allows waste products to pass while preventing the leakage of plasma proteins such as albumin. Podocytes are characterized by interdigitating foot processes connected by slit diaphragms, which serve as a critical final filtration barrier.

A notable feature of podocytes is that they are terminally differentiated, meaning they have limited capacity to proliferate. As a result, podocyte loss is difficult to recover. Injury caused by infection, genetic defects, or immune-mediated damage can lead to foot process effacement, disruption of the slit diaphragm, and proteinuria, currently the most widely used noninvasive biomarker of glomerular injury. Progressive podocyte damage contributes to chronic kidney disease (CKD) and eventual kidney failure.

Genetic mutations remain a key driver of podocyte injury, particularly in pediatric populations. In addition, APOL1 high-risk variants, most commonly identified in individuals of African ancestry, are strongly associated with increased risk of kidney disease. APOL1-mediated glomerular disease often presents similarly to FSGS and is thought to involve mechanisms including dysregulated ion channel activity that contribute to podocyte injury.

Proteinuria, while widely used in clinical practice, may reflect relatively advanced disease, with substantial podocyte injury already present at the time of detection. As a result, emerging therapeutic strategies are being explored, including early-stage gene-based approaches and interventions targeting downstream molecular pathways to restore podocyte function. These approaches align with a broader shift toward precision medicine in nephrology.

In APOL1-associated disease, early-phase clinical trials have demonstrated reductions in proteinuria with small molecule inhibitors targeting APOL1-mediated pathways. Ongoing phase 3 trials are further evaluating these therapies, which could represent the first targeted treatment for a genetically defined subgroup of glomerular disease.

Additional emerging targets include lipid toxicity and metabolic dysfunction. Dysregulated lipid uptake in podocytes can lead to lipotoxicity and cellular injury, prompting investigation into therapies that inhibit lipid accumulation. Furthermore, ion channel dysregulation, such as gain-of-function mutations, has been implicated in podocyte injury. Targeted inhibitors of these pathways are currently being evaluated in phase 2 clinical trials, with early data suggesting potential reductions in proteinuria.

Although these approaches remain investigational, they underscore a growing shift toward mechanism-based, podocyte-directed therapies in glomerular disease.

https://doi.org/10.12688/f1000research.7255.1

Hillenbrand A. Podocyte Injury Emerges as Central Driver of Progression in FSGS, Diabetic Kidney Disease. HCPLive. Published 2026. Accessed April 7, 2026. 

https://www.hcplive.com/view/podocyte-injury-emerges-as-central-driver-of-progression-in-fsgs-and-diabetic-kidney-disease

Zimmerman B, Dakin LA, Fortier A, et al. Small molecule APOL1 inhibitors as a precision medicine approach for APOL1-mediated kidney disease. 

https://doi.org/10.1038/s41467-024-55408-2

Luo Z, Chen Z, Hu J, Ding G. Interplay of lipid metabolism and inflammation in podocyte injury. 

https://doi.org/10.1016/j.metabol.2023.155718

Hu H, Liang W, Ding G. Podocyte Metabolic Reprogramming and Targeted Therapy. 

Journal of the American Society of Nephrology : JASN

Videos

An expert shares his perspective on emerging targets and precision strategies for podocyte injury in glomerular disease. 


Podocyte Injury Emerges as Central Driver of Progression in FSGS, Diabetic Kidney Disease

Podocyte injury plays a central role as the shared mechanism driving proteinuria and progressive kidney dysfunction across both primary and secondary glomerular diseases, including focal segmental glomerulosclerosis (FSGS) and diabetic kidney disease.

Diabetic kidney disease affects approximately 30% to 40% of patients with diabetes, remaining a leading cause of kidney failure worldwide. FSGS accounts for an estimated 20% to 25% of adult nephrotic syndrome cases in the United States.

FSGS and diabetic kidney disease are among the most common glomerular conditions in which podocyte injury plays a central role. In both diseases, progressive podocyte loss is closely associated with worsening proteinuria and declining kidney function, underscoring the importance of these specialized cells in maintaining long-term renal stability.

In these conditions, the overall damage caused by podocyte injury has driven increasing attention toward understanding podocyte biology as both a marker of disease severity and a potential therapeutic target.

“Podocytes form the last barrier of the glomerular filtration system, and they are critical for maintaining that barrier,” John Cijan He, MD, PhD, Professor of Medicine and Pharmacological Sciences and Chief of the Division of Nephrology at the Icahn School of Medicine at Mount Sinai, shared in an interview with HCPLive. “If you lose podocytes, patients can develop proteinuria.”

Podocytes are highly specialized epithelial cells that wrap around glomerular capillaries and form interdigitating foot processes connected by slit diaphragms. They serve as the final selective barrier preventing the passage of proteins into the urine and are essential for maintaining normal glomerular function.

Furthermore, these cells are terminally differentiated, non-proliferating cells, meaning once they are injured or lost, they cannot be regenerated or replaced. This limitation plays a key role in the podocyte depletion hypothesis, which proposes that progressive loss of podocytes directly drives glomerulosclerosis, chronic proteinuria, and ultimately kidney failure.

“Unfortunately, we don’t currently have therapies that can restore podocytes. Another important point is that podocytes can detach or die, but they are what we call quiescent cells—they cannot regenerate or proliferate,” said He. “So, once podocytes are lost, that’s essentially it. The kidney has very limited ability to repair this injury.”

Since the loss of podocytes is irreversible, even modest injury can accumulate and accelerate disease progression over time. As a result, researchers are not only focused on treating the upstream causes of kidney disease, but are also trying to identify strategies to preserve podocyte integrity and slow their loss.

Additionally, He explains the ongoing effort to improve the measurement of podocyte injury. Currently, investigators are exploring new reproducible biomarkers, including urinary markers such as nephrin and other podocyte-associated proteins, to more early identify glomerular injury. Additional approaches include detection of podocyte fragments or intact podocytes shed into the urine, which may reflect ongoing structural damage within the glomerulus.

“Podometrics” is an emerging concept in this space, a method aimed at quantifying podocyte number and density as a way to more directly assess disease progression. Prior research has suggested that podocyte-based measurements may provide a less invasive window into glomerular health and could have utility in conditions beyond FSGS and diabetic kidney disease, including IgA nephropathy.

While proteinuria remains the dominant clinical marker, the field is gradually moving toward earlier and more precise methods of detecting glomerular injury, with the goal of improving risk stratification and enabling earlier intervention.

Pavenstädt H, Kriz W, Kretzler M. Cell biology of the glomerular podocyte. 

https://doi.org/10.1152/physrev.00020.2002

Wiggins RC. The spectrum of podocytopathies: a unifying view of glomerular diseases. 

Puelles VG, Bertram JF. Understanding podocyte depletion in progressive kidney disease. 

https://doi.org/10.1038/s41581-018-0001-7

D’Agati VD, Fogo AB, Bruijn JA, Jennette JC. Pathologic classification of focal segmental glomerulosclerosis. 

https://doi.org/10.1053/j.ajkd.2003.10.024

Alicic RZ, Rooney MT, Tuttle KR. Diabetic kidney disease: challenges, progress, and possibilities. 

Wang G, et al. Urinary nephrin as a biomarker of podocyte injury in kidney disease. 

https://doi.org/10.1016/j.cca.2014.08.020