Iron Dysregulation Exacerbates Ferroptosis and AKI in Diabetic Kidney Disease

Background: Diabetic kidney disease (DKD) is a leading cause of end-stage renal disease. Ferroptosis, an iron-dependent, lipid peroxidation-driven form of cell death, has emerged as a key contributor to DKD. However, the mechanisms driving its activation in specific kidney cell types and its role in acute kidney injury (AKI) that worsens DKD remain poorly defined. Given the high metabolic and oxidative demands of renal epithelial cells, we hypothesized that dysregulation of iron homeostasis increases susceptibility to ferroptosis in DKD, where oxidative stress and inflammation form a vicious cycle that accelerates ferroptosis worsening AKI outcome. Methods: We used induced and genetic mouse models to investigate ferroptosis in a renal cell-type specific manner. Our multimodal approach included gene expression, histopathology, immunofluorescence (IF), and AI-driven image analysis (U-Net). We also used the Undermined AI to identify relevant DKD models and ferroptosis pathways from literature. Protein expression was assessed via IF and Western blotting. Metabolic profiling using LC-MS quantified lipid peroxidation products in vitro and in vivo, revealing ferroptosis-associated oxidative stress. Results: Proximal tubular cells were most vulnerable to ferroptosis in AKI and DKD models, showing lipid peroxidation, mitochondrial damage, and reduced GPX4, NCOA4 and SLC7A11. This correlated with downregulation of ferroportin, increased ACSL4, and intracellular iron. Intercalated cells exhibited elevated ACSL4, and podocytes showed mitochondrial, lipid, and cytoskeletal alterations. LC-MS profiling revealed elevated lipid peroxidation byproducts in kidney cortex of diabetic mice. AI-driven image analysis enabled precise quantification of tubular injury and fibrosis, while literature-mining through Undermined AI supported our model selection and identified conserved ferroptosis-associated pathways across DKD studies. Conclusion: Our findings highlight cell-type-specific iron dysregulation as a central driver of ferroptosis, which exacerbates AKI in the context of DKD. By combining in vitro and in vivo approaches across molecular, histological, imaging and metabolomic analysis, we provide strong evidence linking ferroptosis to DKD progression. Targeting ferroptosis and iron metabolism in a cell-specific manner may offer a novel therapeutic strategy to mitigate AKI in DKD.