Methods for treating diabetes-related kidney and glomerular disease - Patents.com

Abstract

Methods for delaying the onset or progression of kidney damage or treating kidney disease in a subject with type 1 or type 2 diabetes or glomerular disease are provided. These methods include administering to a subject with type 1 or type 2 diabetes or glomerular disease an effective amount of an agent capable of inhibiting NBL1 activity, particularly an effective amount of an agent capable of inhibiting NBL1-mediated toxicity of human podocytes. In some embodiments, the agent is an antibody capable of binding to human NBL1.

Description

[Technical field]

[0001] 1. CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of and priority to U.S. Provisional Patent Application No. 63 / 226,125, filed July 27, 2021, and U.S. Provisional Patent Application No. 63 / 302,460, filed January 24, 2022, which are incorporated by reference in their entireties herein for all purposes. [Background technology]

[0002] 2. BACKGROUND OF THEINVENTION Combined, type 1 diabetes (T1D) and type 2 diabetes (T2D) affect at least 347 million people worldwide, with prevalence rates increasing. Diabetes is characterized by hyperglycemia and complications that significantly affect the quality and life span of patients, and imposes a large economic burden on society. A study conducted by the American Diabetes Association assessed the national economic burden of diabetes in the United States at $327 billion in 2017. This represents a 26% increase from $245 billion in 2012, the last year this cost was examined.

[0003] There is currently no cure for either T1D or T2D. Although most treatments help patients manage their symptoms to some extent, diabetic patients still face multiple long-term health complications. Among these complications is kidney damage, which can progress to end-stage renal disease (ESRD). Diabetes was the leading cause of kidney failure in 44% of all new cases in 2011. Given the prevalence and severity of diabetes-related complications, specifically kidney disease and its progression, there is a need for therapeutic agents that delay the onset and progression of kidney disease in diabetes.

[0004] Kidney damage also has other etiologies. There is a need for therapeutic agents that delay the onset and progression of kidney disease caused by disorders other than diabetes. There is a particular need for therapeutic agents that treat glomerular disorders. Summary of the Invention [Means for solving the problem]

[0005] 3. SUMMARY OF THEINVENTION As detailed in the experimental examples of the present disclosure, the inventors have discovered that a protein called neuroblastoma suppressor of tumorgenicity 1 (NBL1) is directly toxic to renal cells (including podocytes and tubular cells). Its toxic effect is not mediated through the inhibition of renal BMP proteins. The inventors show that BMPs are not expressed in or secreted by renal cells. Furthermore, the inventors have discovered that NBL1 is also not expressed in renal cells, but is expressed in circulating immune cells. Neutralizing NBL1 with an antagonist (either sBMP2 or anti-NBL1 monoclonal antibody) prevents toxicity in vitro. Finally, the inventors show that NBL1 is elevated in type 1 and type 2 diabetes. Thus, inhibition of NBL1 is a novel therapeutic approach to prevent the development and progression of renal damage caused by circulating NBL1, especially in patients with type 1 or type 2 diabetes. Inhibition of NBL1 is also effective in treating non-diabetic glomerular diseases in which damage is mediated by NBL1.

[0006] Thus, in a first aspect, a method is provided for delaying the onset or progression of kidney damage in a subject with type 1 or type 2 diabetes or glomerular disease. The method comprises administering to the subject an effective amount of an agent capable of inhibiting NBL1 activity (particularly, capable of inhibiting NBL1 toxicity to human podocytes). In some embodiments, the method prevents the onset or slows the onset of kidney function decline.

[0007] In a further aspect, a method is provided for slowing down the renal function decline in subjects with type 1 or type 2 diabetes or glomerular disease.The method comprises administering to the subject an effective amount of a drug capable of inhibiting NBL1 activity (particularly, capable of inhibiting the toxicity of NBL1 to human podocytes).

[0008] In yet another aspect, a method is provided for treating diabetes-related kidney disease (DKD) in subjects with type 1 or type 2 diabetes or glomerular disease.The method comprises administering to the subject an effective amount of a drug that can inhibit NBL1 activity (particularly, can inhibit the toxicity of NBL1 to human podocytes).

[0009] In some embodiments of these methods, the agent is capable of binding to NBL1. In some embodiments, the agent is capable of binding to human NBL1.

[0010] In some embodiments, the agent is an antibody or an antigen-binding fragment of an antibody capable of binding to human NBL1.

[0011] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs, wherein the three heavy chain CDRs and the three light chain CDRs are a) SEQ ID NOs: 3, 8, and 13 and SEQ ID NOs: 18, 23, and 28 (Antibody E05); b) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); c) SEQ ID NOs: 63, 68, and 73 and SEQ ID NOs: 78, 83, and 88 (Antibody F06); d) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); e) SEQ ID NOs: 123, 128, and 133 and SEQ ID NOs: 138, 143, and 148 (Antibody G01); f) SEQ ID NOs: 153, 158, and 163 and SEQ ID NOs: 168, 173, and 178 (Antibody E11); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); h) SEQ ID NOs: 213, 218, and 223 and SEQ ID NOs: 228, 233, and 238 (Antibody D12); i) SEQ ID NOs: 243, 248, and 253 and SEQ ID NOs: 258, 263, and 268 (antibody H01); j) SEQ ID NOs: 273, 278, and 283 and SEQ ID NOs: 288, 293, and 298 (antibody C11); k) SEQ ID NOs: 303, 308, and 313 and SEQ ID NOs: 318, 323, and 328 (antibody E05); l) SEQ ID NOs: 333, 338, and 343 and SEQ ID NOs: 348, 353, and 358 (antibody F10); m) SEQ ID NOs: 363, 368, and 373 and SEQ ID NOs: 378, 383, and 388 (antibody G10); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); o) SEQ ID NOs: 423, 428, and 433 and SEQ ID NOs: 438, 443, and 448 (antibody E07); p) SEQ ID NOs: 453, 458, and 463 and SEQ ID NOs: 468, 473, and 478 (antibody E12); q) SEQ ID NOs: 483, 488, and 493 and SEQ ID NOs: 498, 503, and 508 (Antibody D08); r) SEQ ID NOs: 513, 518, and 523 and SEQ ID NOs: 528, 533, and 538 (antibody E10); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from These selected CDR sequence sets (a)-(t) have sequences that differ by at most two conservative amino acid changes in each CDR.

[0012] In some embodiments of these methods, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have sequences identical to the selected CDRs. b) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); d) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from These selected CDR sequence sets b), d), g), n), s), and t) have sequences that differ by at most two conservative amino acid changes in each CDR.

[0013] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have identical sequences to the selected CDRs.

[0014] In some embodiments, the antibody framework region is a human antibody framework region.

[0015] In some embodiments, the antibody is a full-length bivalent monospecific monoclonal antibody. In some embodiments, the antibody comprises a human IgG1 heavy chain constant region, a human IgG2 heavy chain constant region, or a human IgG4 heavy chain constant region. In some embodiments, the antibody comprises a human IgG1 constant region. In some embodiments, the antibody Fc region has engineered mutations that reduce antibody binding to at least one type of Fc receptor and / or reduce complement binding. In some embodiments, the antibody is a Fab, and optionally the Fab is pegylated. In some embodiments, the antibody or antigen-binding fragment is further capable of binding to cynomolgus monkey NBL1. In some embodiments, the antibody or antigen-binding fragment is further capable of binding to mouse NBL1.

[0016] In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D ).

[0017] In some embodiments, the agent comprises a bone morphogenetic protein (BMP) or a soluble fragment thereof. In some embodiments, the agent comprises a soluble fragment of human BMP-2. In some specific embodiments, the agent further comprises a moiety that extends serum half-life. In some embodiments, the half-life extending moiety is an antibody Fc domain. In some embodiments, the half-life extending moiety is at least one covalently attached polyethylene glycol (PEG) moiety.

[0018] In some embodiments, the agent is capable of inhibiting dimerization of NBL1.

[0019] In some embodiments, the agent is capable of inhibiting NBL1 expression.

[0020] In some embodiments, the agent is administered parenterally. In some embodiments, the agent is administered intravenously. In some embodiments, the agent is administered subcutaneously. In some embodiments, the agent is administered for at least 3 months. In some embodiments, the agent is administered for at least 6 months. In some embodiments, the agent is administered for at least 12 months.

[0021] In some embodiments, the subject has elevated pre-treatment plasma NBL1 levels. In some embodiments, the subject has type 1 diabetes. In some embodiments, the subject has type 2 diabetes. In some embodiments, the subject has glomerular disease. In some embodiments, the subject with glomerular disease does not have type 1 or type 2 diabetes. In some embodiments, the glomerular disease is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

[0022] In another aspect, an antibody or antigen-binding fragment is provided that is capable of binding to NBL1 and inhibiting NBL1-induced toxicity of human podocytes.

[0023] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs, wherein the three heavy chain CDRs and the three light chain CDRs are a) SEQ ID NOs: 3, 8, and 13 and SEQ ID NOs: 18, 23, and 28 (Antibody E05); b) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); c) SEQ ID NOs: 63, 68, and 73 and SEQ ID NOs: 78, 83, and 88 (Antibody F06); d) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); e) SEQ ID NOs: 123, 128, and 133 and SEQ ID NOs: 138, 143, and 148 (Antibody G01); f) SEQ ID NOs: 153, 158, and 163 and SEQ ID NOs: 168, 173, and 178 (Antibody E11); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); h) SEQ ID NOs: 213, 218, and 223 and SEQ ID NOs: 228, 233, and 238 (Antibody D12); i) SEQ ID NOs: 243, 248, and 253 and SEQ ID NOs: 258, 263, and 268 (antibody H01); j) SEQ ID NOs: 273, 278, and 283 and SEQ ID NOs: 288, 293, and 298 (antibody C11); k) SEQ ID NOs: 303, 308, and 313 and SEQ ID NOs: 318, 323, and 328 (antibody E05); l) SEQ ID NOs: 333, 338, and 343 and SEQ ID NOs: 348, 353, and 358 (antibody F10); m) SEQ ID NOs: 363, 368, and 373 and SEQ ID NOs: 378, 383, and 388 (antibody G10); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); o) SEQ ID NOs: 423, 428, and 433 and SEQ ID NOs: 438, 443, and 448 (antibody E07); p) SEQ ID NOs: 453, 458, and 463 and SEQ ID NOs: 468, 473, and 478 (antibody E12); q) SEQ ID NOs: 483, 488, and 493 and SEQ ID NOs: 498, 503, and 508 (Antibody D08); r) SEQ ID NOs: 513, 518, and 523 and SEQ ID NOs: 528, 533, and 538 (antibody E10); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from has a sequence that differs from a CDR sequence selected from (a)-(t) by at most two conservative amino acid substitutions in each CDR. In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have a sequence identical to one of these selected CDR sets (a)-(t).

[0024] In some embodiments, the three heavy chain CDRs and the three light chain CDRs are b) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); d) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from These selected CDR sequences b), d), g), n), s), and t) have sequences that differ by at most two conservative amino acid substitutions in each CDR. In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have sequences identical to the selected CDR b), d), g), n), s), or t).

[0025] In some embodiments, the framework region of the antibody or antigen-binding fragment is a human antibody framework region.

[0026] In some embodiments, the antibody or antigen-binding fragment is a full-length bivalent monospecific monoclonal antibody. In some embodiments, the antibody comprises a human IgG1 heavy chain constant region, a human IgG2 heavy chain constant region, or a human IgG4 heavy chain constant region. In some embodiments, the antibody comprises a human IgG1 constant region. In some embodiments, the antibody Fc region has engineered mutations that reduce antibody binding to FcRγ and / or reduce complement fixation.

[0027] In some embodiments, the antigen-binding fragment is a Fab, and optionally the Fab is pegylated.

[0028] In some embodiments, the antibody or antigen-binding fragment is further capable of binding to cynomolgus monkey NBL1. In some embodiments, the antibody or antigen-binding fragment is further capable of binding to mouse NBL1.

[0029] In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K) for human NBL1 of less than 100 nM, less than 10 nM, less than 5 nM, or less than 1 nM. D ).

[0030] In another aspect, a pharmaceutical composition is provided.The composition comprises the above-mentioned anti-NBL1 antibody or antigen-binding fragment and a pharma- ceutical acceptable carrier.In some embodiments, the composition is formulated for parenteral administration.In some embodiments, the composition is formulated for intravenous administration.In some embodiments, the composition is formulated for subcutaneous administration.

[0031] (4. Brief description of some figures of the drawing) These and other features, aspects, and advantages of the present invention will become better understood with regard to the following description and accompanying drawings. [Brief description of the drawings]

[0032] [Figure 1] 1A-1D are bar graphs summarizing cell death analysis in human renal cells. FIG. 1A shows data from human podocytes (HuPodo) cultured with increasing doses of recombinant human NBL1 from 0.2 μg / ml to 2 μg / ml. FIG. 1B shows data from human mesangial cells (HuMRC) cultured in the presence of 2 μg / ml recombinant human NBL1. FIG. 1C shows data from human renal tubular cells (HuK2) cultured in the presence of 2 μg / ml recombinant human NBL1. FIG. 1D shows data from control human umbilical vein endothelial cells (Huvec) cultured in the presence of 2 μg / ml recombinant human NBL1.

[0033] [Figure 2A-B] Figures 2A-B show representative images of confocal analysis performed on human podocytes cultured with 2 μg / ml NBL1 (Figure 2A) or left untreated (Figure 2B). The podocytes were stained with Apoptag (a marker for apoptosis) and Synaptopodin (a marker for podocytes). Figure 2C is a bar graph quantifying the percentage of human podocytes double positive for Apoptag and Synaptopodin (Syn+Apo+). This experiment shows NBL1-induced apoptosis of differentiated human podocytes (arrows in Figure 2B, quantified in Figure 2C). [Figure 2C] Same as above.

[0034] [Diagram 3] FIG. 3 shows changes in apoptosis-related transcript levels in human podocytes cultured with 2 μg / ml NBL1 compared to untreated cells.

[0035] [Figure 4] Figure 4 is a bar graph quantifying NBL1 mRNA expression in human immune cells and cell lines. mRNA levels were normalized to β-actin levels.

[0036] [Figure 5A] Figure 5A-B show high expression of NBL1 protein in T cells and different T cell subsets (CD3+ T cells, CD4+ T cells and CD8+ T cells) as well as myeloid cells (CD14+) using flow cytometry analysis. The top left panel of Figure 5A shows the physical gating for monocytes (upper gate) and lymphocytes (lower gate). All analyses were performed on peripheral blood mononuclear cells (PBMCs) isolated from blood samples of healthy volunteers. Figure 5C-D show the results of the NBL1 Atlas study investigating NBL1 expression in different human tissues by immunohistochemistry. Figure 5C shows images of different tissue samples showing the presence of NBL1 by immunohistochemistry techniques. Figure 5D is a bar graph showing high expression of NBL1 protein in intestinal and muscle tissues. [Figure 5B] Same as above. [Figure 5C] Same as above. [Figure 5D] Same as above.

[0037] [Figure 6] Figure 6 shows the neutralizing effect of soluble BMP2 on NBL1-mediated apoptosis. Human podocytes were cultured for 48 hours in the presence of NBL1 (2 μg / ml) and in the presence / absence of soluble BMP2 (1 μg / ml).

[0038] [Figure 7]Figures 7A-7B show elevated NBL1 serum levels measured by ELISA, with Figure 7A comparing levels in patients with long-standing type 1 diabetes (T1D), levels in patients with long-standing type 2 diabetes (T2D), and levels in non-diabetic subjects (CTRL), and Figure 7B showing NBL1 serum levels in patients with stages 2-3 diabetes-related kidney disease (DKD) compared to patients without DKD.

[0039] [Figure 8] 8 is a bar graph quantifying cell death in human podocytes cultured in the presence of NBL1 (2 μg / ml) in the presence and absence of either anti-NBL1 antibody (20 μg / ml) or soluble BMP2 (1 μg / ml). The leftmost bar shows data from cells incubated in medium alone, without NBL1, and without antibody or sBMP treatment. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0040] 5. DETAILED DESCRIPTION OF THE PRESENT EMBODIMENT (5.1.Definition) Unless otherwise defined, all technical and scientific terms used herein have the meaning commonly understood by one of ordinary skill in the art to which this disclosure belongs.

[0041] The terms "individual" and "subject" are used interchangeably, and refer to the animal to be treated, including, but not limited to, humans; non-human primates; rodents (including rats and mice); cattle; horses; sheep; cats; and dogs.

[0042] The term "patient" refers to a human subject.

[0043] The terms "treating", "treatment" and their grammatical variants are used in the broadest sense as understood in the clinical field. Thus, this term does not require cure or complete remission of disease, but includes obtaining any clinically desirable pharmacological and / or physiological effect. As used herein, "treating diabetes-related kidney disease (DKD)" explicitly includes delaying the onset of kidney damage, delaying the progression to kidney damage, and slowing the decline of kidney function in patients with type 1 or type 2 diabetes or glomerular disorder.

[0044] The phrase "therapeutically effective amount" refers to the amount of a compound that, when administered to a mammalian or other subject for treating a disease, condition, or disorder, is sufficient to effect treatment for that disease, condition, or disorder, as treatment is defined herein. Determining that "therapeutically effective amount" is within the skill of the art.

[0045] Neuroblastoma tumor suppressor 1 (NBL1) is an early member of the DAN (genes abnormal in neuroblastoma selected by differential screening) gene family. This DAN gene family member is expressed during development and functions as a bone morphogenetic protein (BMP) antagonist. DAN protein binds to BMP and prevents it from interacting with BMP receptors. Neuroblastoma tumor suppressor 1 (NBL1) (also known as D1S1733E, DAN, DAND1, NB, and NO3) is identified by NCBI Gene ID:4681. The protein sequence of NCBI Gene ID:4681 is incorporated herein by reference.

[0046] Bone morphogenetic proteins (BMPs) are a group of growth factors originally identified by their ability to induce bone and cartilage formation, and are now believed to constitute a group of central morphogenetic signals that coordinate tissue architecture throughout the body. Human BMP-2 (also known as BDA2, BMP2A, SSFSC, and SSFSC1) is identified by NCBI Gene ID:650. The protein sequence of NCBI Gene ID:650 is incorporated herein by reference. Human BMP-4 (also known as BMP2B, BMP2B1, MCOPS6, OFC11, and ZYME) is identified by NCBI Gene ID:652. The protein sequence of NCBI Gene ID:652 is incorporated herein by reference. Human BMP-7 (also known as OP-1) is identified by NCBI Gene ID:655. The protein sequence of NCBI Gene ID:655 is incorporated herein by reference.

[0047] As used herein, the term "antibody" has its broadest meaning recognized by the art, and thus includes all known formats. This term specifically includes, but is not limited to, polyclonal antibodies, monoclonal antibodies, monospecific antibodies, multispecific antibodies (including bispecific antibodies), chimeric antibodies, humanized antibodies, and fully human antibodies. Antibodies that include a heavy chain constant region domain can be of any class (including IgG, IgE, IgM, IgD, and IgA) and any subclass (including IgG1, IgG2, IgG3, IgG4, IgA1, and IgA2). An "antigen-binding fragment" of an antibody is an antibody fragment (and / or a polypeptide that includes an antibody fragment) that retains the binding characteristics (e.g., specificity, monovalent affinity, or bivalent avidity) of the antibody from which it is derived, and has its broadest meaning recognized by the art. The term includes, but is not limited to, Fab, Fab', F(ab')2, Fv, scFv, (scFv)2, single domain antibodies (including camelid VHH formats and shark VNAR formats), and multispecific antibodies formed from antibody fragments (including, but not limited to, F(ab)2, and diabodies).

[0048] As used herein, "chronic kidney disease" (CKD) has the meaning ascribed to it in the National Kidney Foundation KDOQI guidelines, and the stages of CKD are defined as set forth in the NKF KDOQI guidelines. "End stage kidney disease" (ESKD) and "end stage renal disease" (ESRD) are used interchangeably herein and have the meaning ascribed to them in the National Kidney Foundation KDOQI guidelines.

[0049] In this disclosure, the words "comprise," "comprising," "containing," "having," "include," "including," and variations of these languages ​​have the meanings ascribed to them in United States patent law and permit the presence of additional components beyond those explicitly listed.

[0050] Unless specifically stated otherwise or clear from the context, as used herein, the term "or" is understood to be inclusive.

[0051] Unless specifically stated or clear from the context, as used herein, the terms "a," "an," and "the" are understood to be in the singular or plural.

[0052] As used herein, a "conservative amino acid substitution" is one in which the original and substituted amino acids have similar biochemical properties or their biochemical effects are similarly maintained between the substitutions shown in Table 45.

[0053] (5.2. Overview of Experimental Results) As detailed in the experimental examples in this disclosure, the inventors have found that NBL1 is directly toxic to renal cells (including podocytes and tubular cells). Its toxic effect is not mediated through the inhibition of renal BMP proteins. The inventors show that BMPs are not expressed in or secreted by renal cells. Furthermore, the inventors have found that NBL1 is also not expressed in renal cells, but is expressed in circulating immune cells. Neutralizing NBL1 with an antagonist prevents toxicity. Finally, the inventors show that NBL1 is elevated in type 1 and type 2 diabetes.

[0054] 5.3. Methods of Delaying the Onset or Progression of Renal Damage Thus, in a first aspect, a method is provided for delaying the onset or progression of renal damage in the subject with type 1 or type 2 diabetes or the subject with risk of type 1 or type 2 diabetes or the subject with glomerular disease or the subject with risk of developing glomerular disease.This method comprises administering to the subject an effective amount of the drug that can inhibit NBL1 activity (particularly, can inhibit the NBL1-mediated toxicity of human podocyte).

[0055] In various embodiments, the method delays the onset or progression of damage to one or more of renal blood vessels, podocytes, renal tubular cells, or glomerular or tubular basement membranes, hi some embodiments, the method delays the onset or progression of thickening of glomerular and tubular basement membranes, increased mesangial matrix, Kimmelstiel-Wilson nodes, microaneurysms, exudative or hyaline lesions, Capsular drops, or afferent and efferent arteriole hyaline degeneration.

[0056] In some embodiments, the subject has type 1 diabetes.In some embodiments, the subject has type 2 diabetes.In some embodiments, the subject is pre-diabetic.In some embodiments, the subject is not pre-diabetic as measured by hemoglobin A1c level or blood glucose level, but is at risk of type 1 diabetes or type 2 diabetes and has elevated plasma NBL1 level.

[0057] In some embodiments, the subject has glomerular disease.In certain embodiments, the subject with glomerular disease does not have type 1 or type 2 diabetes.In certain embodiments, the glomerular disease is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

[0058] In some embodiments, the subject has a pre-treatment plasma NBL1 level that is at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or 100% higher than a normal subject with no type 1 diabetes, no type 2 diabetes or pre-diabetes. In some embodiments, the subject to be treated has a plasma NBL1 level that is at least 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold or 10-fold higher than a normal subject with no type 1 diabetes, no type 2 diabetes or pre-diabetes.

[0059] In some embodiments, the method effectively reduces the availability of circulating free NBL1 in subjects with type 1 or type 2 diabetes, or in subjects with prediabetes, or in subjects at risk of type 1 or type 2 diabetes, and has elevated plasma NBL1 levels compared with normal subjects without type 1 or type 2 diabetes or prediabetes.In some embodiments, the method effectively reduces the availability of circulating free NBL1 in subjects with glomerular disease.In certain embodiments, the method effectively reduces the availability of circulating free NBL1 in subjects with glomerular disease selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

[0060] In some embodiments, the agent capable of inhibiting NBL1 activity can bind to NBL1. In some embodiments, the binding occurs at the N-terminus of NBL1. In some embodiments, the binding occurs at the functional DAN domain of NBL1. In some embodiments, the binding occurs at the C-terminus of NBL1. In some embodiments, the binding is non-covalent. In some embodiments, the binding is covalent. In certain covalent embodiments, the inhibitor binds to NBL1 by disulfide bond in the DAN domain.

[0061] In some embodiments, the agent capable of inhibiting NBL1 activity is capable of inhibiting dimerization of NBL1.

[0062] In some embodiments, the agent capable of inhibiting NBL1 activity is a dimerization inhibitor that prevents the formation of stabilizing hydrogen bonds between two NBL1 monomers. In some embodiments, the dimerization inhibitor disrupts at least one of the three disulfide bonds that form a ring-like structure (also known as a cysteine ​​knot) in each monomer, or disrupts the disulfide bond that connects F1 and F2 (F1 and F2 are finger 1, the first loop from the N-terminus, and finger 2, the third loop from the N-terminus, respectively).

[0063] 5.3.1. Soluble BMP Inhibitors In some embodiments, the agent capable of inhibiting NBL1 activity comprises a bone morphogenetic protein (BMP) or a soluble NBL1-binding fragment thereof. In some embodiments, the BMP is BMP-2 or a soluble NBL1-binding fragment thereof. In some embodiments, the BMP is BMP-4 or a soluble NBL1-binding fragment thereof. In some embodiments, the BMP is BMP-7 or a soluble NBL1-binding fragment thereof. In a currently preferred embodiment, the BMP is a human BMP or a soluble NBL1-binding fragment thereof.

[0064] In some embodiments, the agent capable of inhibiting NBL1 further comprises a moiety that increases serum half-life.

[0065] In some embodiments, the serum half-life extending moiety is provided through covalent chemical modification. In some embodiments, the serum half-life extending moiety is at least one polyethylene glycol (PEG) moiety. In some embodiments, the PEG moiety is permanently attached to the agent. In some embodiments, the PEG moiety is a releasable carrier provided through covalent chemical modification. In certain embodiments, the agent comprises PEGylated BMP or a soluble NBL1 binding fragment thereof.

[0066] In some embodiments, the serum half-life extending moiety is an antibody Fc domain. In some embodiments, the Fc domain is engineered to optimize pH-dependent IgG Fc-FcRn interactions. In certain embodiments, the Fc domain is engineered to have the YTE triple mutation (M252Y / S254T / T256E). In certain embodiments, the Fc domain is engineered to have the M428L / N434S mutation. In certain embodiments, the Fc domain is fused in-frame to a BMP or a soluble NBL1-binding fragment thereof.

[0067] In some embodiments, the serum half-life enhancing moiety is a serum albumin molecule. In certain embodiments, the serum half-life enhancing moiety is a human serum albumin molecule fused in-frame to BMP or its soluble NBL1-binding fragment.

[0068] In some embodiments, the serum half-life extending moiety is an XTEN protein polymer covalently attached to the agent as described in Podust et al., Protein Eng. Des. Sel. 26(11):743-53 (2013), the disclosure of which is incorporated herein by reference in its entirety.

[0069] 5.3.2. Antibodies and Antigen-Binding Fragments Thereof In some embodiments, the agent capable of inhibiting NBL1 activity is an antibody or its NBL1-binding fragment, which can bind to NBL1 and inhibit NBL1 activity, particularly inhibiting the NBL1-mediated toxicity of human podocytes. In a preferred embodiment, the antibody or antigen-binding antibody fragment can bind to human NBL1.

[0070] In some embodiments, the antibody or antigen-binding fragment thereof binds to an epitope in the N-terminal domain of NBL1. In some embodiments, the antibody or antigen-binding fragment thereof binds to an epitope in the DAN domain of NBL1. In some embodiments, the antibody or antigen-binding fragment thereof binds to an epitope in the C-terminal domain of NBL1.

[0071] In some embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain CDR and a light chain CDR selected from Tables 23 to 44 below, or a heavy chain CDR and a light chain CDR selected from Tables 23 to 44 below with no more than 10 amino acid deletions, insertions or conservative amino acid substitutions (as defined in Table 45) compared thereto. [Table 45]

[0072] In some embodiments, the amino acid deletions, insertions, or conservative substitutions are 8 or less. In some embodiments, the amino acid deletions, insertions, or conservative substitutions are 6 or less. In some embodiments, the amino acid deletions, insertions, or conservative substitutions are 4 or less.

[0073] In some embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain V region and a light chain V region selected from Tables 1-22 below.

[0074] In some embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain CDR and a light chain CDR selected from Tables 23-44 with no more than 10 amino acid deletions, insertions, or conservative amino acid substitutions (as defined in Table 45) compared thereto. In some embodiments, no more than 8 amino acid deletions, insertions, or conservative substitutions are made. In some embodiments, no more than 6 amino acid deletions, insertions, or conservative substitutions are made. In some embodiments, no more than 4 amino acid deletions, insertions, or conservative substitutions are made.

Table A

Table H

Table I

Table J

Table L

Table M

Table N

Table O

Table P

Table Q

Table R

[0075] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs, wherein the three heavy chain CDRs and the three light chain CDRs are a) SEQ ID NOs: 3, 8, and 13 and SEQ ID NOs: 18, 23, and 28 (Antibody E05); b) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); c) SEQ ID NOs: 63, 68, and 73 and SEQ ID NOs: 78, 83, and 88 (Antibody F06); d) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); e) SEQ ID NOs: 123, 128, and 133 and SEQ ID NOs: 138, 143, and 148 (Antibody G01); f) SEQ ID NOs: 153, 158, and 163 and SEQ ID NOs: 168, 173, and 178 (Antibody E11); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); h) SEQ ID NOs: 213, 218, and 223 and SEQ ID NOs: 228, 233, and 238 (Antibody D12); i) SEQ ID NOs: 243, 248, and 253 and SEQ ID NOs: 258, 263, and 268 (antibody H01); j) SEQ ID NOs: 273, 278, and 283 and SEQ ID NOs: 288, 293, and 298 (antibody C11); k) SEQ ID NOs: 303, 308, and 313 and SEQ ID NOs: 318, 323, and 328 (antibody E05); l) SEQ ID NOs: 333, 338, and 343 and SEQ ID NOs: 348, 353, and 358 (antibody F10); m) SEQ ID NOs: 363, 368, and 373 and SEQ ID NOs: 378, 383, and 388 (antibody G10); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); o) SEQ ID NOs: 423, 428, and 433 and SEQ ID NOs: 438, 443, and 448 (antibody E07); p) SEQ ID NOs: 453, 458, and 463 and SEQ ID NOs: 468, 473, and 478 (antibody E12); q) SEQ ID NOs: 483, 488, and 493 and SEQ ID NOs: 498, 503, and 508 (Antibody D08); r) SEQ ID NOs: 513, 518, and 523 and SEQ ID NOs: 528, 533, and 538 (antibody E10); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from These selected CDR sequences (a) to (t) have sequences that differ by at most two conservative amino acid substitutions in each CDR.

[0076] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have sequences identical to the selected CDRs (a)-(t). In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have sequences that differ from the selected CDR sequences (a)-(t) by at most two conservative amino acid substitutions in each CDR or by at most one conservative amino acid substitution in each CDR. In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs which have sequences that differ from the selected CDR sequences (a)-(t) by a total of six conservative amino acid changes across all six CDRs, a total of five conservative amino acid substitutions across all six CDRs, a total of four conservative amino acid substitutions across all six CDRs, a total of three conservative amino acid substitutions across all six CDRs, a total of two conservative amino acid substitutions across all six CDRs, or a total of one conservative amino acid substitution across all six CDRs.

[0077] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs, wherein the three heavy chain CDRs and the three light chain CDRs are b) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); d) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from These selected CDR sequences b), d), g), n), s), and t) have sequences that differ by at most two conservative amino acid substitutions in each CDR.

[0078] In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have sequences identical to the selected CDR (b), (d), (g), (n), (s) or (t). In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs that have sequences that differ from the selected CDR sequence (b), (d), (g), (n), (s) or (t) by at most two conservative amino acid substitutions in each CDR or by at most one conservative amino acid substitution in each CDR. In some embodiments, the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs which have sequences that differ from the selected CDR sequence (b), (d), (g), (n), (s) or (t) by a total of six conservative amino acid changes across all six CDRs, a total of five conservative amino acid substitutions across all six CDRs, a total of four conservative amino acid substitutions across all six CDRs, a total of three conservative amino acid substitutions across all six CDRs, a total of two conservative amino acid substitutions across all six CDRs, or a total of one conservative amino acid substitution across all six CDRs.

[0079] In some embodiments, the antibody framework region is a human antibody framework region. In some embodiments, the antibody is a full-length bivalent monospecific monoclonal antibody. In some embodiments, the antibody comprises a human IgG1 heavy chain constant region, a human IgG2 heavy chain constant region, or a human IgG4 heavy chain constant region. In some embodiments, the antibody comprises a human IgG1 constant region. In some embodiments, the antibody Fc region has at least one engineered mutation that reduces antibody binding to at least an Fcγ receptor. In some embodiments, the mutation is N297A. In some embodiments, the antibody Fc region has at least one engineered mutation that reduces complement binding. In some embodiments, the mutation is K322A.

[0080] In some embodiments, the antibody is a Fab, and optionally the Fab is pegylated.

[0081] In some embodiments, the antibody or antigen-binding fragment is further capable of binding to cynomolgus monkey NBL1. In some embodiments, the antibody or antigen-binding fragment is further capable of binding to mouse NBL1.

[0082] In some embodiments, the antibody is an IgG monoclonal antibody. In certain embodiments, the antibody is an IgG1 monoclonal antibody or an IgG4 monoclonal antibody.

[0083] In some embodiments, the antibody is a human monoclonal antibody. In some embodiments, the antibody is a humanized antibody. In some embodiments, the antibody is a chimeric mouse-human antibody. In some embodiments, the agent comprises a NBL1-binding antigen-binding fragment selected from a Fab, Fab', F(ab')2, Fv, scFv, Fd, or diabody.

[0084] In some embodiments, the antibody or antigen-binding fragment has a binding affinity (KD In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D In some embodiments, the antibody or antigen-binding fragment has a binding affinity (K D ). In certain embodiments, the NBL1 dimerization inhibitor is an antibody. In some of these embodiments, the antibody is a monoclonal antibody. In some of these embodiments, the antibody is a polyclonal antibody. In some embodiments, the dimerization inhibitor binds to at least one of the synonymous β-strands from each NBL1 monomer.

[0085] (5.3.3. NBL1 Expression Inhibitors) In some embodiments, the agent is capable of inhibiting NBL1 expression.

[0086] In certain embodiments, the agent inhibits transcription of the NBL1 gene. In certain embodiments, the agent causes degradation of NBL1 mRNA. In certain embodiments, the agent inhibits translation of NBL1 mRNA. In certain embodiments, the agent targets the NBL1 protein for degradation.

[0087] In certain embodiments, the agent is an antisense oligonucleotide. In certain embodiments, the agent mediates RNA interference. In certain RNA interference embodiments, the agent is a small hairpin RNA (shRNA) or a small interfering RNA (siRNA). In certain embodiments, the agent is a microRNA (miRNA). In certain embodiments, the agent is a sequence-specific mRNA interferase.

[0088] (5.4. Methods for slowing the decline of kidney function) In a further aspect, a method is provided for slowing down renal function decline in subjects with type 1 or type 2 diabetes or subjects at risk of type 1 or type 2 diabetes or subjects with glomerular disease or subjects at risk of developing glomerular disease.The method comprises administering to the subject an effective amount of a drug capable of inhibiting NBL1 activity.In various embodiments, the drug capable of inhibiting NBL1 activity is the inhibitor described in section 5.3.1, 5.3.2, or 5.3.3 above.

[0089] In some embodiments, the method slows the progression of microalbuminuria, slows the progression of macroalbuminuria, slows the progression of proteinuria, or slows the decline in glomerular filtration rate (GFR).

[0090] In some embodiments, the method prevents the onset of or slows the onset of progressive renal function decline (PKFD). In some embodiments, the agent inhibits the progression of at least one or more symptoms associated with PKFD. In some embodiments, the rate of renal function decline in the subject compared to an untreated control group is reduced by 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80% or 90%.

[0091] In some embodiments, the method prevents the onset of or slows the progression to end stage kidney disease (ESKD). In some embodiments, the method inhibits the progression of at least one or more symptoms associated with ESKD. In some embodiments, the method inhibits the progression to required dialysis.

[0092] In some embodiments, the method slows the progression of chronic kidney disease (CKD) from stage 1 to stage 2, from stage 2 to stage 3, from stage 3A to stage 3B, from stage 3B to stage 4, from stage 4 to stage 5, or from stage 5 without dialysis to stage 5 with dialysis.

[0093] In some embodiments, the subject has type 1 diabetes. In some embodiments, the subject has type 2 diabetes. In some embodiments, the subject is pre-diabetic. In some embodiments, the subject is not pre-diabetic as measured by hemoglobin A1c level or blood glucose level, but is at risk of type 1 diabetes or type 2 diabetes, and has elevated plasma NBL1 level. In some embodiments, the subject has glomerular disorder. In certain embodiments, the subject has glomerular disorder and does not have type 1 or type 2 diabetes. In certain embodiments, the glomerular disorder is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

[0094] In some embodiments, the method effectively reduces the availability of circulating free NBL1 in subjects with type 1 or type 2 diabetes, or in subjects with prediabetes, or in subjects at risk of type 1 or type 2 diabetes, and has elevated plasma NBL1 levels compared with normal subjects without type 1 or type 2 diabetes or prediabetes.In some embodiments, the method effectively reduces the availability of circulating free NBL1 in subjects with glomerular disease.In certain embodiments, the method effectively reduces the availability of circulating free NBL1 in subjects with glomerular disease selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

[0095] In various embodiments, the agent is an agent described in Sections 5.3.1, 5.3.2, or 5.3.3, supra, which are incorporated herein by reference.

[0096] 5.5. Methods of Treating Diabetes-Related Kidney or Glomerular Disease In a further aspect, a method for treating diabetes-related kidney disease (DKD) in a subject with type 1 or type 2 diabetes or a subject with glomerular disease is provided.The method comprises administering to the subject an effective amount of a drug that can inhibit NBL1 activity.

[0097] In some embodiments, the subject has type 1 or type 2 diabetes and one or more of glomerular hypertrophy, glomerulosclerosis, tubulointerstitial inflammation, fibrosis, glomerular hyperfiltration, progressive albuminuria, declining GFR, and ESKD.

[0098] In some embodiments, the subject has glomerular disease.In certain embodiments, the subject has glomerular disease and does not have type 1 or type 2 diabetes.In certain embodiments, the glomerular disorder is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

[0099] In various embodiments, the agent is an agent described in Sections 5.3.1, 5.3.2, or 5.3.3, supra, which are incorporated herein by reference.

[0100] 5.6. Dosing Regimen In some embodiments of the methods described herein, the agent is administered parenterally. In certain embodiments, the agent is administered intravenously. In certain embodiments, the subject is on dialysis and the agent is administered intravenously. In certain embodiments, the agent is administered subcutaneously.

[0101] In some embodiments, the agent is administered once. In some embodiments, the agent is administered more than once. In certain embodiments, the agent is administered for at least 3 months. In certain embodiments, the agent is administered for at least 6 months. In certain embodiments, the agent is administered for at least 12 months.

[0102] 5.7. Antibodies and Pharmaceutical Formulations Thereof In another aspect, an antibody or antigen-binding fragment is provided that can bind to NBL1 and inhibit NBL1-induced toxicity of human podocytes.Embodiments include all antibody and antigen-binding fragment embodiments described in Section 5.3.2 above, which are incorporated herein by reference.

[0103] In a further aspect, a pharmaceutical composition is provided. The pharmaceutical composition comprises an antibody or antigen-binding fragment described herein and a pharma- ceutically acceptable carrier. In some embodiments, the composition is formulated for parenteral administration. In some embodiments, the composition is formulated for intravenous administration. In some embodiments, the composition is formulated for subcutaneous administration.

[0104] (5.8. Further embodiments) Further embodiments are set forth in the following numbered clauses. 1. A method for delaying the onset or progression of kidney damage in a subject with type 1 or type 2 diabetes or glomerular disease, comprising: administering to the subject an effective amount of an agent capable of inhibiting NBL1 activity. A method comprising: 2. The method of clause 1, wherein the agent is capable of binding to NBL1. 3. The method of clause 2, wherein the agent comprises a bone morphogenetic protein (BMP) or a soluble fragment thereof. 4. The method of clause 3, wherein the agent comprises a soluble fragment of human BMP-2. 5. The method of clause 3 or clause 4, wherein the agent further comprises a moiety that extends serum half-life. 6. The method of clause 5, wherein the half-life extending moiety is an antibody Fc domain. 7. The method of clause 5, wherein the half-life extending moiety is at least one covalently attached polyethylene glycol (PEG) moiety. 8. The method of clause 2, wherein the agent comprises an antibody or an antigen-binding fragment thereof. 9. The method according to clause 2, wherein the agent is capable of inhibiting dimerization of NBL1. 10. The method of clause 1, wherein the agent is capable of inhibiting NBL1 expression. 11. The method of any one of clauses 1 to 10, wherein the subject has type 1 diabetes. 12. The method of any one of clauses 1 to 10, wherein the subject has type 2 diabetes. 13. The method of any one of clauses 1 to 10, wherein the subject has a glomerular disease. 14. The method of clause 13, wherein the subject with glomerular disease does not have type 1 or type 2 diabetes. 15. The method of clause 13 or clause 14, wherein the glomerular disease is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease. 16. The method according to clause 15, wherein the glomerular disease is focal segmental glomerulosclerosis. 17. The method according to clause 15, wherein the glomerular disease is a chronic glomerulopathy. 18. The method according to clause 15, wherein the glomerular disease is hereditary nephritis. 19. The method according to clause 15, wherein the glomerular disease is minimal change disease. 20. The method according to any one of clauses 1 to 19, which prevents the onset of renal function decline or slows down renal function decline. 21. A method of slowing the decline in renal function in a subject with type 1 or type 2 diabetes or glomerular disease, comprising: administering to the subject an effective amount of an agent capable of inhibiting NBL1 activity. A method comprising: 22. The method according to clause 21, which prevents the onset of progressive renal function decline (PKFD) or slows progressive renal function decline (PKFD). 23. The method according to clause 21, which prevents the onset of or slows the progression to end stage kidney disease (ESKD). 24. The method of any one of clauses 21 to 23, wherein the agent is capable of binding to NBL1. 25. The method of clause 24, wherein the agent comprises a bone morphogenetic protein (BMP) or a soluble fragment thereof. 26. The method of clause 25, wherein the agent comprises a soluble fragment of human BMP-2. 27. The method of clause 25 or clause 26, wherein the agent further comprises a moiety that extends serum half-life. 28. The method of clause 27, wherein the half-life extending moiety is an antibody Fc domain. 29. The method of clause 27, wherein the half-life extending moiety is at least one covalently attached polyethylene glycol (PEG) moiety. 30. The method of clause 24, wherein the agent comprises an antibody or an antigen-binding fragment thereof. 31. The method according to clause 24, wherein the agent is capable of inhibiting dimerization of NBL1. 32. The method according to any one of clauses 21 to 23, wherein the agent is capable of inhibiting NBL1 expression. 33. The method of any one of clauses 21 to 32, wherein the subject has type 1 diabetes. 34. The method of any one of clauses 21 to 32, wherein the subject has type 2 diabetes. 35. The method of any one of clauses 21 to 32, wherein the subject has a glomerular disease. 36. The method according to clause 35, wherein the subject with glomerular disease does not have type 1 or type 2 diabetes. 37. The method according to clause 35 or clause 36, wherein the glomerular disease is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, minimal change glomerulopathy. 38. The method according to clause 37, wherein the glomerular disease is focal segmental glomerulosclerosis. 39. The method according to clause 37, wherein the glomerular disease is a chronic glomerulopathy. 40. The method according to clause 37, wherein the glomerular disease is hereditary nephritis. 41. The method according to clause 37, wherein the glomerular disease is minimal change disease. 42. A method of treating diabetes-related kidney disease (DKD) or glomerular disease in a subject with type 1 or type 2 diabetes or glomerular disease, comprising: administering to the subject an effective amount of an agent capable of inhibiting NBL1 activity. A method comprising: 43. The method of clause 42, wherein the agent is capable of binding to NBL1. 44. The method of clause 43, wherein the agent comprises a bone morphogenetic protein (BMP) or a soluble fragment thereof. 45. The method of clause 44, wherein the agent comprises a soluble fragment of human BMP-2. 46. ​​The method of clause 44 or clause 45, wherein the agent further comprises a moiety that extends serum half-life. 47. The method of clause 46, wherein the half-life extending moiety is an antibody Fc domain. 48. The method of clause 46, wherein the half-life extending moiety is at least one covalently attached polyethylene glycol (PEG) moiety. 49. The method of clause 43, wherein the agent comprises an antibody or an antigen-binding fragment thereof. 50. The method according to clause 43, wherein the agent is capable of inhibiting dimerization of NBL1. 51. The method of clause 42, wherein the agent is capable of inhibiting NBL1 expression. 52. The method according to any one of clauses 42 to 51, wherein the subject has type 1 diabetes. 53. The method according to any one of clauses 42 to 51, wherein the subject has type 2 diabetes. 54. The method according to any one of clauses 42 to 51, wherein the subject has a glomerular disease. 55. The method according to clause 54, wherein the subject with glomerular disease does not have type 1 or type 2 diabetes. 56. The method according to clause 54 or clause 55, wherein the glomerular disease is selected from the group consisting of focal segmental glomerulosclerosis, chronic glomerulopathy, hereditary nephritis, minimal change glomerulopathy. 57. The method according to clause 56, wherein the glomerular disease is focal segmental glomerulosclerosis. 58. The method according to clause 56, wherein the glomerular disease is a chronic glomerulopathy. 59. The method according to clause 56, wherein the glomerular disease is hereditary nephritis. 60. The method according to claim 56, wherein the glomerular disease is minimal change disease. 61. The method according to any one of clauses 1 to 60, wherein the agent is administered parenterally. 62. The method according to any one of clauses 1 to 61, wherein the agent is administered for at least 3 months. 63. The method according to clause 62, wherein the agent is administered for at least 6 months. 64. The method according to clause 63, wherein the agent is administered for at least 12 months. EXAMPLES

[0105] 6. Working Examples Below are examples of specific embodiments for carrying out the present disclosure.These examples are provided for illustrative purposes only and are not intended to limit the scope of the present disclosure in any way.Efforts have been made to ensure accuracy with respect to the numbers used (e.g., amounts, temperatures, etc.), but some experimental error and deviation should, of course, be allowed for.

[0106] The practice of the present disclosure will employ, unless otherwise indicated, conventional methods of protein chemistry, biochemistry, recombinant DNA technology, and pharmacology, such techniques being fully described herein.

[0107] 6.1. Example 1. NBL1 is directly toxic to podocytes and renal tubular cells Elevated DAN protein (Grem1, Grem2, Grem3, Cerberus, NBL1, SOST, and USG1) levels are associated with severe disease states in the adult kidney. Wen et al., Biochimie, 160:113-121 (2019).

[0108] To assess whether the increased presence of DAN protein has a causal effect on renal injury, we cultured human podocytes (HuPodo), human mesangial cells (HuHMRC), and human renal tubular cells (HuK2) in the presence or absence of human NBL1 for 48 hours in vitro. Human umbilical vein endothelial cells (Huvec) were used as a control. Podocytes were cultured with increasing concentrations of NBL1 (0.2 μg / ml, 1.0 μg / ml, and 2.0 μg / ml). Mesangial and tubular cells were cultured in 2 μg / ml of NBL1. Human umbilical vein endothelial cells were cultured with increasing concentrations of NBL1: 0.2 μg / ml, 2 μg / ml, and 10 μg / ml.

[0109] Figures 1A-1D are bar graphs summarizing the cell death analysis data, quantified using arbitrary units (AU) for convenience. The results showed increased apoptosis / death of human podocytes and to a lesser extent increased apoptosis / death of mesangial and tubular cells, which directly correlated with the presence of NBL1 added to the culture medium. Cell death was undetectable in human umbilical vein endothelial cells (Huvecs) cultured with NBL1, even at higher concentrations.

[0110] Figures 2A-B show representative images of confocal analysis performed on human podocytes left untreated (Figure 2A) or cultured with 2 μg / ml NBL1 (Figure 2B), which were stained with Synaptopodin and Apoptag. Merged images are presented. These micrographs show evidence of NBL1-induced apoptosis of human podocytes. The arrows highlight the colocalization of Apoptag and Synaptopodin, which are markers for apoptosis and podocytes, respectively. The image highlights that the majority of podocytes are undergoing apoptosis. Figure 2C shows the colocalization of Apoptag in the presence / absence of NBL1. + Synaptopodyn+ 1 is a bar graph quantifying the percentage of double positive human podocytes (n=3). The results show increased levels of apoptotic differentiated human podocytes in the presence of NBL1.

[0111] Figure 3 shows transcriptomic analysis of apoptosis-related genes in human podocytes cultured with 2 μg / ml NBL1 or left untreated. The data show a significant increase in apoptosis-related gene expression upon exposure to NBL-1 in vitro.

[0112] Taken together, these experiments indicate that NBL1 is directly toxic to podocytes and renal tubular cells, and that exposure to NBL1 induces apoptosis of human podocytes and human renal tubular cells.

[0113] 6.2. Example 2. BMP Proteins are not Expressed in and Secreted by Renal Cells In Vitro Like other DAN proteins, NBL1 is known to interact with bone morphogenetic proteins. Hung et al., Biol. of Reprod. (2012) 86(5):158, 1-9.

[0114] To determine whether NBL1 exerts its toxicity through the inhibition of BMP in kidney, we analyzed whether BMP2, BMP4 and BMP7 are expressed as mRNA in human podocytes.We did not detect any mRNA expression of any of those BMPs.Next, we evaluated whether BMP2, BMP4 or BMP7 are secreted from podocytes into the supernatant, thereby enabling autocrine / paracrine survival-promoting effects.We did not detect any of those BMPs in the supernatant of human podocytes, thereby confirming that podocytes are not capable of synthesizing and secreting BMPs in vitro (data not shown).

[0115] Thus, the toxicity of NBL1 to podocytes is independent of the presence of BMPs. The proapoptotic effects of NBL1 are not mediated by inhibition of BMPs.

[0116] 6.3. Example 3. NBL1 is not expressed in kidney cells but is expressed in circulating immune cells, intestinal tissue and muscle tissue Having determined that NBL1 is directly toxic to podocytes and renal tubular cells, we explored the physiological origin of NBL1 by measuring its mRNA expression in a number of human cell lines, including renal cell lines, using RT-PCR to normalize expression to β-actin expression. Figure 4 shows that NBL1 was undetectable in kidney-derived cells. NBL1 was also undetectable in a variety of other cell lines. However, NBL1 was found to be toxic to immune cells, such as CD14 + Monocytes and CD4 + T cells and CD8 + It was highly expressed in T cells (see FIG. 4).

[0117] Further analysis using flow cytometry of peripheral blood mononuclear cells (PBMCs) isolated from blood samples of healthy volunteers identified myeloid lineage (CD14 + ) cells and various T cell subsets (CD3 + T cells, CD4 + T cells and CD8 +We confirmed high expression of NBL1 protein in human T cells (see Figures 5A-5B). Human PBMCs were purified from 8 ml blood samples collected from non-diabetic subjects (n=5) at the ASST Sacco-FBF in Milan (Italy) by using Lymphoprep (07801, Stem Cell Technologies, Cambridge, MA), and then stained cells for flow cytometry analysis with anti-human CD3 (300330), anti-CD45 (560178), anti-CD4 (561030), anti-CD8 (560774), anti-CD14 (561707) from Biolegend (San Diego, CA) and BD Biosciences (San Jose, CA) to quantify surface expression. Rabbit polyclonal anti-NBL1 (Sigma, HPA007394) was used to stain for NBL1, followed by donkey anti-rabbit AlexaFluor488 antibody (ThermoFisher Scientific). Cells were analyzed using a BD FACS Celesta (BD Biosciences).

[0118] To further explore the expression of NBL1, a comprehensive immunostaining study of NBL1 human tissue expression was performed. In this study, NBL1 expression was detected by immunohistochemistry and flow cytometry on human tissue specimens. NBL1 immunoreactivity was scored semiquantitatively based on the percentage of NBL1 positive cells in the total cells per area of ​​interest. The scoring was as follows: <10%, 1+; 10%-30%, 2+; 30%-50%, 3+; 50%-80%, 4+, and >80%, 5+. Formalin-fixed paraffin-embedded tissue sample archives of non-diabetic subjects obtained from the Pathology Unit (University of Parma) were used for NBL1 immunostaining (anti-NBL1 primary antibody #HPA007394, Merck). Further enlargements of each panel are shown in the black square insets at the top right, with black arrows highlighting the positive staining. Original magnification is 20x and scale bar is 100 μm (see FIG. 5C).

[0119] A semiquantitative score was determined based on quantification of the percentage of double positive cells, T cells (CD3 + NBL1 + ), B cells (CD19 + NBL1 + ) and monocytes (CD14 + NBL1 + ), the following classifications were also applied to NBL1 expression detected in: <15%, 1+; 15%-45%, 2+; 45%-75%, 3+; 75%-90%, 4+, and >90%, 5+ (see Figure 5A).

[0120] The semi-quantitative scores showing NBL1 protein expression in human cells are shown in the bar graph presented in Figure 5D. For cell histochemistry, the average scores calculated in n=3 separate slides are shown. For flow cytometry, the scores showing T cells, B cells and monocytes are shown as the average scores obtained in n=5 samples analyzed. (See Figure 5D).

[0121] The results of this study show that NBL1, which is not expressed in the kidney, is expressed in circulating immune cells (especially T cells and monocytes), various intestinal tissues and muscle, and is expressed to a lesser extent in reproductive tissues, bone and bone marrow.

[0122] 6.4. Example 4. Neutralizing NBL1 with an antagonist prevents toxicity Having shown that NBL1 is toxic to podocytes and renal tubular cells, that this toxicity is directly mediated, and that NBL1 is not produced locally in renal cells but is instead expressed in circulating immune cells and other non-renal tissues, we tested whether NBL1 might be a suitable target for direct therapeutic intervention to protect renal cells from injury.

[0123] Human podocytes were cultured in the presence of NBL1 (2 μg / ml) with or without soluble BMP2 at a ratio of 1:1 (NBL1:sBMP2=1:1) for 48 hours. Cell death was detected by ELISA. Incubation with soluble BMP2 significantly reduced the cell death effect experienced by human podocytes cultured in the presence of NBL1. This indicates that soluble BMP2 can partially neutralize the pro-apoptotic effect of NBL1 on human podocytes in vitro. The results for the above experiment are shown in FIG. 6. Three independent experiments were performed in duplicate. Data are presented as mean±SEM. A commercially available anti-NBL1 tool antibody (Sigma) showed a smaller effect (data not shown).

[0124] (6.5. Example 5. Strategy for discovering human anti-NBL1 antibodies) A naive human phage display library was panned to discover Fabs capable of binding to human NBL1 (UniProt ID P41271) and further screened for potential cross-species reactivity against mouse NBL1 (UniProt ID Q61477) and / or cynomolgus monkey ("cyno") NBL1 (UniProt ID A0A2K5WIY3). The top 25 Fabs were cloned into an expression vector and expressed as full-length human IgG1 antibodies. The antigen binding of those IgG1 format antibodies was tested by ELISA and EC50 values ​​were assessed. Twenty (20) IgG1 antibodies were shown to bind human NBL1, mouse NBL1, and cynomolgus monkey (cyno) NBL1 in ELISA with EC50s between 10 ng / mL and 100 ng / mL (approximately 0 pM to approximately 600 pM).

[0125] The table presented in section 5.3.2 above presents the VH and VL sequences of these 20 IgG1 antibodies, and the CDR sequences separately.

[0126] 6.6. Example 6. Monoclonal anti-NBL1 antibodies rescue NBL1-mediated apoptosis of human podocytes in vitro Since it has been shown that NBL1 is directly toxic to podocytes and renal tubule cells, and its toxicity can be prevented by using sBMP2 (which can specifically bind to NBL1), the present inventors decided to evaluate the effect of monoclonal anti-NBL1 antibodies on the cell death effect experienced by human podocytes cultured in the presence of NBL1. Among the monoclonal antibodies made in Example 6, the present inventors tested 16 antibodies and evaluated their ability to prevent cell death and apoptosis in human podocytes cultured in vivo.

[0127] Human podocytes were cultured in RPMI supplemented with 10% FBS and ITS (1x). Human NBL1 recombinant protein was obtained from Genscript (Piscataway, NJ). Human monoclonal NBL1 antibody (Example 6 above), obtained by cloning phage-displayed NBL1-binding Fab into human IgG1 format, was tested at a concentration of 20 μg / ml.

[0128] The human podocytes were cultured for 48 hours in the presence / absence of human NBL1 (2 μg / ml) at a 1:1 ratio (monoclonal antibody (mAb):NBL1) and in the presence / absence of anti-NBL1 monoclonal antibody (mAb) (20 μg / ml) generated by the inventors. Cell lysates were collected at 48 hours of culture, and cell death / apoptosis was assessed by using ELISA (Roche Diagnostics GmbH, 11544675001, Mannheim, Germany). Quantification of cell death was normalized to untreated cells.

[0129] We observed that after incubation in the presence of these newly generated monoclonal antibodies (mAbs), many of them were able to prevent / reduce NBL1-induced cell death to various degrees (p<0.0001). Most importantly, 6 of these 16 monoclonal antibodies (mAbs) (YU1018-H08, YU1019-B06, YU1018-E01, YU1018-E04, YU1019-A12, YU1018-D06) were able to reduce the cell death effect experienced by human podocytes cultured with NBL1 to the level of the negative control (leftmost bar, "medium") or lower. This indicates that these monoclonal antibodies (mAbs) can completely neutralize the pro-apoptotic effect of NBL1 on human podocytes in vitro, which further indicates that among the antibodies tested, these antibodies are the most potent at reducing the progression of glomerular / kidney disease in subjects with elevated circulating NBL1 levels, including human subjects with T1D and human subjects with T2D. The results are shown in FIG. 8.

[0130] In the same experiment, we tested the ability of soluble BMP2 (1 μg / ml, 1:1 BMP2:NBL1 ratio) to neutralize the effect of NBL1. As shown in Figure 8, monoclonal antibodies (mAbs) H08, B06, and E01 were significantly stronger than sBMP2 in reducing the NBL1-mediated apoptotic effect on human podocytes. This highlights the beneficial effectiveness of anti-NBL1 antibodies in protecting podocytes from NBL1-mediated toxicity and damage.

[0131] 6.7. Example 7. NBL1 is elevated in type 1 and type 2 diabetes To determine whether NBL1 is involved in renal injury in diabetes, NBL1 serum levels were evaluated using an immunotargeted assay. NBL1 serum levels were measured in patients with long-standing type 1 diabetes (T1D, n=150) and compared to NBL1 serum levels observed in serum of non-diabetic subjects (n=15). NBL1 serum levels in patients with long-standing type 1 diabetes showed a significant elevation of NBL1. A parallel comparison of NBL1 serum levels in patients with type 2 diabetes (T2D, n=70) to levels in non-diabetic subjects also showed a significant elevation of NBL1. The results are shown in Figure 7A.

[0132] We then selected patients with T1D or T2D who also had a diagnosis of diabetes-related kidney disease (DKD) and analyzed their NBL1 serum levels. The analysis included patients with stage 2-3 chronic kidney disease (CKD) (eGFR < 60 ml / min / m 2 , n=60) had three-fold elevated NBL1 serum levels compared to nondiabetic subjects and two-fold elevated NBL1 serum levels compared to diabetic patients without CKD (see FIG. 7B ).

[0133] Therefore, inhibition of NBL1 is a novel therapeutic approach to prevent the onset and progression of renal damage in patients with type 1 or type 2 diabetes. Inhibition of NBL1 is also effective in treating non-diabetic glomerular diseases in which damage is mediated by NBL1.

[0134] 7. EQUIVALENTS AND INCORPORATION BY REFERENCE While the present invention has been particularly shown and described with reference to preferred and various alternative embodiments, it will be understood by those skilled in the art that various changes in form and detail can be made in those embodiments without departing from the spirit and scope of the invention.

[0135] All references, issued patents, and patent applications cited within this specification are hereby incorporated by reference in their entirety for all purposes.

Claims

1. A composition for delaying the onset or progression of kidney damage in a subject with type 1 or type 2 diabetes or a glomerular disease, the composition comprising an agent capable of inhibiting NBL1 activity.

2. The composition of claim 1 , wherein the agent is capable of binding to NBL1.

3. The composition of claim 2 , wherein the agent is capable of binding to human NBL1.

4. The composition of claim 3 , wherein the agent is an antibody or an antigen-binding fragment of an antibody capable of binding to human NBL1.

5. the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs, the three heavy chain CDRs and the three light chain CDRs being a) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); b) SEQ ID NOs: 3, 8, and 13 and SEQ ID NOs: 18, 23, and 28 (antibody E05a); c) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); d) SEQ ID NOs: 63, 68, and 73 and SEQ ID NOs: 78, 83, and 88 (antibody F06); e) SEQ ID NOs: 123, 128, and 133 and SEQ ID NOs: 138, 143, and 148 (Antibody G01); f) SEQ ID NOs: 153, 158, and 163 and SEQ ID NOs: 168, 173, and 178 (antibody E11); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); h) SEQ ID NOs: 213, 218, and 223 and SEQ ID NOs: 228, 233, and 238 (antibody D12); i) SEQ ID NOs: 243, 248, and 253 and SEQ ID NOs: 258, 263, and 268 (antibody H01); j) SEQ ID NOs: 273, 278, and 283 and SEQ ID NOs: 288, 293, and 298 (antibody C11); k) SEQ ID NOs: 303, 308, and 313 and SEQ ID NOs: 318, 323, and 328 (antibody E05b); l) SEQ ID NOs: 333, 338, and 343 and SEQ ID NOs: 348, 353, and 358 (antibody F10); m) SEQ ID NOs: 363, 368, and 373 and SEQ ID NOs: 378, 383, and 388 (antibody G10); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); o) SEQ ID NOs: 423, 428, and 433 and SEQ ID NOs: 438, 443, and 448 (antibody E07); p) SEQ ID NOs: 453, 458, and 463 and SEQ ID NOs: 468, 473, and 478 (antibody E12); q) SEQ ID NOs: 483, 488, and 493 and SEQ ID NOs: 498, 503, and 508 (antibody D08); r) SEQ ID NOs: 513, 518, and 523 and SEQ ID NOs: 528, 533, and 538 (antibody E10); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (Antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from having a sequence that differs from the selected CDR sequences (a) to (t) by at most two conservative amino acid substitutions in each CDR; The composition of claim 4.

6. 6. The composition of claim 5, wherein the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs having sequences identical to the selected CDRs.

7. the three heavy chain CDRs and three light chain CDRs a) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); c) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (Antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from having a sequence that differs from the selected CDR sequences a), c), g), n), s), and t) by at most two conservative amino acid substitutions in each CDR; The composition of claim 5.

8. 8. The composition of claim 7, wherein the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs having sequences identical to the selected CDRs.

9. The composition of any one of claims 4 to 8, wherein the antibody framework region is a human antibody framework region.

10. The composition of any one of claims 4 to 8, wherein the antibody is a full-length bivalent monospecific monoclonal antibody.

11. The composition of claim 10, wherein the antibody comprises a human IgG1 heavy chain constant region, a human IgG2 heavy chain constant region, or a human IgG4 heavy chain constant region.

12. The composition of claim 11 , wherein the antibody comprises a human IgG1 constant region.

13. 11. The composition of claim 10, wherein the antibody Fc region has engineered mutations that reduce antibody binding to at least one type of Fc receptor and / or reduce complement fixation.

14. The composition of any one of claims 4 to 8, wherein the antibody is a Fab, and optionally the Fab is pegylated.

15. The composition of any one of claims 4 to 8, wherein the antibody or antigen-binding fragment is further capable of binding to cynomolgus monkey NBL1.

16. The composition of claim 15, wherein the antibody or antigen-binding fragment is further capable of binding to mouse NBL1.

17. The antibody or antigen-binding fragment has a binding affinity (K Ｄ The composition according to any one of claims 4 to 8, wherein

18. The antibody or antigen-binding fragment has a binding affinity (K Ｄ 18. The composition of claim 17, wherein

19. The antibody or antigen-binding fragment has a binding affinity (K Ｄ 20. The composition of claim 18, wherein

20. The composition of any one of claims 1 to 3, wherein the agent comprises a bone morphogenetic protein (BMP) or a soluble fragment thereof.

21. The composition of claim 20, wherein the agent comprises a soluble fragment of human BMP-2.

22. 21. The composition of claim 20, wherein the agent further comprises a moiety that extends serum half-life.

23. 23. The composition of claim 22, wherein the half-life extending moiety is an antibody Fc domain.

24. 23. The composition of claim 22, wherein the half-life extending moiety is at least one covalently attached polyethylene glycol (PEG) moiety.

25. The composition of any one of claims 1 to 8, wherein the agent is capable of inhibiting dimerization of NBL1.

26. The composition of claim 1 , wherein the agent is capable of inhibiting NBL1 expression.

27. The composition according to any one of claims 1 to 8, characterized in that the composition is administered parenterally.

28. 28. The composition of claim 27, wherein the composition is administered intravenously.

29. 28. The composition of claim 27, wherein the composition is administered subcutaneously.

30. The composition according to any one of claims 1 to 8, characterized in that the composition is administered for at least 3 months.

31. 31. The composition of claim 30, wherein the composition is administered for at least six months.

32. 32. The composition of claim 31, wherein the composition is administered for at least 12 months.

33. The composition of any one of claims 1 to 8, wherein the subject has elevated pre-treatment plasma NBL1 levels.

34. The composition of any one of claims 1 to 8, wherein the subject has type 1 diabetes.

35. The composition of any one of claims 1 to 8, wherein the subject has type 2 diabetes.

36. The composition of any one of claims 1 to 8, wherein the subject has a glomerular disease.

37. 37. The composition of claim 36, wherein the subject with the glomerular disease does not have type 1 or type 2 diabetes.

38. 37. The composition of claim 36, wherein the glomerular disease is selected from the group consisting of focal segmental glomerulosclerosis (FSGS), chronic glomerulopathy, hereditary nephritis, and minimal change disease.

39. A composition described in any one of claims 1 to 8, wherein the composition prevents the onset of or slows the decline in renal function.

40. A composition for treating diabetes-related kidney disease (DKD) or glomerular disease in a subject with type 1 or type 2 diabetes or glomerular disease, the composition comprising an agent capable of inhibiting NBL1 activity.

41. The composition of claim 40, wherein the agent is an antibody or an antigen-binding fragment of an antibody capable of binding to human NBL1.

42. An antibody or antigen-binding fragment, which is capable of binding to NBL1 and inhibiting NBL1-induced toxicity of human podocytes.

43. the antibody or antigen-binding fragment comprises three heavy chain CDRs and three light chain CDRs, the three heavy chain CDRs and the three light chain CDRs being a) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); b) SEQ ID NOs: 3, 8, and 13 and SEQ ID NOs: 18, 23, and 28 (antibody E05a); c) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); d) SEQ ID NOs: 63, 68, and 73 and SEQ ID NOs: 78, 83, and 88 (antibody F06); e) SEQ ID NOs: 123, 128, and 133 and SEQ ID NOs: 138, 143, and 148 (Antibody G01); f) SEQ ID NOs: 153, 158, and 163 and SEQ ID NOs: 168, 173, and 178 (antibody E11); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); h) SEQ ID NOs: 213, 218, and 223 and SEQ ID NOs: 228, 233, and 238 (antibody D12); i) SEQ ID NOs: 243, 248, and 253 and SEQ ID NOs: 258, 263, and 268 (antibody H01); j) SEQ ID NOs: 273, 278, and 283 and SEQ ID NOs: 288, 293, and 298 (antibody C11); k) SEQ ID NOs: 303, 308, and 313 and SEQ ID NOs: 318, 323, and 328 (antibody E05b); l) SEQ ID NOs: 333, 338, and 343 and SEQ ID NOs: 348, 353, and 358 (antibody F10); m) SEQ ID NOs: 363, 368, and 373 and SEQ ID NOs: 378, 383, and 388 (antibody G10); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); o) SEQ ID NOs: 423, 428, and 433 and SEQ ID NOs: 438, 443, and 448 (antibody E07); p) SEQ ID NOs: 453, 458, and 463 and SEQ ID NOs: 468, 473, and 478 (antibody E12); q) SEQ ID NOs: 483, 488, and 493 and SEQ ID NOs: 498, 503, and 508 (antibody D08); r) SEQ ID NOs: 513, 518, and 523 and SEQ ID NOs: 528, 533, and 538 (antibody E10); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (Antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from having a sequence that differs from the selected CDR sequences (a) to (t) by at most two conservative amino acid substitutions in each CDR; 43. The antibody of claim 42.

44. 44. The antibody or antigen-binding fragment of claim 43, comprising three heavy chain CDRs and three light chain CDRs having sequences identical to the selected CDRs.

45. the three heavy chain CDRs and three light chain CDRs a) SEQ ID NOs: 93, 98, and 103 and SEQ ID NOs: 108, 113, and 118 (Antibody A12); c) SEQ ID NOs: 33, 38, and 43 and SEQ ID NOs: 48, 53, and 58 (antibody H08); g) SEQ ID NOs: 183, 188, and 193 and SEQ ID NOs: 198, 203, and 208 (Antibody B06); n) SEQ ID NOs: 393, 398, and 403 and SEQ ID NOs: 408, 413, and 418 (antibody E04); s) SEQ ID NOs: 543, 548, and 553 and SEQ ID NOs: 558, 563, and 568 (Antibody D06); and t) SEQ ID NOs: 573, 578, and 583 and SEQ ID NOs: 588, 593, and 598 (Antibody E01) or having a sequence selected from having a sequence that differs from the selected CDR sequences a), c), g), n), s), and t) by at most two conservative amino acid substitutions in each CDR; 44. The antibody or antigen-binding fragment of claim 43.

46. 46. The antibody or antigen-binding fragment of claim 45, comprising three heavy chain CDRs and three light chain CDRs having sequences identical to the selected CDRs.

47. 47. The antibody or antigen-binding fragment of any one of claims 43 to 46, wherein the antibody framework region is a human antibody framework region.

48. The antibody or antigen-binding fragment of any one of claims 43 to 46, wherein the antibody is a full-length bivalent monospecific monoclonal antibody.

49. 49. The antibody or antigen-binding fragment of claim 48, wherein the antibody comprises a human IgG1 heavy chain constant region, a human IgG2 heavy chain constant region, or a human IgG4 heavy chain constant region.

50. 50. The antibody or antigen-binding fragment of claim 49, wherein the antibody comprises a human IgG1 constant region.

51. 49. The antibody or antigen-binding fragment of claim 48, wherein the antibody Fc region has engineered mutations that reduce antibody binding to FcRγ and / or reduce complement fixation.

52. 47. The antibody or antigen-binding fragment of any one of claims 43 to 46, wherein the antibody is a Fab, and optionally the Fab is pegylated.

53. The antibody or antigen-binding fragment of any one of claims 42 to 46, further capable of binding to cynomolgus monkey NBL1.

54. 54. The antibody or antigen-binding fragment of claim 53, further capable of binding to mouse NBL1.

55. Binding affinity (K) for human NBL1 of less than 100 nM Ｄ 47. The antibody or antigen-binding fragment of any one of claims 42 to 46, having the following structure:

56. Binding affinity (K) for human NBL1 of less than 10 nM Ｄ 56. The antibody or antigen-binding fragment of claim 55, having the following structure:

57. Binding affinity (K) for human NBL1 of less than 5 nM Ｄ 56. The antibody or antigen-binding fragment of claim 55, having the following structure:

58. An antibody or antigen-binding fragment according to any one of claims 42 to 46, and Pharmaceutically Acceptable Carriers A pharmaceutical composition comprising:

59. 59. The pharmaceutical composition of claim 58, formulated for parenteral administration.

60. 60. The pharmaceutical composition of claim 59, formulated for intravenous administration.

61. 60. The pharmaceutical composition of claim 59, formulated for subcutaneous administration.

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