Sephin1 and related compound therapy

Abstract

Methods of treating diseases and disorders treatable by with Sephin1 and related compounds, for example kidney diseases and disorders.

Description

SEPHIN1 AND RELATED COMPOUND THERAPY1. CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the priority benefit of U.S. provisional application no. 63 / 703,794, filed October 4, 2024, the contents of which are incorporated herein in their entireties by reference thereto.2. BACKGROUND

[0002] Sephinl (also known as IFB-088 and icerguastat) is a benzylideneguanidine derivative under development for treatment of amyotrophic lateral sclerosis (ALS) and Charcot-Marie-Tooth disorder (CMT).3. SUMMARY

[0003] This disclosure provides new uses for sephinl and related compounds, for example in the treatment of diseases and disorders, for example kidney diseases and disorders. The Examples in Section 7 show, inter alia, that the compound sephinl suppressed renal tubular cell death and preserved renal function in an animal model of acute kidney injury. Renal tubular cell death is associated with various kidney diseases and disorders and frequently occurs following kidney transplant. Accordingly, in various aspects, this disclosure provides methods of treating subjects having or at risk of a kidney disease or disorder with sephinl and related compounds, and provides methods of using sephinl and related compounds in the kidney transplantation context.

[0004] In one aspect, the disclosure provides a method of treating a subject having a kidney disease or disorder or at risk of a kidney disease or disorder comprising administering to the subject an agent which is a compound of Formula (I)Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms (such as N) in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.

[0005] Exemplary kidney diseases and disorders include acute kidney injury, for example caused by exposure to a toxin (e.g., an environmental or occupational toxin or a medication), acute tubular necrosis, for example caused by exposure to a toxin (e.g., an environmental or occupational toxin or a medication), focal segmental glomerulosclerosis (FSGS), diabetic nephropathy (also referred to as diabetic kidney disease), chronic kidney disease, and inherited kidney diseases.

[0006] Sephinl is an exemplary compound of Formula (I).

[0007] Compounds of Formula (I), tautomers thereof, and pharmaceutically acceptable salts of the foregoing (for avoidance of doubt, “pharmaceutically acceptable salts of the foregoing” refers to pharmaceutically acceptable salts of compounds of Formula (I) and pharmaceutically acceptable salts of tautomers of compounds of Formula (I)) are sometimes collectively referred to herein as “agents of the disclosure” for convenience.

[0008] In another aspect, the disclosure provides a method of treating a subject having or at risk of nephrotoxicity comprising administering an agent of the disclosure to the subject.

[0009] In another aspect, the disclosure provides a method of treating a subject who is a donor kidney recipient comprising administering an agent of the disclosure to the subject.

[0010] In another aspect, the disclosure provides a method of enhancing the viability of and / or improving the function of and / or decreasing damage (e.g., renal tubule damage) to a donor kidney comprising administering to the donor and / or a recipient of the donor kidney an agent of the disclosure.

[0011] The Examples in Section 7 further show, inter alia, that the compound sephinl activates AMP-activated protein kinase (AMPK). AMPK is a regulator of energy homeostasis and increased AMPK activity is associated with a variety of health benefits (Steinberg & Carling, 2019, Nat. Rev. Drug Discov. 18(7):527-551). Activated AMPK phosphorylates C / EBP homologous protein (CHOP), an endoplasmic reticulum (ER) stress-induced transcription factor. Phosphorylation of CHOP by AMPK triggers the proteosomal degradation of CHOP (Dai et al., 2016, Circ Res. 119(10):1089-1100). AMPK is a known target for treating various diseases and disorders such as metabolic syndrome, type-2 diabetes, and cancer (Li et al., 2015, Oncotarget 6(10):7365-7378), and CHOP is also implicated in various diseases and disorders including cancer, diabetes, and fibrosis (Yang et al., 2017, Frontiers in Immunology 8:1612). CHOP also regulates GDF-15, which plays a role in lipid hypermetabolism (Li et al., 2019, Biochem Biophys Res Commun 498(3):388- 394, Townsend et al., 2022, J Appl Physiol 132: 413-422). Lipid hypermetabolism is associated with diseases and disorders including cancer cachexia, advanced cancer, and mitochondrial disease (Sturm et al., 2023, Communications Biology 6:22).

[0012] Accordingly, in another aspect, the disclosure provides a method of activating AMPK and / or increasing phosphorylated AMPK (pAMPK) / AMPK ratio in a cell by contacting a cell of a subject (e.g., a cell in vivo) with an agent of the disclosure.

[0013] In another aspect, the disclosure provides a method of inhibiting CHOP and / or increasing the phosphorylated CHOP (pCHOP)ZCHOP ratio in a cell by contacting a cell of a subject (e.g., a cell in vivo) with an agent of the disclosure.

[0014] In another aspect, the disclosure provides a method of treating a subject having or at risk of disease or disorder treatable by AMPK activation and / or treatable by CHOP inhibition, the method comprising administering an agent of the disclosure to the subject. Exemplary diseases and disorders treatable by AMPK activation and / or inhibiting CHOP include metabolic syndrome, non-alcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH), obesity, diabetes (e.g., type 1 or type 2 diabetes), insulin resistance, glucose intolerance, chronic pain, sarcopenia, a neuromuscular disorder, heart failure, cardiac hypertrophy, diabetic cardiomyopathy, cardiac reperfusion injury, chronic kidney disease, polycystic kidney disease, acute kidney injury, diabetic nephropathy, cardiovascular diseases, inflammatory bowel disease, arthritis, hypertension, peripheral vascular disease,nephrogenic diabetes insipidus, glaucoma, an eye disease or disorder, ocular neovascularization, p-hemoglobinopathy, cancer, and fibrosis. Further exemplary diseases and disorders treatable by AMPK activation and / or inhibiting CHOP include cancer cachexia, advanced cancer, mitochondrial diseases, and amyotrophic lateral sclerosis (ALS).

[0015] In some embodiments of the methods of the disclosure, the agent is sephinl or a tautomer thereof, a salt of sephinl , or a salt of a tautomer of sephinl .

[0016] Methods of the disclosure are further described in Section 5.2 and numbered embodiments 1 to 165, infra.

[0017] Agents of the disclosure and compositions comprising the agents are further described in Section 5.3 and numbered embodiments 1 to 169, infra.4. BRIEF DESCRIPTION OF THE FIGURES

[0018] FIG. 1 shows the study timeline of Example 1 .

[0019] FIG. 2 shows Western blots for phosphorylated AMPK (pAMPK), AMPK, and GAPDH (control) from HK-2 cells treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated cells (CNT) (Example 1).

[0020] FIGS. 3A-3C show pAMPH / GAPDH (FIG. 3A), AMPK / GAPDH (FIG. 3B) and pAMPK / AMPK (FIG. 3C) ratios from HK-2 cells treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated cells (Sham) (Example 1).

[0021] FIG. 4 shows the study timeline of Example 2.

[0022] FIG. 5 shows protein expression levels for CHOP, p-CHOP, and a-Tubulin from cells treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated cells (Sham) (Example 2).

[0023] FIG. 6 shows relative CHOP, p-CHOP and p-CHOP / CHOP levels from the study of Example 2.

[0024] FIG. 7 shows the study timeline of Example 3.

[0025] FIG. 8 shows protein expression levels and relative protein expression levels for CHOP, p-CHOP, and a-Tubulin from cells treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated cells (Sham) (Example 3).

[0026] FIG. 8 shows protein expression levels and relative protein expression levels in cytoplasm and nucleus for CHOP, a-Tubulin, and histone from cells treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated cells (CNT) (Example 3).

[0027] FIG. 9 shows cell number and cell viability for the treatment groups of Example 3.

[0028] FIGS. 10A-10E show the effect of Sephinl on tunicamycin-induced ER stress markers in vivo in mice treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated mice (Sham). FIGS. 10A and 10B show Kaplan-Meier survival curves of mice receiving tunicamycin intraperitoneal injections at 1 mg / kg, n = 9 (FIG. 10A) and at 2 mg / kg, n = 12 (FIG. 10B) without or with Sephinl . FIG. 10C shows body, kidney and heart weights measured on Day 3 (n = 4). FIG. 10D shows BUN and Nppb expressions measured on Day 3 (n = 4 for BUN, n=3 for Nppb). FIG. 10E shows representative M-mode of ultrasound cardiography and percentages of ejection fraction (EF), left ventricular diameter (LVDs), and left ventricular diastolic wall thickness were measured on Day 3 (n = 4). The error bars indicate the SDs. The number of asterisks can be obtained by indicating a range of p values as follows; * < 0.05, ** < 0.01 , *** < 0.001 , **** < 0.0001 (Example 4).

[0029] FIGS. 11A-11C show the results of immunostaining and qPCR analyses in kidneys of mice treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated mice (Sham). FIG. 11A shows representative images of PAS staining of the kidney of mice on Day 3 and quantification of kidney injuries (n=4). FIG. 11 B shows representative images of Megalin staining and Kim-1 staining of kidneys of mice on Day 3, wherein Kim-1 positivity reflects damaged tubular epithelium (n = 4). FIG. 11C shows mRNA expression of cell death related genes in murine kidney on Day 3 (n = 9). Error bars indicate SDs. The number of asterisks can be obtained by indicating a range of p values as follows; * < 0.05, ** < 0.01 , *** <0.001 , **** < 0.0001 (Example 5).

[0030] FIGS. 12A-12C show the results of Western blot (WB) and immunostaining analyses in kidneys of mice treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated mice (Sham). FIG. 12A shows elF2a WB results on Day 3. The graph shows the expression ratio of each protein corrected by a-Tubulin protein expression level (n = 3). FIG. 12B shows WB analysis of CHOP on Day 3. The graph shows the expression ratio of each protein corrected by a-Tubulin protein expression level. FIG. 12C shows representative images of CHOP staining of mouse kidneys on Day 3 and the CHOP-positive rate in the nucleus in either the cortex or medulla (n = 3). All bars in the images are 100 pm. The error bars indicate the SDs. The number of asterisks can be obtained by indicating a range of p values as follows; * < 0.05, ** < 0.01 , *** < 0.001 , **** < 0.0001 (Example 6).

[0031] FIGS. 13A-13F show the effect of Sephinl on measures of CHOP pathway in mice treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated mice (CNT). FIG. 13A shows the numbers of HK-2 cells exposed to 20 pg / ml tunicamycin without or with 2pM Sephinl for 24 h (n = 3). FIG. 13B shows results of apoptosis analysis using PI and annexin V of HK-2 cells at 24 hours following the administration of 1 mg / ml tunicamycinwithout or with 1 pM Sephinl by FACS (n = 3). FIG. 13C shows patterns of mRNA expression of HK-2 cells at 24 h following the administration of 20 pg / ml tunicamycin without or with 1 pM Sephinl (n = 3). FIG. 13D shows results of WB analysis of CHOP and elF2a of HK-2 cells at 24 h following the administration of 20 pg / ml tunicamycin without or with 1 M Sephinl . The graph shows the expression ratio of each protein corrected by a-Tubulin protein expression level (n = 3). FIG. 13E shows results of WB analysis of CHOP in the nuclear fraction of HK-2 cells at 24 h following the administration of 20 pg / ml tunicamycin without or with 1 pM Sephinl (n = 3). FIG. 13F shows results of immunocytochemical staining using anti-CHOP antibody to HK-2 cells over time. The error bars indicate the SDs. The number of asterisks can be obtained by 929 indicating a range of p values as follows; * < 0.05, ** < 0.01 , *** < 0.001 , **** < 0.0001 (Example 7).

[0032] FIGS. 14A-14I show the effect of Sephinl on measures of CHOP degradation in mice treated with Tunicamycin (Tu), Tunicamycin + Sephinl (Tu + Se) or untreated mice (CNT). FIG. 14A shows the numbers of CHOP-KD HK-2 cells at 24 hours following the administration of 20 pg / ml tunicamycin without or with 1 pM Sephinl (n=6). FIG. 14B shows the numbers of HK-2 cells in the ER stress model under 1 pM of compound C, an AMPK inhibitor (n=3). FIG. 14C shows the numbers of HK-2 cells in the ER stress model to examine the effects of FTY720 at the concentration of 1 pg / ml. FIG. 14D shows results obtained with LB-100, an antagonist for PP2A, at the concentration of 0.01 pg / ml, which was used instead of Sephinl . FIG. 14E shows results of WB analysis for AMPK and phosphorylated AMPK on Thr172 of HK-2 at 24 hours following drug administration. The graph shows the expression ratio of each protein corrected by GAPDH protein expression level (n = 3). FIG. 14F shows results of a coimmunoprecipitation assay for AMPK and PP2A or PP2C. Following immunoprecipitation for AMPK, either PP2A or PP2C were blotted for their binding status. Relative values of PP2A or PP2C to AMPK in tunicamycin-exposed group and Sephinl -treated group were adjusted with those in the control group (n = 3). FIG. 14G shows results of a coimmunoprecipitation assay for AMPK and PP2AB6. Following immunoprecipitation for AMPK, PP2AB6 was blotted for their binding status. Relative values of PP2AB6 to AMPK in tunicamycin-exposed group and Sephinl -treated group were calculated (n=3). FIG. 14H shows results of a coimmunoprecipitation assay for PP2AB6 and PP2AC. Following immunoprecipitation for PP2AB6, PP2AC was blotted fortheir binding status. Relative values of PP2AC to PP2AB6 in tunicamycin exposed group and Sephinl treated group were calculated (n=3). FIG. 141 shows results of a coimmunoprecipitation assay for PP2AC and PP2AB6. Following immunoprecipitation for PP2AC, PP2AB6 was blotted fortheir binding status. Relative values of PP2AB6 to PP2AC in tunicamycin-exposed group and Sephinl -treated group were calculated (n=3). The error bars indicate the SDs.The number of asterisks can be obtained by indicating a range of p values as follows; * < 0.05, ** < 0.01 , *** < 0.001 , **** < 0.0001 (Example 8).

[0033] FIG. 15 shows a schematic representation showing a proposed mechanism of action of Sephinl .5. DETAILED DESCRIPTION5.1. Definitions

[0034] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood to one of ordinary skill in the art to which this invention belongs. The following definitions are provided for the full understanding of terms used in this specification.

[0035] As used herein, the following terms are intended to have the following meanings:

[0036] A, An, The: As used herein, the term “a”, “an”, “the” and similar terms used in the context of the present disclosure (especially in the context of the claims) are to be construed to cover both the singular and plural unless otherwise indicated herein or clearly contradicted by the context. As such, the terms “a” (or “an”), “one or more”, and “at least one” can be used interchangeably herein.

[0037] Alkenyl: As used herein, the term “alkenyl” refers to a group containing one or more carbon-carbon double bonds, and which can be branched or unbranched. An alkenyl group can be, for example, a C2-20 alkenyl group, a C2-15 alkenyl group, a C2-12 alkenyl group, a C2-6alkenyl group, or a C2-3 alkenyl group. The term “cyclic alkenyl” is to be construed accordingly.

[0038] Alkyl: As used herein, the term “alkyl” includes both saturated straight chain and branched alkyl groups. An alkyl group can be, for example, a C1-20 alkyl group, a C1-15 alkyl group, a C1-12 alkyl group, a Ci-6alkyl group, or a C1-3 alkyl group. Examples of alkyl groups include methyl, ethyl, propyl, isopropyl, butyl, isobutyl, tert-butyl, pentyl and hexyl.

[0039] AMPK: The term “AMPK” refers to AMP-activated protein kinase. AMPK is a heterotrimeric protein complex that is formed by a, p, and y subunits. The a, p, and y subunits can be found in different isoforms: the y subunit can exist as the y1 , y2 or y3 isoform; the p subunit can exist as the p1 or p2 isoform; and the a subunit can exist as the a1 or a2 isoform. The a subunits are encoded by the PRKAA1 (a1 isoform) and PRKAA2 (a2 isoform) genes; the p subunits are encoded by the PRKAB1 (p1 isoform) and PRKAB2 (p2 isoform) genes, and the y subunits are encoded by the PRKAG1 (y1 isoform), PRKAG2 (y2 isoform), and PRKAG3 (y3 isoform) genes. AMPK becomes activated when phosphorylation takes place at Thr-172 of the a subunit (Sanders et al., 2007, Biochem J. 403(Pt.1):139-148;Steinberg & Carling, 2019, Nat. Rev. Drug Discov. 18(7):527-551). Phosphorylated AMPK is referred to herein as “pAMPK.”

[0040] And / or: The term “and / or” means that each one or both or all the components or features of a list are possible variants, especially two or more thereof in an alternative or cumulative way.

[0041] Aralkyl: As used herein, the term “aralkyl” refers to a group having both aryl and alkyl functionalities. By way of example, the term includes groups in which one of the hydrogen atoms of the alkyl group is replaced by an aryl group, e.g. a phenyl group. Exemplary aralkyl groups include benzyl, phenethyl and the like.

[0042] Aryl: As used herein, the term “aryl” refers to a C6-12 aromatic group. Examples include phenyl and naphthyl, etc.

[0043] CHOP: The term “CHOP” refers to C / EBP homologous protein. CHOP is a pro- apoptotic transcription factor that is encoded by the DDIT3 gene and induced in response to certain stressors (Yang et al., 2017, Frontiers in Immunology 8:1612). Phosphorylation of Ser-30 of CHOP by AMPK triggers the proteosomal degradation of CHOP (Dai et al., 2016, Circ Res. 119(10):1089-1100). CHOP phosphorylated at Ser-30 is referred to herein as “phosphorylated CHOP,” “pCHOP,” or “p-CHOP.” The expressions “inhibiting CHOP,” “CHOP inhibition” and the like do not require total inhibition of CHOP. Inhibition can be achieved, for example, by increasing the amount of pCHOP and / or increasing a pCHOP / CHOP ratio and / or reducing the amount of CHOP, for example due to proteosomal degradation of pCHOP.

[0044] Cycloalkyl: As used herein, the term “cycloalkyl” refers to a cyclic alkyl group.

[0045] Effective amount: The term “effective amount” or “therapeutically effective amount” means the amount or quantity of an agent or composition that is sufficient to elicit the required or desired response, or in other words, the amount that is sufficient to elicit an appreciable biological response when administered, e.g., to a subject. Said amount preferably relates to an amount that is therapeutically or in a broader sense also prophylactically effective against the progression of a disease or disorder as disclosed herein. It is understood that an “effective amount” or a “therapeutically effective amount” can vary from subject to subject, due to variation in metabolism of an agent, age, weight, general condition of the subject, the condition being treated, the severity of the condition being treated, and the judgment of the prescribing physician.

[0046] Heteroaryl: As used herein, the term “heteroaryl” refers to a 4 to 12 membered aromatic group, which comprises one or more heteroatoms. An exemplary heteroaryl groupis a 4 to 12 membered aromatic group comprising one or more heteroatoms selected from N, O and S. Exemplary heteroaryl groups include pyrrolyl, pyrazolyl, pyrimidinyl, pyrazinyl, pyridinyl, quinolinyl, thiophenyl, 1 ,2,3-triazolyl, 1 ,2,4-triazolyl, thiazolyl, oxazolyl, isothiazolyl, iso-oxazolyl, imidazolyl, furanyl and the like.

[0047] Heterocycle: As used herein, the term “heterocycle” (also referred to herein as “heterocyclyl” and “heterocyclic”) refers to 4 to 12 membered, for example 4 to 12 membered saturated, unsaturated or partially unsaturated, cyclic group containing one or more heteroatoms selected from N, O and S, and which optionally further contains one or more CO groups. The term “heterocycle” encompasses both heteroaryl groups and heterocycloalkyl groups as defined herein.

[0048] Heterocycloalkyl: As used herein, the term “heterocycloalkyl” refers to a 4 to 12 membered cyclic aliphatic group which contains one or more heteroatoms. Exemplary heterocycloalkyl groups include piperidinyl, pyrrolidinyl, piperazinyl, thiomorpholinyl and morpholinyl. Further examples include N-piperidinyl, N-pyrrolidinyl, N-piperazinyl, N- thiomorpholinyl and N-morpholinyl.

[0049] Or: Unless indicated otherwise, an “or” conjunction is intended to be used in its correct sense as a Boolean logical operator, encompassing both the selection of features in the alternative (A or B, where the selection of A is mutually exclusive from B) and the selection of features in conjunction (A or B, where both A and B are selected). In some places in the text, the term “and / or” is used for the same purpose, which shall not be construed to imply that “or” is used with reference to mutually exclusive alternatives.

[0050] Subject: As used herein, the term “subject” means a human.

[0051] Treat, treating, treatment: The terms “treat,” “treating,” “treatment,” and grammatical variations thereof as used herein, include reducing or ameliorating a disease or disorder, and / or signs or symptoms associated therewith, or slowing or halting the progression thereof. It will be appreciated that, although not precluded, treating a disease or disorder does not require that the disease, disorder or symptoms associated therewith be completely eliminated. Treatments according to the disclosure may be applied prophylactically (e.g., to a subject at risk of developing a disease or disorder), palliatively or remedially. Prophylactic treatments can be administered to a subject prior to onset of a sign or symptom, during early onset of a sign or symptom (e.g., upon initial signs and symptoms), or after an established development of a sign or symptom. Prophylactic administration can occur for several days to years prior to the manifestation of a symptom.5.2. Methods

[0052] The disclosure provides new uses for compounds of Formula (I), tautomers thereof, and pharmaceutically acceptable salts of the foregoing. Compounds of Formula (I), tautomers thereof, and pharmaceutically acceptable salts of the foregoing are described in greater detail in Section 5.3.

[0053] In one aspect, the disclosure provides a method of activating AMPK and / or increasing the phosphorylated AMPK (pAMPK) / AMPK ratio in a cell by contacting a cell of a subject with an agent of the disclosure (e.g., sephinl) in an amount effective to activate AMPK and / or increase the pAMPK / AMPK ratio in the cell. The contacting of the cell with the agent can be in vivo, for example by orally administering an amount of the agent to the subject effective to activate AMPK and / or increase the pAMPK / AMPK ratio in one or more cell types, tissues, and / or organs of the subject, for example heart, liver, kidney, lung, skeletal muscle, or eye.

[0054] In one aspect, the disclosure provides a method of inhibiting CHOP and / or increasing the phosphorylated CHOP (pCHOP)ZCHOP ratio in a cell by contacting a cell of a subject with an agent of the disclosure (e.g., sephinl) in an amount effective to inhibit CHOP and / or increase the pCHOP / CHOP ratio in the cell. The contacting of the cell with the agent can be in vivo, for example by orally administering an amount of the agent to the subject effective to inhibit CHOP and / or increase the pCHOP / CHOP ratio in one or more cell types, tissues, and / or organs of the subject, for example heart, liver, kidney, lung, skeletal muscle, or eye.

[0055] In another aspect, the disclosure provides a method of treating a subject having or at risk of disease or disorder treatable by AMPK activation and / or CHOP inhibition, the method comprising administering a therapeutically effective amount of an agent of the disclosure (e.g., sephinl) to the subject. In some embodiments, the amount of the agent administered is an amount effective to activate AMPK and / or inhibit CHOP in one or more cell types, tissues, and / or organs, for example heart, liver, kidney, lung, skeletal muscle, or eye.

[0056] In some embodiments, the amount of the agent administered is an amount effective to increase the pAMPK / AMPK ratio in one or more cell types, tissues, and / or organs, for example heart, liver, kidney, lung, skeletal muscle, or eye. In some embodiments, the amount of the agent administered is an amount effective to increase the pCHOP / CHOP ratio in one or more cell types, tissues, and / or organs, for example heart, liver, kidney, lung, skeletal muscle, or eye. AMPK, pAMPK, CHOP, and pCHOP levels and ratios can be evaluated, for example, by measuring their levels using standard laboratory techniques, e.g., by Western blotting, flow cytometry, or fluorescence microscopy.

[0057] Activation of AMPK can suppress fatty acid and cholesterol synthesis. Accordingly, in some embodiments, the amount of agent administered to a subject is an amount effective to suppress fatty acid synthesis. In some embodiments, the amount of the agent administered to a subject is an amount effective to suppress cholesterol synthesis. In some embodiments, the amount of the agent administered to a subject is an amount effective to lower a subject’s cholesterol level, for example, lower serum and / or liver cholesterol levels.

[0058] Activation of AMPK can increase skeletal muscle glucose uptake. Accordingly, in some embodiments, the amount of agent administered to a subject is an amount effective to increase skeletal muscle glucose uptake in the subject. Skeletal muscle glucose uptake can be measured, for example, by measuring forearm glucose uptake.

[0059] Exemplary diseases and disorders treatable by AMPK activation and / or by inhibiting CHOP include metabolic syndrome, non-alcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH), obesity, type 2 diabetes, insulin resistance, glucose intolerance, chronic pain, sarcopenia, a neuromuscular disorder, heart failure, cardiac hypertrophy, diabetic cardiomyopathy, cardiac reperfusion injury, chronic kidney disease, polycystic kidney disease, acute kidney injury, diabetic nephropathy, cardiovascular diseases, inflammatory bowel disease, arthritis, hypertension, peripheral vascular disease, nephrogenic diabetes insipidus, glaucoma, an eye disease or disorder, ocular neovascularization, p-hemoglobinopathy, cancer, and fibrosis. Further exemplary diseases and disorders treatable by AMPK activation and / or inhibiting CHOP include cancer cachexia, advanced cancer, mitochondrial diseases, and amyotrophic lateral sclerosis (ALS). Diseases and disorders treatable by AMPK activation and / or treatable by inhibiting CHOP are described, for example, in Steinberg & Carling, 2019, Nat. Rev. Drug Discov. 18(7):527-551 ; Li et al., 2015, Oncotarget 6(10):7365-7378; Yang et al., 2017, Frontiers in Immunology 8:1612; Dai et al., 2016, Circ Res. 119(10):1089-1100; US 2017 / 0020909; US 10,016,486; US 10,143,703; US 10,596,144; WO 2007 / 097751 ; WO 2017 / 011917; WO 2019 / 063792, and WO 2022 / 072397, the contents of which are incorporated herein by reference in their entireties.

[0060] Accordingly, in some embodiments, the subject administered an agent of the disclosure has or is at risk of developing a disease or disorder described in the preceding paragraph.

[0061] In some embodiments, the subject has or is at risk of metabolic syndrome.

[0062] In some embodiments, the subject has or is at risk of non-alcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH).

[0063] In some embodiments, the subject has or is at risk of obesity.

[0064] In some embodiments, the subject has or is at risk of diabetes (e.g., type 1 or type 2 diabetes).

[0065] In some embodiments, the subject has or is at risk of type 2 diabetes.

[0066] In some embodiments, the subject has or is at risk of insulin resistance.

[0067] In some embodiments, the subject has or is at risk of glucose intolerance.

[0068] In some embodiments, the subject has or is at risk of chronic pain, for example post- surgical pain.

[0069] In some embodiments, the subject has or is at risk of sarcopenia.

[0070] In some embodiments, the subject has or is at risk of a neuromuscular disorder, for example Duchenne muscular dystrophy or myotonic dystrophy type 1 .

[0071] In some embodiments, the subject has or is at risk of heart failure.

[0072] In some embodiments, the subject has or is at risk of cardiac hypertrophy.

[0073] In some embodiments, the subject has or is at risk of diabetic cardiomyopathy.

[0074] In some embodiments, the subject has or is at risk of cardiac reperfusion injury.

[0075] In some embodiments, the subject has or is at risk of a kidney disease (e.g., chronic kidney disease or acute kidney injury).

[0076] In some embodiments, the subject has or is at risk of chronic kidney disease.

[0077] In some embodiments, the subject has or is at risk of polycystic kidney disease, for example autosomal dominant polycystic kidney disease.

[0078] In some embodiments, the subject has or is at risk of acute kidney injury (AKI).

[0079] In some embodiments, the subject has or is at risk of diabetic nephropathy.

[0080] In some embodiments, the subject has or is at risk of a cardiovascular disease, for example atherosclerosis, coronary artery disease, peripheral artery disease, or cerebrovascular disease. In some embodiments, the amount of agent administered is effective to reduce the risk of and / or prevent atherosclerotic plaque rupture. Thus, in some embodiments, the method is a method of promoting atherosclerotic plaque stability. In some embodiments, the amount of agent administered is effective to inhibit initiation of or slow progression of atherosclerosis. Thus, in some embodiments, administration of an agent can reduce the likelihood of acute coronary heart disease and / or stroke.

[0081] In some embodiments, the subject has or is at risk of inflammatory bowel disease.

[0082] In some embodiments, the subject has or is at risk of arthritis.

[0083] In some embodiments, the subject has or is at risk of hypertension.

[0084] In some embodiments, the subject has or is at risk of peripheral vascular disease.

[0085] In some embodiments, the subject has or is at risk of nephrogenic diabetes insipidus.

[0086] In some embodiments, the subject has or is at risk of glaucoma.

[0087] In some embodiments, the subject has or is at risk of an eye disease or disorder, for example retinopathy, symptoms associated with microangiopathy, neovascular glaucoma, corneal graft rejection, glaucoma, herpetic and infectious keratitis, ocular ischemia, neovascular glaucoma, corneal, uveal and / or iris neovascularization, orbital and / or eyelid tumor(s), Stevens Johnson Syndrome, ocular cicatricial pemphigoid, injury, or ocular surface disease. In some embodiments, the eye disease or disorder is macular degeneration, for example wet age-related macular degeneration (AMD).

[0088] In some embodiments, the subject has or is at risk of ocular neovascularization, for example characterized by surface, corneal, retinal, choroidal, uveal, or iris neovascularization.

[0089] In some embodiments, the subject has or is at risk of p-hemoglobinopathy.

[0090] In some embodiments, the subject has or is at risk of cancer. In some embodiments, the cancer is hepatocellular carcinoma. In some embodiments, the cancer is lung cancer. In some embodiments, the cancer is colorectal cancer. In some embodiments, the cancer is liver cancer. In some embodiments, the cancer is melanoma. In some embodiments, the cancer is breast cancer. In some embodiments, the cancer is prostate cancer. In some embodiments, the cancer is ovarian cancer. In some embodiments, the cancer is leukemia.

[0091] In some embodiments, the subject has or is at risk of fibrosis. In some embodiments, the fibrosis is lung fibrosis. In some embodiments, the fibrosis is kidney fibrosis, for example glomerulosclerosis and / or tubulointerstitial fibrosis. In some embodiments, the fibrosis is liver fibrosis. In some embodiments, the fibrosis is cardiac fibrosis.

[0092] In some embodiments, the subject has cancer cachexia. In some embodiments, the subject has advanced cancer. In some embodiments, the subject has a mitochondrial disease.

[0093] In some embodiments, the subject has or is at risk of a disease or disorder associated with lipid hypermetabolism, for example cancer cachexia, advanced cancer, a mitochondrial disease, or ALS.

[0094] In another aspect, the disclosure provides a method of treating a subject having a kidney disease or disorder or at risk of a kidney disease or disorder comprising administeringan agent of the disclosure to the subject. Exemplary kidney diseases and disorders include acute kidney injury, acute tubular necrosis, focal segmental glomerulosclerosis (FSGS), diabetic nephropathy (also referred to as diabetic kidney disease), chronic kidney disease, and inherited kidney diseases. Exemplary inherited kidney diseases include autosomal dominant polycystic kidney disease (ADPKD), alport syndrome, cystinosis, Fabry disease, Gitelman syndrome, and nephronophthisis.

[0095] Certain kidney diseases and disorders, for example acute kidney injury and acute tubular necrosis, can be caused by exposure to toxins. The toxins can damage renal tubules. Toxins include environmental and occupational toxins, for example metals (e.g., heavy metals) and radioactive materials. Exemplary toxins include lead, uranium, mercury, and cadmium. Certain medications can also damage kidneys and be considered toxins, for example some antibiotics (e.g., aminoglycoside antibiotics such as gentamicin) , nonsteroidal anti-inflammatory (NSAID) drugs (e.g., aspirin, ibuprofen, diclofenac), angiotensin converting enzyme (ACE) inhibitors (e.g., lisinopril, enalapril, ramipril, captopril, benazepril), ciclosporin, lithium salts, cyclophosphamide, sulphonamides, methotrexate, and acyclovir). Agents of the disclosure can be administered to subjects prior to, concurrently with, or after exposure to a toxin. For example, an agent of the disclosure can be administered before, concurrently with, or after administration of a medication capable of causing acute kidney injury. As another example, an agent of the disclosure can be administered after exposure to an environmental or occupational toxin.

[0096] In another aspect, the disclosure provides a method of treating a subject having or at risk of nephrotoxicity comprising administering an agent of the disclosure to the subject. The subject can be a subject having or at risk of nephrotoxicity due to exposure to a toxin, for example a toxin described in the preceding paragraph.

[0097] In some embodiments of the methods of the disclosure, administration of the agent is effective to decrease the subject’s blood urea nitrogen (BUN); improve cardiac injection fraction; reduce and / or slow the rate of renal tubular damage; reduce loss of brush border in renal tubules; reduce renal tubular cell death; reduce renal tubular cell detachment; reduce KIM-1 expression in renal tubular cells; or a combination of the foregoing.

[0098] In another aspect, the disclosure provides a method of treating a subject who is a donor kidney recipient comprising administering an agent of the disclosure to the subject. The agent can be administered to the subject before receipt of the donor kidney, concurrently with a kidney transplant procedure, or after a kidney transplant procedure. In some embodiments, the donor kidney is from a donor who was administered the agent prior to removal of the kidney from the donor.

[0099] In another aspect, the disclosure provides a method of enhancing the viability of and / or improving the function of and / or decreasing damage (e.g., renal tubule damage) to a donor kidney comprising administering to the donor and / or a recipient of the donor kidney an agent of the disclosure. The agent can be administered to the donor prior to removal of the kidney from the donor. Alternatively, or in addition, the agent can be administered to the recipient, for example before, concurrently with, or after the kidney transplant procedure.

[0100] Agents of the disclosure can be administered to a subject by any suitable route. Suitable routes of administration include, but are not limited to, the oral route of administration. Other routes include topical (including dermal, buccal, ocular and sublingual), rectal or parenteral (including subcutaneous, intradermal, intramuscular and intravenous), nasal, intra-ocularly and pulmonary administration e.g., by inhalation. The most suitable route may depend upon the condition or disorder of the subject. In some embodiments, the agent is administered orally.

[0101] A person of ordinary skill in the art can determine an appropriate dose of an agent of the disclosure to administer to a subject. Typically, a physician will determine the actual dosage which will be most suitable for an individual patient and it will depend on a variety of factors including the activity of the specific agent employed, the metabolic stability and length of action of that agent, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity of the particular condition, and the individual undergoing therapy. Exemplary dose ranges include the ranges 0.01 mg / kg to 100 mg / kg, 0.1 mg / kg to 20 mg / kg, 0.1 mg / kg to 50 mg / kg, and 0.1 mg / kg to 20 mg / kg. An exemplary daily dose range is 0.4 mg / kg / day to 400 mg / kg / day.5.3. Agents and Compositions

[0102] Agents useful in the methods of the disclosure include compounds of Formula (I):Formula (I) tautomers thereof, and pharmaceutically acceptable salts of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is selected H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl, and alkoxy;X and Z are each independently CR11;Y is CR11or N; andR11is H, alkyl or F.

[0103] Preferably, each alkyl group is a Ci-20alkyl group, more preferably a C1-15, more preferably still a Ci-i2alkyl group, more preferably still, a C1-6 alkyl group, more preferably a C1-3 alkyl group. Particularly preferred alkyl groups include, for example, methyl, ethyl, propyl, isopropyl, butyl, isobutyl, tert-butyl, pentyl and hexyl.

[0104] Preferably, each cycloalkyl group is a C3-i2cycloalkyl group.

[0105] Preferably, each alkenyl group is a C2-20alkenyl group, a C2-i5alkenyl group, a C2-i2alkenyl group, a C2-6alkenyl group, or a C2-3alkenyl group.

[0106] Preferably, each "aryl" group is a C6-i2aromatic group, for example phenyl or naphthyl.

[0107] In some embodiments, R1is Cl, Br, CH3, H, or F.

[0108] In some embodiments, R2is H.

[0109] In some embodiments, Y is CR11.

[0110] In some embodiments, X, Y, and Z are each CH.

[0111] In some embodiments, R3and R4are both H.

[0112] In some embodiments, R3is H, R4is C(O)R6, and R6is CH3or OCH3.

[0113] In some embodiments, the compound of Formula (I) has one of the following structures:

[0114] In some embodiments, the compound of Formula (I) has the structure: corresponding to the structure of sephinl). diments, the compound of Formula (I) has the structure:

[0116] In some embodiments, the compound of Formula (I) has the structure:ents, the compound of Formula (I) has the structure:

[0118] In some embodiments, the compound of Formula (I) has the structure: ents, the compound of Formula (I) has the structure:

[0120] In some embodiments, the compound of Formula (I) has the structure:

[0122] In some embodiments, the compound of Formula (I) has the structure:

[0123] In some embodiments, the compound of Formula (I) has the structure:ments, the compound of Formula (I) has the structure:

[0125] In some embodiments, the compound of Formula (I) has the structure:

[0127] In some embodiments, the compound of Formula (I) has the structure:

[0128] In some embodiments, the compound of Formula (I) has the structure:

[0129] In some embodiments, the compound of Formula (I) has the structure:

[0130] In some embodiments, the compound of Formula (I) has the structure:

[0131] In some embodiments, the compound of Formula (I) has the structure:

[0132] Methods for synthesizing compounds of Formula (I) are known in the art. See, for example, WO 2016 / 001389, the contents of which are incorporated herein by reference in their entireties.

[0133] Those skilled in the art will appreciate that compounds of Formula (I) can undergo ci tautomerization. For example, the compound having the structurecan ci convert to the tautomer. Thus, tautomers of compounds of Formula (I)(including tautomeric mixtures) can be used in the methods and compositions of the disclosure.

[0134] Compounds of Formula (I) and tautomers thereof can be used in a salt form. Pharmaceutically acceptable salts that can be used include suitable acid addition or base salts thereof. A review of suitable pharmaceutical salts is found in Berge et al, 1977, J Pharm Sci 66:1-19.

[0135] Salts can be formed, for example with strong inorganic acids such as mineral acids, e.g. hydrohalic acids such as hydrochloric, hydrobromidic and hydroiodic acids, sulfuric acid, phosphoric acid sulphate, bisulphate, hemisulphate, thiocyanate, persulphate and sulphonic acids; with strongorganic carboxylic acids, such as alkanecarboxylic acids of 1 to 4 carbon atoms which are unsubstituted or substituted (e.g., by halogen), such as acetic acid; with saturated or unsaturated dicarboxylic acids, for example oxalic, malonic, succinic, maleic, fumaric, phthalic or tetraphthalic; with hydroxycarboxylic acids, for example ascorbic, glycolic, lactic, malic, tartaric or citric acid; with amino acids, for example aspartic or glutamic acid; with benzoic acid; or with organic sulfonic acids, such as (Ci-C4)-alkyl- or aryl-sulfonic acids which are unsubstituted or substituted (for example, by a halogen) such as methane- or p-toluene sulfonic acid.

[0136] Exemplary salts include, acetate, trifluoroacetate, lactate, gluconate, citrate, tartrate, maleate, malate, pantothenate, adipate, alginate, aspartate, benzoate, butyrate, digluconate, cyclopentanate, glucoheptanate, glycerophosphate, oxalate, heptanoate, hexanoate,fumarate, nicotinate, palmoate, pectinate, 3-phenylpropionate, picrate, pivalate, proprionate, tartrate, lactobionate, pivolate, camphorate, undecanoate, and succinate, organic sulphonic acids such as methanesulphonate, ethanesulphonate, 2-hydroxyethane sulphonate, camphorsulphonate, 2-naphthalenesulphonate, benzenesulphonate, p- chlorobenzenesulphonate and p-toluenesulphonate; and inorganic acids such as hydrochloride, hydrobromide, hydroiodide, sulphate, bisulphate, hemisulphate, thiocyanate, persulphate, phosphoric and sulphonic acids. In some embodiments, the salt is an acetic acid salt. In other embodiments, the salt is a carbonic acid salt.

[0137] In another aspect, the disclosure provides agents of the disclosure (e.g., sephinl) for use in treating a disease or disorder treatable by AMPK activation, for example a disease or disorder identified in Section 5.2.

[0138] In another aspect, the disclosure provides use of agents of the disclosure (e.g., sephinl) in the manufacture of a medicament for treating a disease or disorder treatable by AMPK activation, for example a disease or disorder identified in Section 5.2.

[0139] Agents of the disclosure (e.g., sephinl) can be formulated for the intended route of administration, for example according to techniques known in the art (e.g., as described in Allen et al., eds., 2012, Remington: The Science and Practice of Pharmacy, 22ndEdition, Pharmaceutical Press, London, UK).

[0140] Agents of the disclosure (e.g., sephinl) can be formulated as a pharmaceutical composition comprising the agent and one or more pharmaceutical excipients, for example one or more excipients described in Handbook of Pharmaceutical Excipients, 8thRevised Ed. (2017), incorporated by reference in its entirety. The pharmaceutical compositions can be presented in unit dosage form (e.g., containing from 1 mg to 250 mg, 10 mg to 100 mg, 1 mg to 100 mg, 2.5 mg to 60 mg, or 15 mg to 50 mg of an agent of the disclosure).6. SPECIFIC EMBODIMENTS

[0141] The present disclosure is exemplified by the specific embodiments below.1 . A method of activating AMP-activated protein kinase (AMPK) and / or increasing phosphorylated AMPK (pAMPK) / AMPK ratio, comprising contacting a cell of a subject with an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, in an amount effective to activate AMPK and / or increase the pAMPK / AMPK ratio in the cell, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl, and alkoxy;X and Z are each independently CR11;Y is CR11or N; andR11is H, alkyl or F.2. A method of inhibiting C / EBP homologous protein (CHOP) and / or increasing phosphorylated a CHOP (pCHOP)ZCHOP ratio in a cell, comprising contacting a cell of a subject with an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, in an amount effective to inhibit C / EBP homologous protein (CHOP) and / or increase the pCHOP / CHOP ratio in the cell, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl, and alkoxy;X and Z are each independently CR11;Y is CR11or N; andR11is H, alkyl or F.3. The method of embodiment 1 or embodiment 2, wherein the contacting is in vivo.4. A method of treating a subject having or at risk of disease or disorder treatable by (a) AMP-activated protein kinase (AMPK) activation and / or (b) inhibiting C / EBP homologous protein (CHOP), comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.5. The method of any one of embodiments 2 to 4, wherein the amount of the agent is an amount effective to activate AMPK in one or more cell types, tissues, and / or organs, e.g., renal tubules.6. The method of any one of embodiments embodiment 2 to 5, wherein the amount of the agent is an amount effective to increase the pAMPK / AMPK ratio in one or more cell types, tissues, and / or organs, e.g., renal tubules.7. The method of any one of embodiments 2 to 6, wherein the amount of the agent in an amount effective to suppress fatty acid and / or cholesterol synthesis in the subject.8. The method of any one of embodiments 2 to 7, wherein the amount of the agent in an amount effective to lower serum and / or liver cholesterol levels.9. The method of any one of embodiments 2 to 8, wherein the amount of the agent in an amount effective to increase skeletal muscle glucose uptake.10. The method of any one of embodiments 2 to 9, wherein the amount of the agent in an amount effective to inhibit CHOP in one or more cell types, tissues, and / or organs, e.g., renal tubules.11 . The method of any one of embodiments 2 to 10, wherein the amount of the agent in an amount effective to increase the pCHOP / CHOP ratio in one or more cell types, tissues, and / or organs.12. The method of any one of embodiments 1 to 11 , wherein the subject has or is at risk of a disease or disorder which is metabolic syndrome, non-alcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH), obesity, diabetes (e.g., type 1 or type 2 diabetes), insulin resistance, glucose intolerance, chronic pain, sarcopenia, a neuromuscular disorder, heart failure, cardiac hypertrophy, diabetic cardiomyopathy, cardiac reperfusion injury, chronic kidney disease, polycystic kidney disease, diabetic nephropathy, a cardiovascular disease, inflammatory bowel disease, arthritis, hypertension, peripheral vascular disease, nephrogenic diabetes insipidus, glaucoma, an eye disease or disorder, ocular neovascularization, p-hemoglobinopathy, cancer, fibrosis, cancer cachexia, or a mitochondrial disease.13. The method of any one of embodiments 1 to 11 , wherein the subject has or is at risk of a disease or disorder which is metabolic syndrome, non-alcoholic fatty liver disease, nonalcoholic steatohepatitis (NASH), obesity, type 2 diabetes, insulin resistance, glucose intolerance, chronic pain, sarcopenia, a neuromuscular disorder, heart failure, cardiac hypertrophy, diabetic cardiomyopathy, cardiac reperfusion injury, chronic kidney disease, polycystic kidney disease, acute kidney injury, diabetic nephropathy, a cardiovascular disease, inflammatory bowel disease, arthritis, hypertension, peripheral vascular disease, nephrogenic diabetes insipidus, glaucoma, an eye disease or disorder, ocular neovascularization, p-hemoglobinopathy, cancer, fibrosis, cancer cachexia, or a mitochondrial disease.14. The method of any one of embodiments 1 to 11 , wherein the subject has or is at risk of a disease or disorder associated with lipid hypermetabolism.15. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is metabolic syndrome.16. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is non-alcoholic fatty liver disease.17. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is nonalcoholic steatohepatitis (NASH).18. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is obesity.19. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is diabetes (e.g., type 1 or type 2 diabetes).20. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is insulin resistance.21. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is glucose intolerance.22. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is chronic pain.23. The method of embodiment 22, wherein the chronic pain is post-surgical pain.24. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is sarcopenia.25. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is a neuromuscular disorder.26. The method of embodiment 25, wherein the neuromuscular disorder is Duchenne muscular dystrophy or myotonic dystrophy type 1 .27. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is heart failure.28. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is cardiac hypertrophy.29. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is diabetic cardiomyopathy.30. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is cardiac reperfusion injury.31. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is chronic kidney disease.32. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is polycystic kidney disease33. The method of embodiment 32, wherein the polycystic kidney disease is autosomal dominant polycystic kidney disease.34. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is diabetic nephropathy.35. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is a cardiovascular disease.36. The method of embodiment 35, wherein the cardiovascular disease is atherosclerosis.37. The method of embodiment 35, wherein the cardiovascular disease is coronary artery disease.38. The method of embodiment 35, wherein the cardiovascular disease is peripheral artery disease.39. The method of embodiment 35, wherein the cardiovascular disease is cerebrovascular disease.40. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is inflammatory bowel disease.41. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is arthritis.42. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is hypertension.43. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is peripheral vascular disease.44. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is nephrogenic diabetes insipidus.45. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is an eye disease or disorder.46. The method of embodiment 45, wherein the eye disease or disorder is retinopathy, symptoms associated with microangiopathy, neovascular glaucoma, corneal graft rejection, glaucoma, herpetic and infectious keratitis, ocular ischemia, neovascular glaucoma, corneal, uveal and / or iris neovascularization, orbital and / or eyelid tumor(s), Stevens Johnson Syndrome, ocular cicatricial pemphigoid, injury, or ocular surface disease.47. The method of embodiment 45, wherein the disease or disorder is macular degeneration.48. The method of embodiment 46, wherein the disease or disorder is wet age- related macular degeneration (AMD).49. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is ocular neovascularization.50. The method of embodiment 45, wherein the neovascularization is characterized by surface, corneal, retinal, choroidal, uveal, or iris neovascularization.51. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is glaucoma.52. The method of any one of embodiments 1 to 51 , wherein the amount of the agent is an amount effective to reduce intraocular pressure.53. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is p-hemoglobinopathy.54. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is cancer, optionally wherein the cancer is advanced cancer.55. The method of embodiment 54, wherein the cancer is hepatocellular carcinoma.56. The method of embodiment 54, wherein the cancer is lung cancer.57. The method of embodiment 54, wherein the cancer is colorectal cancer.58. The method of embodiment 54, wherein the cancer is liver cancer.59. The method of embodiment 54, wherein the cancer is melanoma.60. The method of embodiment 54, wherein the cancer is breast cancer.61 . The method of embodiment 54, wherein the cancer is prostate cancer.62. The method of embodiment 54, wherein the cancer is ovarian cancer.63. The method of embodiment 54, wherein the cancer is leukemia.64. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is fibrosis.65. The method of embodiment 64, wherein the fibrosis is lung fibrosis.66. The method of embodiment 64, wherein the fibrosis is kidney fibrosis.67. The method of embodiment 66, wherein the fibrosis is glomerulosclerosis and / or tubulointerstitial fibrosis.68. The method of embodiment 66 or embodiment 67, wherein the kidney fibrosis is kidney fibrosis resulting from chronic kidney disease (CKD), optionally wherein the CKD is hypertensive CKD.69. The method of embodiment 64, wherein the fibrosis is liver fibrosis.70. The method of embodiment 64, wherein the fibrosis is cardiac fibrosis.71. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is cancer cachexia.72. The method of embodiment 12 or embodiment 13, wherein the disease or disorder is a mitochondrial disease.73. The method of embodiment 13, of any one of embodiments 1 to 11 , wherein the subject has or is at risk of a disease or disorder which is a kidney disease or disorder.74. The method of embodiment 13 or 73, wherein the disease or disorder is acute kidney injury, e.g., AKI characterized by acute tubular necrosis.75. The method of any one of embodiments 12 to 74, wherein the subject has the disease or disorder.76. The method of any one of embodiments 12 to 74, wherein the subject is at risk of the disease or disorder.77. A method of treating a subject having or at risk of a kidney disease or disorder comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.78. The method of embodiment 77, wherein the kidney disease or disorder is acute kidney injury, e.g., caused by exposure to a toxin.79. The method of embodiment 77, wherein the kidney disease or disorder is acute tubular necrosis, e.g., caused by exposure to a toxin.80. The method of embodiment 77, wherein the kidney disease or disorder is focal segmental glomerulosclerosis (FSGS).81 . The method of embodiment 77, wherein the kidney disease or disorder is diabetic nephropathy (diabetic kidney disease).82. The method of embodiment 77, wherein the kidney disease or disorder is chronic kidney disease.83. The method of embodiment 77, wherein the kidney disease or disorder is an inherited kidney disease.84. The method of embodiment 83, wherein the inherited kidney disease is autosomal dominant polycystic kidney disease (ADPKD).85. The method of embodiment 83, wherein the inherited kidney disease is alport syndrome.86. The method of embodiment 83, wherein the inherited kidney disease is cystinosis.87. The method of embodiment 83, wherein the inherited kidney disease is Fabry disease.88. The method of embodiment 83, wherein the inherited kidney disease is Gitelman syndrome.89. The method of embodiment 83, wherein the inherited kidney disease is nephronophthisis.90. The method of any one of embodiments 1 to 89, wherein the subject is experiencing ER stress, e.g. acute ER stress, e.g., due to exposure to a toxin.91 . The method of any one of embodiments 1 to 90, wherein the subject has been exposed to a toxin (e.g., wherein the exposure is acute exposure).92. The method of any one of embodiments 1 to 91 , wherein the amount of the agent is an amount effective to decrease blood urea nitrogen.93. The method of any one of embodiments 1 to 92, wherein the amount of the agent is an amount effective to improve cardiac ejection fraction in the subject.94. The method of any one of embodiments 1 to 93, wherein the amount of the agent is an amount effective to reduce renal tubular damage (e.g., toxin-induced renal tubular damage).95. The method of any one of embodiments 1 to 94, wherein the amount of the agent is an amount effective to slow the rate of renal tubular damage in the subject.96. The method of any one of embodiments 1 to 95, wherein the amount of the agent is an amount effective to reduce loss of brush border.97. The method of any one of embodiments 1 to 96, wherein the amount of the agent is an amount effective to reduce renal tubular cell apoptosis.98. The method of any one of embodiments 1 to 97, wherein the amount of the agent is an amount effective to reduce tubular cell detachment from the basement membrane.99. The method of any one of embodiments 1 to 98, wherein the amount of the agent is an amount effective to reduce KIM-1 expression in renal tubular cells (e.g. cortex and / or medulla cells).100. The method of any one of embodiments 77 to 99, wherein the amount of the agent is an amount effective to slow progression of the kidney disease or disorder.101 . The method of any one of embodiments 1 to 100, wherein the amount of the agent is an amount effective to improve kidney function in the subject.102. The method of any one of embodiments 77 to 101 , wherein the subject has the kidney disease or disorder.103. The method of any one of embodiments 77 to 101 , wherein the subject is at risk of the kidney disease or disorder104. A method of treating a subject having or at risk of nephrotoxicity comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.105. The method of embodiment 104, wherein subject has or is at risk of nephrotoxicity due to exposure to an environmental or occupational toxin (e.g., a metal such as lead, uranium, mercury, or cadmium).106. The method of embodiment 104, wherein subject has or is at risk of nephrotoxicity due to exposure to a medication, e.g., an aminoglycoside antibiotic (e.g., gentamicin), amphotericin B, cisplatin, radiocontrast media, an immunoglobulin, an NSAID (e.g., aspirin, ibuprofen, or diclofenac), an ACE inhibitor, ciclosporin, a lithium salt, cyclophosphamide, a sulphonamide, methotrexate, or acyclovir).107. The method of embodiment 106, wherein the agent is administered in combination with the medication.108. The method of any one of embodiments 104 to 107, wherein the subject has nephrotoxicity.109. The method of any one of embodiments 104 to 107, wherein the subject is at risk of nephrotoxicity, e.g., due to exposure to an environmental or occupational toxin or a medication.110. The method of any one of embodiments 1 to 109, wherein the amount of the agent is an amount effective to activate AMPK in one or more cell types, tissues, and / or organs.111. The method of any one of embodiments 1 to 110, wherein the amount of the agent is an amount effective to activate AMPK in renal tubules.112. The method of any one of embodiments embodiment 1 to 111 , wherein the amount of the agent is an amount effective to increase the pAMPK / AMPK ratio in one or more cell types, tissues, and / or organs.113. The method of any one of embodiments 1 to 112, wherein the amount of the agent is an amount effective to increase the pAMPK / AMPK ratio in renal tubules.114. The method of any one of embodiments 1 to 113, wherein the amount of the agent in an amount effective to suppress fatty acid and / or cholesterol synthesis in the subject.115. The method of any one of embodiments 1 to 114, wherein the amount of the agent in an amount effective to lower serum and / or liver cholesterol levels.116. The method of any one of embodiments 1 to 115, wherein the amount of the agent in an amount effective to increase skeletal muscle glucose uptake.117. The method of any one of embodiments 1 to 116, wherein the amount of the agent in an amount effective to inhibit CHOP in one or more cell types, tissues, and / or organs118. The method of any one of embodiments 1 to 117, wherein the amount of the agent in an amount effective to inhibit CHOP in renal tubules (e.g., reduce the level of CHOP in renal tubule cortex and / or medulla cells).119. The method of any one of embodiments 1 to 117, wherein the amount of the agent in an amount effective to increase the pCHOP / CHOP ratio in one or more cell types, tissues, and / or organs.120. The method of any one of embodiments 1 to 117, wherein the amount of the agent in an amount effective to increase the pCHOP / CHOP ratio in renal tubules.121. A method of treating a subject who is a donor kidney recipient, comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups;each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.122. The method of embodiment 121 , which comprises administering the agent to the subject prior to receiving the donor kidney.123. The method of embodiment 121 or 122, which comprises administering the agent to the subject after receiving the kidney.124. The method of any one of embodiments 121 to 123, which comprises administering the agent to the subject during a kidney transplant procedure.125. The method of any one of embodiments 121 to 124, wherein the amount of the agent is an amount effective to reduce the risk of renal tubular dysfunction and / or damage.126. The method of any one of embodiments 121 to 125, wherein the amount of the agent is an amount effective improve the likelihood of donor kidney survival.127. The method of any one of embodiments 121 to 126, wherein the donor kidney is from a donor administered the agent prior to removal of the donor kidney from the donor.128. A method of enhancing the viability of and / or improving the function of and / or decreasing damage to a donor kidney, comprising administering to the donor and / or a recipient of the donor kidney an amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.129. The method of embodiment 128, which comprises administering the agent to the donor prior to removal of the kidney from the donor.130. The method of embodiment 128 or embodiment 129, which comprises administering the agent to the recipient of the donor kidney.131. The method of embodiment 128 to 130, which comprises administering the agent to the subject prior to the kidney transplant.132. The method of any one of embodiments embodiment 128 to 131 , which comprises administering the agent to the subject after to the kidney transplant.133. The method of any one of embodiments 128 to 132, which comprises administering the agent to the subject during the kidney transplant procedure.134. The method of any one of embodiments 128 to 133, which reduces injury to the kidney during transplantation.135. The method of any one of embodiments 1 to 134, wherein R1is Cl, Br, CH3,H, or F.136. The method of embodiment 135, wherein R1is Cl.137. The method of any one of embodiments 1 to 136, wherein R2is H.138. The method of any one of embodiments 1 to 137, wherein Y is CR11.139. The method of any one of embodiments 1 to 138, wherein X, Y, and Z are each CH.140. The method of any one of embodiments 1 to 139, wherein R3and R4are both H.141 . The method of any one of embodiments 1 to 139, wherein R3is H, R4is C(O)R6, and R6is CH3or OCH3.142. The method of any one of embodiments 1 to 134, wherein the agent istautomer thereof, or a pharmaceutically acceptable salt of the foregoing.143. The method of embodiment 142, wherein the agent isor a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing.144. The method of embodiment 142, wherein the agent isor a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing.145. The method of embodiment 142, wherein the agent isor a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing.146. The method of embodiment 142, wherein the agent isor a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing.147. The method of embodiment 142, wherein the agent is, e foregoing.149. The method of embodiment 142, wherein the agent istautomer thereof, or a pharmaceutically acceptable salt of the foregoing.150. The method of embodiment 142, wherein the agent istautomer thereof, or a pharmaceutically acceptable salt of the foregoing.151. The method of embodiment 142, wherein the agent is, foregoing.153. The method of embodiment 142, wherein the agent isor a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing.154. The method of embodiment 142, wherein the agent istautomer thereof, or a pharmaceutically acceptable salt of the foregoing.155. The method of embodiment 142, wherein the agentor a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing.156. The method of embodiment 142, wherein the agent is, the foregoing.158. The method of embodiment 142, wherein the agent istautomer thereof, or a pharmaceutically acceptable salt of the foregoing.159. The method of embodiment 142, wherein the agent istautomer thereof, or a pharmaceutically acceptable salt of the foregoing.160. The method of any one of embodiments 1 to 159, wherein the agent is a pharmaceutically acceptable salt of a compound of Formula (I) or tautomer thereof.161 . The method of embodiment 160, wherein the salt is an acetic acid salt.162. The method of embodiment 160, wherein the salt is a carbonic acid salt.163. The method of any one of embodiments 1 to 159, wherein the agent is a compound of Formula (I) or tautomer thereof.164. The method of any one of embodiments 1 to 159, wherein the agent is a compound of Formula (I) or pharmaceutically acceptable salt thereof.165. The method of any one of embodiments 1 to 164, wherein the agent is administered to the subject orally.166. An agent as described in any one of the preceding embodiments for use in a method of any one of the preceding embodiments.167. A pharmaceutical composition comprising an agent as described in any one of the preceding embodiments and a pharmaceutically acceptable excipient for use in a method of any one of the preceding embodiments.168. Use of an agent as described in any one of the preceding embodiments for the manufacture of a medicament for treating a disease or disorder described in any of the preceding embodiments.169. Use of an agent as described in any one of the preceding embodiments for the manufacture of a medicament for use in a method as described in any of the preceding embodiments.7. EXAMPLES7.1. Example 1 : AMPK activating activity of sephinl

[0142] AMPK activating activity of sephinl was evaluated in human kidney 2 (HK-2) cells. The HK-2 cell line is a proximal tubular cell line derived from normal kidney immortalized by transduction with human papilloma virus 16 (HPV-16) E6 / E7 genes.

[0143] HK-2 cells were seeded in a six well plate at a cell density of 7 x 104cells per well 24 hours prior to the start of the study (T.24). At To, tunicamycin (a chemical ER stress-inducer) and sephinl were added to the culture medium at a concentration of 5 pg / ml and 1 pM,respectively. 24 hours later (at T24) cells were recovered and protein was analyzed by Western blot analysis. The timeline of the study is shown in FIG. 1 .

[0144] Western blots for phosphorylated AMPK (p-AMPK), AMPK, and GAPDH (control) are shown in FIG. 2. Ratios of pAMPK / GAPDH, AMPK / GAPDH, and pAMPK / AMPK are shown in FIGS. 3A-3C. As shown in FIG. 2 and FIG. 3A, pAMPK levels were strongly elevated in cells treated with sephinl compared to untreated cells (sham) and cells treated with tunicamycin (Tu) alone. As shown in FIG. 2 and FIG. 3B, AMPK levels were not elevated by either tunicamycin or tunicamycin + sephinl tretament; rather, AMPK levels were reduced compared to untreated cells. As shown in FIG. 2 and FIG. 3C, the pAMPK / AMPK ratio was greatly elevated in cells treated with sephinl compared to untreated cells (sham) and cells treated with tunicamycin (Tu) alone. Thus, the data shows that sephinl treatment resulted in activation of AMPK.7.2. Example 2: Sephinl treatment decreases CHOP expression and increases p-CHOP

[0145] The effect of sephinl on CHOP expression and p-CHOP levels was evaluated.

[0146] At the start of the study (To), cells were treated with tunicamycin (Tu) and either 1 pM sephin 1 (Se) or DMSO (sham). 24 hours and 48 hours later, cells were again treated with 1 pM sephin 1 (Se) or DMSO (sham). Sampling was performed at 72 hours. The study timeline is shown in FIG. 4.

[0147] Protein levels are shown in FIG. 5 and relative protein expression is shown in FIG. 6. Sephinl treatment reduced CHOP levels and increased p-CHOP compared to tunicamycin only treatment (FIG. 5 and FIG. 6).7.3. Example 3: Sephinl treatment of HK-2 cells

[0148] The effect of sephinl on CHOP expression and p-CHOP levels was evaluated in human kidney 2 (HK-2) cells.

[0149] HK-2 cells were seeded one day prior to the start of the study (T.iday). At To, tunicamycin and sephinl were added to the culture medium. 24 hours later (at T24) cells were recovered and protein levels were analyzed. The timeline of the study is shown in FIG. 7.

[0150] Protein levels are shown in FIG. 8 and FIG. 9. Cell number and cell viability are shown in FIG. 10. An increase in p-CHOP / CHOP ratio was observed in sephinl treated cells compared to tunicamycin only treated cells (FIG. 8). An increase in CHOP expression in the cytoplasm, decreased CHOP expression in the nucleus, and a decreased nucleus / cytoplasmCHOP ratio was observed in sephinl treated cells compared to tunicamycin only treated cells (FIG. 9).7.4. Example 4: Sephinl treatment rescues tunicamycin-induced ER stress

[0151] The protective effect of sephinl against organ damage due to tunicamycin-induced ER stress was evaluated in tunicamycin-treated C57BL / 6 mice.

[0152] Male C57BL / 6 mice (Shimizu Laboratory Supplies Company Ltd., Kyoto, Japan) were housed in pathogen-free conditions with access to food and water ad libitum and all experiments were performed according to the animal experiment guidelines issued by the Animal Care and Use Committee at the Kyoto Prefectural University of Medicine. On Day 0, mice were administered a single intraperitoneal (i.p.) dose tunicamycin (1 or 2 mg / kg) or dimethyl sulfoxide (DMSO) vehicle followed by a once-daily intraperitoneal dose of 4 mg / kg of Sephinl or DMSO for 3 consecutive days.

[0153] When tunicamycin was administered at a dose of 1 mg / kg, half of the mice in the vehicle group died on Day 3, whereas all mice in the Sephinl group treated with 1 mg / kg survived on Day 3. On Day 7, survival rates were analyzed using a Kaplan-Meier survival curve and log-rank (Mantel-Cox) test. Sephinl -treated mice displayed significantly better survival (FIG. 10A). When tunicamycin was administered at a dose of 2 mg / kg, the difference in survival rates was even greater (FIG. 10B).

[0154] At Day 3, mice in the 1 mg / kg tunicamycin protocol had significantly lower body weight than in the sham group, whereas mice treated with Sephinl displayed no differences in body weight (p=0.062) (FIG. 10C). The weights of heart and kidney relative to body weight did not show significant changes (FIG. 10C).

[0155] As surrogate markers of renal and cardiac function, level of BUN in blood samples and level of Nppb expression in excised heart tissue were analyzed by qPCR. The results were associated with significant impaired organ function in the tunicamycin-treated group and significant improvement in the Sephinl -treated group (FIG 10D). On Day 3, cardiac function was assessed by transthoracic echocardiography. As observed with the Nppb evaluation, cardiac ejection fraction was significantly reduced in the tunicamycin-only group and recovered to a level comparable to the sham group in the Sephinl treatment group (FIG 10E). On the other hand, the left ventricular diameter and wall thickness did not significantly change during this period. None of the genes related to the three major branches of unfolding protein response (UPR) against ER stress in the heart were significantly altered. Similarly, none of the genes for mitochondria biosynthesis, dynamics, or constituent proteins showed any significant changes (results not shown).7.5. Example 5: Renoprotective effects of Sephinl

[0156] Renoprotective effects of Sephinl was evaluated in tunicamycin-treated C57BL / 6 mice.

[0157] Treatment with 1 mg / kg tunicamycin, was associated with tubular damage on Day 3 based on PAS 140 staining, which was ameliorated by Sephinl (FIG 11 A). Loss of brush border (LBB), loss of tubular cells detachment from the basement membrane (Cell Det), apoptosis / necrosis, presence of vitreous material (Casts) in the tubular lumen, and tubular dilatation (Tub Dil) were further analyzed (FIG.11 A). The tunicamycin group showed a significant increase in the loss of brush border, tubular cell shedding from the basement membrane, and apoptosis, which were significantly decreased by Sephinl treatment. On the other hand, the presence of vitreous substances and tubular dilation were found to be elevated in the tunicamycin group, but were not significantly reduced by Sephinl treatment (FIG. 11 A). The total score, which is representative of the degree of tubular damage calculated by adding these five parameters, was significantly higher in tunicamycin group, which was reduced in Sephinl group (FIG. 11 A).

[0158] Next, the damaged tubules were identified by immunostaining with Megalin expression in the entire tubular cells and Kim-1 expression in the damaged tubular cells. Tunicamycin was associated with 70% of the total number of cells being impaired tubular cells, whereas Sephinl treatment reduced this impairment to approximately 50% (FIG. 11 B). Sephinl rescued the damage with a significant difference from the tunicamycin group in either the medullary or cortical regions. The protective effect of Sephinl in the kidney was mainly due to the inhibition of tubular epithelial cell death, as other constituent cell groups, such as the cells of the vascular system and stroma were not significantly altered.

[0159] Gene expression in the kidney on Day 3 was examined for UPR-related, mitochondria-related, and cell death-related genes. The expression of genes related to ER stress was enhanced by tunicamycin treatment, albeit to varying degrees. In particular, Chop was the most significantly upregulated gene, while elF2a was the least upregulated gene of the genes tested(FIG. 11 C). Sephinl treatment decreased the expression of Chop, Gadd34, Grp78, and Atf6, with statistically significant differences. The gene expression of Atf6 was suppressed by Sephinl , whereas the gene expression of Xbpls, which is strongly affected by ATF6, was not significantly reduced by Sephinl . This result suggests that the point of action of Sephinl in this experimental system is the PERK pathway rather than IRE1a or ATF6 in the UPR. On the other hand, neither tunicamycin nor Sephinl treatment significantly altered Caspase3 as an apoptosis executor, Caspase9 in the mitochondrial pathway, or Caspase8 in the non-mitochondrial pathway (FIG. 11C).7.6. Example 6: Reversal of acute kidney injury associated with tubular epithelial cell death by Sephinl

[0160] To examine that the mode of action of Sephinl against ER stress involved the pancreatic ER kinase (PERK) pathway, the phosphorylation status of elF2a was quantified by western blotting (WB). WB was performed on kidney samples on Day 3 after a single dose of tunicamycin (1 mg / kg) with or without Sephinl treatment once daily for 3 consecutive days.

[0161] Eif2a was significantly increased by tunicamycin treatment, whereas Sephinl had no significant effect on eif2a protein levels (FIG 12A). Tunicamycin-treated group displayed minimal change in phosphorylated Eif2a (FIG 12A). However, the results that phosphorylated elF2a was lower in the tunicamycin- and Sephinl -treated groups than in the sham group(FIG 12A) suggests that the cell death phenotype has already passed its climax at this time point and ER stress may be in an off phase in the cells.

[0162] Cell death induced by ER stress is closely related to CHOP, and the translocation of CHOP to the nucleus transcriptionally induces cell death-related factors. The CHOP protein was also significantly increased by tunicamycin treatment and decreased in the Sephinl - treated group, although not significantly (FIG 12B). Phosphorylated CHOP, which was evaluated by an antibody recognizing the phosphorylation of CHOP at Ser30, was significantly increased in the Sephinl -treated group, and the total CHOP / phosphorylated CHOP ratio was significantly decreased, compared to those in the tunicamycin-treated group (FIG 12B). These results indicate that the increased CHOP in ER stress decreased by its decay in the UPS.

[0163] Next, nuclear translocation of CHOP was examined via immunostaining. Mice were treated with only one dose of 2 mg / kg tunicamycin with or without 4 mg / kg Sephinl , and kidneys were harvested after 12 hours for examination. The positive rate of CHOP in the nucleus was calculated for the cortex and medulla. In the sham group, CHOP was minimal in the nucleus, but increased in approximately 60% of tubular cells by tunicamycin treatment both in the cortex and medulla (FIG. 12C). In the Sephinl treatment group, the percentage of cells decreased in both areas relative to the tunicamycin treatment group, with a significant decrease in the cortex (FIG. 12C). These results suggest that phosphorylation of CHOP Ser30 causes protein decay in the cytoplasm, reducing total CHOP protein levels and lowering the amount of CHOP that migrates to the nucleus.7.7. Example 7: Intervention in CHOP regulation by Sephinl

[0164] The molecular mechanism of Sephinl 's inhibitory effect on cell death was evaluated in an ER stress model using a human tubular epithelial cell, HK-2.

[0165] Tunicamycin at 20 pg / ml significantly suppressed cell numbers of HK-2 at 24 h, and 2 pM Sephinl treatment significantly restored cell numbers (FIG. 13A). To verify the stage of cell death rescued by Sephinl , cell staining with PI and annexin V was analyzed by FACS (FIG. 13B). Exposure to 20 pg / ml tunicamycin for 24 hours increased the percentage of annexin V-positive and Pl-negative cells, which is a phenotype of early apoptosis. The treatment also increased the percentage of annexin V and PI double positive cells, which indicates late apoptosis. However, these changes were not significant.

[0166] Next, the effect of Sephinl on the role of CHOP as a transcription factor in the HK-2 ER stress model was evaluated via qPCR fortranscripts of cell death-related genes downstream of CHOP, mitochondria-related genes, and UPR pathway-related genes. All three pathways of the UPR showed significant increases in mRNA expression after 24 hours of tunicamycin exposure, but only elF2a was significantly downregulated by Sephinl (FIG. 13C). CHOP showed no significant change in response to Sephinl , suggesting that Sephinl acts through post-translational modification rather than transcriptional regulation. Mitochondria-related gene expression was not significantly altered by either tunicamycin or Sephinl exposure at the concentration and durations of the experiment. In contrast, the expression of cell death-related genes was significantly altered: caspase 3, Bak and Bax, were significantly elevated by tunicamycin exposure and significantly decreased by Sephinl treatment (FIG. 13C).

[0167] Protein expression was investigated in HK-2 model to examine whether Sephinl is involved in the post-translational modification of CHOP. CHOP, which was increased by tunicamycin, was significantly decreased by Sephinl treatment (FIG. 14D). Level of phosphorylated CHOP Ser30 was unchanged by tunicamycin exposure and significantly increased by Sephinl treatment. The decrease in CHOP at the protein level could be due to the decay of CHOP, as there was no decrease in CHOP transcripts (FIG. 14B) and an increase in phosphorylated CHOP Ser30, which is then degraded in UPS.

[0168] The total amount of CHOP protein in the cytoplasm resulting in reduced nuclear translocation of CHOP was demonstrated by quantifying CHOP in the nuclear fraction (FIG. 13E). Because the kinetics of this nuclear translocation is assumed to be very rapid, CHOP nuclear translocation was evaluated by immunocytochemical staining of intracellular CHOP overtime (FIG. 13F). The nuclear migration started 3 hours after exposure to tunicamycin, and strong coloration was observed even at 12 hours (FIG. 13F). In contrast, the presence of CHOP was barely detectable at 3 hours after Sephinl treatment but was detectable at 6 hours and slightly elevated at 12 hours (FIG. 13F). These results indicate that Sephinl is a reliable regulator of CHOP.-M-7.8. Example 8: CHOP degradation by Sephinl in HK-2 cells under ER stress

[0169] CHOP knockdown (CHOP KD) cells were generated by transducing a recombinant lentivirus encoded with a CRISPR guide RNA against CHOP and Cas9. Cell survival was examined by exposing CHOP KD cells to tunicamycin with or without Sephinl .

[0170] Sephinl did not inhibit cell death in CHOP KD cells (FIG. 14A), indicating that Sephinl is involved in the CHOP associated cell death pathway. Tunicamycin treatment significantly reduced the number of viable HK-2 cells, and Sephinl treatment suppressed this reduction. In the presence of 1 pM compound C, an inhibitor of AMPK (which phosphorylates Ser30), the cell death inhibitory effect of Sephinl was abolished (FIG. 14A). These results suggest that in the presence of Sephinl , AMPK activation results in phosphorylation of CHOP, which may contribute to the inhibition of cell death.

[0171] AMPK is activated by Thr172 phosphorylation and inactivated by dephosphorylation of PP2A / 2C. Since both PP2A / 2C acquire substrate specificity by association with regulatory subunits, and their catalytic efficiency is also affected, the involvement of Sephinl in this pathway was investigated. FTY720 was used as an agonist of PP2A and LB-100 as an antagonist against PP2A in the HK-2 ER stress model. FTY720 at a concentration of 1 pg / ml canceled the effect of Sephinl on cell death (FIG. 14C), while 0.01 pg / ml LB-100, used as an alternative to Sephinl , showed a tendency to inhibit cell death with tunicamycin, but did not restore cell numbers with significant differences from tunicamycin administration (FIG. 14D). These results suggest that PP2A activation dephosphorylates AMPK, leading to its inactivation, resulting in CHOP accumulation and tilting toward cell death. On the other hand, PP2A inhibition accumulates phosphorylated forms of AMPK, leading to the maintenance of AMPK activation, resulting in increased phosphorylated CHOP and tilting toward cell death inhibition.

[0172] Next, AMPK Thr172 phosphorylation under ER stress was evaluated. The AMPK Thr172 phosphorylation levels were not significantly altered by tunicamycin exposure but were significantly increased by nearly 4-fold with Sephinl treatment, and the phosphorylated AMPK / total AMPK ratio was also significantly increased (FIG. 14E). To verify that Sephinl targets AMPK by inhibiting PP2A holoenzyme formation, co-immunoprecipitation (CoIP) was performed to determine which PP2A or PP2C subunits directly interacted with AMP kinase (FIG. 14F). The CoIP showed that Sephinl treatment in the ER stress state significantly attenuated the binding of AMPK to PP2A, but not to PP2C. Next, the regulatory subunits that make up the PP2A holoenzyme were evaluated with CoIP, where cell extracts were incubated with anti-AMPK antibody, and the bound proteins were determined in Western blot analysis (WB) with anti-PP2AB6 antibody. PP2AB6 associated with AMPK wassignificantly reduced by Sephinl treatment (FIG. 14G). To examine PP2A holoenzyme formation under Sephinl treatment, CoIP was performed with PP2AB6 and PP2ACa / p. Both CoIP of immunoprecipitation with PP2AB6 and immunoblotting with PP2ACa / p (FIG. 14H) and the opposite combination (FIG. 141) showed that the association between the two proteins was significantly inhibited by Sephinl treatment.

[0173] Taken together, these results demonstrate that Sephinl reduces pathogenesis by inhibiting cell death in the ER stress environment of the kidneys associated with tunicamycin treatment, wherein survival is likely signaled by the promotion of CHOP decay by AMPK activation. At the molecular level, Sephinl likely targets PP2A holoenzyme formation inhibition with PP2AB6 as a regulatory subunit (FIG. 15).8. CITATION OF REFERENCES

[0174] All publications, patents, patent applications and other documents cited in this application are hereby incorporated by reference in their entireties for all purposes to the same extent as if each individual publication, patent, patent application or other document were individually indicated to be incorporated by reference for all purposes. In the event that there is an inconsistency between the teachings of one or more of the references incorporated herein and the present disclosure, the teachings of the present specification are intended.

Claims

WHAT IS CLAIMED IS:1 . A method of treating a subject having or at risk of nephrotoxicity comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.

2. The method of claim 1 , wherein subject has or is at risk of nephrotoxicity due to exposure to an environmental or occupational toxin (e.g., a metal such as lead, uranium, mercury, or cadmium).

3. The method of claim 1 , wherein subject has or is at risk of nephrotoxicity due to exposure to a medication, e.g., an aminoglycoside antibiotic (e.g., gentamicin), amphotericin B, cisplatin, radiocontrast media, an immunoglobulin, an NSAID (e.g., aspirin, ibuprofen, or diclofenac), an ACE inhibitor, ciclosporin, a lithium salt, cyclophosphamide, a sulphonamide, methotrexate, or acyclovir.

4. The method of claim 3, wherein the agent is administered in combination with the medication.

5. A method of treating a subject who is a donor kidney recipient, comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups;each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.

6. The method of claim 5, which comprises (a) administering the agent to the subject prior to receiving the donor kidney, (b) administering the agent to the subject after receiving the kidney, (c) administering the agent to the subject during a kidney transplant procedure, or (d) any combination of (a)-(c).

7. A method of enhancing the viability of and / or improving the function of and / or decreasing damage to a donor kidney, comprising administering to the donor and / or a recipient of the donor kidney an amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups;each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.

8. The method of claim 7, which comprises (a) administering the agent to the donor prior to removal of the kidney from the donor, (b) administering the agent to the recipient of the donor kidney, (c) administering the agent to the subject prior to the kidney transplant, (d) administering the agent to the subject after to the kidney transplant, (e) administering the agent to the subject during the kidney transplant procedure, or (f) any combination of (a)-(e).

9. A method of treating a subject having or at risk of a kidney disease or disorder comprising administering to the subject a therapeutically effective amount of an agent which is a compound of Formula (I):Formula (I) or a tautomer thereof, or a pharmaceutically acceptable salt of the foregoing, wherein:R1is alkyl, O-alkyl, Cl, F or Br;R2is H or F;R3is H or alkyl;R4is H or C(O)R6;R5is H; or R4and R5are linked to form a 5 to 6 membered saturated or unsaturated heterocyclic group optionally comprising 1 or 2 heteroatoms in addition to the N atoms to which R4and R5are bound, and where said heterocyclic group is optionally substituted with one or more R10groups;R6is selected R7, OR7or NR8R9;R7, R8and R9are each independently selected from alkyl, cycloalkyl, aralkyl, cycloalkenyl, heterocyclyl and aryl, each of which is optionally substituted with one or more R10groups; each R10is independently selected from halogen, OH, =O, CN, COO-alkyl, aralkyl, SO2- alkyl, SO2-aryl, COOH, CO-alkyl, CO-aryl, NH2, NH-alkyl, N(alkyl)2, CF3, alkyl and alkoxy;X and Z are each independently CR11Y is CR11or N; andR11is H, alkyl or F.

10. The method of claim 9, wherein the kidney disease or disorder is acute kidney injury caused by exposure to a toxin, acute tubular necrosis, e.g., caused by exposure to a toxin, focal segmental glomerulosclerosis (FSGS), an inherited kidney disease, e.g., autosomal dominant polycystic kidney disease (ADPKD), alport syndrome, cystinosis, Fabry disease, Gitelman syndrome, or nephronophthisis.11 . The method of claim 9 or claim 10, wherein the subject is experiencing ER stress, e.g. acute ER stress, e.g., due to exposure to a toxin.

12. The method of any one of claims 9 to 11 , wherein the subject has been exposed to a toxin (e.g., wherein the exposure is acute exposure).

13. The method of any one of claims 1 to 12, wherein R1is Cl, Br, CH3, H, or F.

14. The method of any one of claims 1 to 13, wherein R2is H.

15. The method of any one of claims 1 to 14, wherein Y is CR11.

16. The method of any one of claims 1 to 15, wherein X, Y, and Z are each CH.

17. The method of any one of claims 1 to 16, wherein R3and R4are both H.

18. The method of any one of claims 1 to 16, wherein R3is H, R4is C(O)R6, and R6is CH3or OCH3.

19. The method of any one of claims 1 to 12, wherein the agent ispharmaceutically acceptable salt of the foregoing.

20. The method of any one of claims 1 to 19, wherein the agent is administered to the subject orally.

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