Fabry Disease Podocytes Reveal Ferroptosis as a Potential Regulator of Cell Pathology

Introduction: Fabry disease (FD) results from pathogenic GLA variants, leading to a deficiency in lysosomal α-galactosidase A (α-Gal A) and accumulation of the sphingolipid globotriaosylceramide (Gb3). This leads to severe renal and cardiovascular complications, primarily affecting kidney podocytes. As a multisystemic disorder, FD initiates at the cellular level; however, the mechanism(s) underlying Gb3-induced cell dysfunction remain largely unknown. This study aimed to identify potential drivers of FD and explore the underlying cell pathology in induced pluripotent stem cell (iPSC)–derived podocytes from patients with FD. Methods: iPSCs were derived from patients with FD with GLA^c.851T>C or GLA^{c.1193_1196del} variants and compared with controls or CRISPR-Cas9–corrected cell lines. iPSCs were differentiated into podocytes; and α-Gal A activity, Gb3 accumulation, and cell morphology were assessed. Label-free mass spectrometry identified the top, differentially expressed proteins which were validated by using western blot. Results: Podocytes derived from patients with FD exhibited expression of podocyte-specific markers and morphological features of FD. Reduced α-Gal A activity was observed in FD iPSC-derived podocytes along with the accumulation of Gb3. Proteomic profiling revealed distinct proteomic signatures between control and iPSC-derived podocytes from a patient with FD, with apparent variations among FD lines, highlighting GLA variant–specific proteomic alterations. Notably, the ferroptosis-associated protein, arachidonate 15-lipoxygenase (ALOX15), was the most upregulated protein in FD podocytes and ferroptosis was the most enriched pathway. Western blot analysis confirmed the upregulation of ALOX15 in FD podocytes, with validation of other markers implicating ferroptosis in FD pathology. Conclusion: These findings underscore the heterogeneity of FD and, for the first time, implicate ferroptosis as a potential common pathway driving its pathology.