# Four missense genetic variants in CUBN are associated with higher levels of eGFR in non-diabetes but not in diabetes mellitus or its subtypes: A genetic association study in Europeans

Nicoline Uglebjerg, Fariba Ahmadizar, Dina M. Aly, Marisa Canadas-Garre, Claire Hill, Annemieke Naber, Asmundur Oddsson, Sunny S. Singh, Laura Smyth, David-Alexandre Tregouet, et al.

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## ► To cite this version:

Nicoline Uglebjerg, Fariba Ahmadizar, Dina M. Aly, Marisa Canadas-Garre, Claire Hill, et al. Four missense genetic variants in CUBN are associated with higher levels of eGFR in non-diabetes but not in diabetes mellitus or its subtypes: A genetic association study in Europeans. Frontiers in Endocrinology, 2023, 14, pp.1081741. 10.3389/fendo.2023.1081741. hal-04073024

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EDITED BY
Anandwardhan Hardikar,
Western Sydney University, Australia

REVIEWED BY
Sameet Mehta,
Yale University, United States
Marija Petkovic,
Roskilde University, Denmark
Jalal Taneera,
University of Sharjah, United Arab Emirates

*CORRESPONDENCE
Tarunveer S. Ahluwalia
✉ tarun.veer.singh.ahluwalia@regionh.dk

SPECIALTY SECTION
This article was submitted to
Systems Endocrinology,
a section of the journal
Frontiers in Endocrinology

RECEIVED 27 October 2022
ACCEPTED 07 February 2023
PUBLISHED 28 February 2023

CITATION
Uglebjerg N, Ahmadizar F, Aly DM, Cañadas-Garre M, Hill C, Naber A, Oddsson A, Singh SS, Smyth L, Trégouët D-A, Chaker L, Ghanbari M, Steinthorsdottir V, Ahlqvist E, Hadjadj S, Van Hoek M, Kavousi M, McKnight AJ, Sijbrands EJ, Stefansson K, Simons M, Rossing P and Ahluwalia TS (2023) Four missense genetic variants in *CUBN* are associated with higher levels of eGFR in non-diabetes but not in diabetes mellitus or its subtypes: A genetic association study in Europeans.
*Front. Endocrinol.* 14:1081741.
doi: 10.3389/fendo.2023.1081741

COPYRIGHT
© 2023 Uglebjerg, Ahmadizar, Aly, Cañadas-Garre, Hill, Naber, Oddsson, Singh, Smyth, Trégouët, Chaker, Ghanbari, Steinthorsdottir, Ahlqvist, Hadjadj, Van Hoek, Kavousi, McKnight, Sijbrands, Stefansson, Simons, Rossing and Ahluwalia. This is an open-access article distributed under the terms of the *Creative Commons Attribution License (CC BY)*. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# Four missense genetic variants in *CUBN* are associated with higher levels of eGFR in non-diabetes but not in diabetes mellitus or its subtypes: A genetic association study in Europeans

Nicoline Uglebjerg ID<fnref n="1" />, Fariba Ahmadizar²,<fnref n="3" />, Dina M. Aly ID⁴,
Marisa Cañadas-Garre ID⁵,⁶,⁷, Claire Hill ID⁵, Annemieke Naber ID⁸,
Asmundur Oddsson ID⁹, Sunny S. Singh⁸, Laura Smyth ID⁵,
David-Alexandre Trégouët ID¹⁰, Layal Chaker²,⁸,
Mohsen Ghanbari², Valgerdur Steinthorsdottir ID⁹,
Emma Ahlqvist ID⁴, Samy Hadjadj¹¹, Mandy Van Hoek ID⁸,
Maryam Kavousi², Amy Jayne McKnight ID⁵, Eric J. Sijbrands ID⁸,
Kari Stefansson ID⁹,¹², Matias Simons¹³, Peter Rossing ID <fnref n="1" />,¹⁴
and Tarunveer S. Ahluwalia ID <fnref n="1" />,¹⁵*

**Aim:** Rare genetic variants in the *CUBN* gene encoding the main albumin-transporter in the proximal tubule of the kidneys have previously been associated with microalbuminuria and higher urine albumin levels, also in diabetes. Sequencing studies in isolated proteinuria suggest that these variants might not affect kidney function, despite proteinuria. However, the relation of these *CUBN* missense variants to the estimated glomerular filtration rate (eGFR) is largely unexplored. We hereby broadly examine the associations between four *CUBN* missense variants and eGFR*creatinine* in Europeans with Type 1 (T1D) and Type 2 Diabetes (T2D). Furthermore, we sought to deepen our understanding of these variants in a range of single- and aggregate- variant analyses of other kidney-related traits in individuals with and without diabetes mellitus.

**Methods:** We carried out a genetic association-based linear regression analysis between four *CUBN* missense variants (rs141640975, rs144360241, rs45551835, rs1801239) and eGFR*creatinine* (ml/min/1.73 m², CKD-EPI*creatinine*(2012), natural log-

<footnote n="1">¹Complications Research, Steno Diabetes Center Copenhagen, Herlev, Denmark, ²Department of Epidemiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands,</footnote>

<footnote n="3">³Department of Data Science & Biostatistics, Julius Global Health, University Medical Center Utrecht, Utrecht, Netherlands, ⁴Department of Clinical Sciences, Lund University, Malmö, Sweden, ⁵Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom, ⁶GENYO Centre for Genomics and Oncological Research, Pfizer-University of Granada-Andalusian Regional Government, Granada, Spain, ⁷Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain, ⁸Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands, ⁹deCODE Genetics, Amgen, Inc., Reykjavik, Iceland, ¹⁰University of Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM), Bordeaux Population Health Research Center, Bordeaux, France, ¹¹Nantes Université, Centre Hospitalier Universitaire Nantes, Centre National de la Recherche Scientifique, INSERM, l'institut du thorax, Nantes, France, ¹²Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland, ¹³Institute of Human Genetics, University Hospital Heidelberg, Heidelberg, Germany, ¹⁴Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark, ¹⁵The Bioinformatics Center, Department of Biology, University of Copenhagen, Copenhagen, Denmark</footnote>
transformed) in populations with T1D (n ~ 3,588) or T2D (n ~ 31,155) from multiple European studies and in individuals without diabetes from UK Biobank (UKBB, n ~ 370,061) with replication in deCODE (n = 127,090). Summary results of the diabetes-group were meta-analyzed using the fixed-effect inverse-variance method.

**Results:** Albeit we did not observe associations between eGFR<sub>creatinine</sub> and <i>CUBN</i> in the diabetes-group, we found significant positive associations between the minor alleles of all four variants and eGFR<sub>creatinine</sub> in the UKBB individuals without diabetes with <i>rs141640975</i> being the strongest (Effect=0.02, P<sub>eGFR_creatinine</sub>=2.2 × 10<sup>-9</sup>). We replicated the findings for <i>rs141640975</i> in the Icelandic non-diabetes population (Effect=0.026, P<sub>eGFR_creatinine</sub>=7.7 × 10<sup>-4</sup>). For <i>rs141640975</i>, the eGFR<sub>creatinine</sub>-association showed significant interaction with albuminuria levels (normo-, micro-, and macroalbuminuria; p = 0.03). An aggregated genetic risk score (GRS) was associated with higher urine albumin levels and eGFR<sub>creatinine</sub>. The <i>rs141640975</i> variant was also associated with higher levels of eGFR<sub>creatinine-cystatin C</sub> (ml/min/1.73 m<sup>2</sup>, CKD-EPI<sub>2021</sub>, natural log-transformed) and lower circulating cystatin C levels.

**Conclusions:** The positive associations between the four *CUBN* missense variants and eGFR in a large population without diabetes suggests a pleiotropic role of *CUBN* as a novel eGFR-locus in addition to it being a known albuminuria-locus. Additional associations with diverse renal function measures (lower cystatin C and higher eGFR<sub>creatinine-cystatin C</sub> levels) and a *CUBN*-focused GRS further suggests an important role of *CUBN* in the future personalization of chronic kidney disease management in people without diabetes.

KEYWORDS

genetics, CUBN, cubilin, kidney function, eGFR, diabetes, non-diabetes, chronic kidney disease (CKD)

# 1 Introduction

Urine albumin or albuminuria is one of the most important biomarkers of kidney damage in individuals with or without diabetes. In healthy individuals, the glomerular filter in the kidneys retains most of the albumin, although a small amount can usually pass through to the tubular system (1). Reabsorption of albumin is facilitated by the kidney's proximal tubular cells (PTCs), ensuring that almost no albumin is excreted in urine under normal conditions (2, 3). Elevated excretion of albumin in the urine - initially coined as "microalbuminuria" - is one of the earliest signs of chronic kidney disease (CKD) and may be the kidney-related

manifestation of general endothelial damage, where scarring of the glomerulus causes chronic leakiness through the filter of albumin and other proteins (4).

Over the past decades, the number of people with diabetes mellitus has more than doubled to a global prevalence of 537 million in 2021 (5), with serious consequences for the healthcare system and society. According to a recent European study (6), one in four hospitalized patients has diabetes. Up to 40% of individuals with diabetes develop diabetic kidney disease (DKD), which is associated with elevated cardiovascular morbidity and mortality and progresses to dependency on kidney replacement therapies such as dialysis and transplantation and is a leading cause of CKD (7).

In the recent years, studies have begun to unravel genetic aspects of albuminuria. Recently, we and others identified that genetic variants (single nucleotide variants (SNVs)) in the gene encoding for cubilin (*CUBN*) – the main albumin-transporter in PTCs (1, 8) – are associated with microalbuminuria and higher urine albumin levels in populations with and without diabetes (8–14). Four variants in the C-terminal end of cubilin have been of particular interest (rs141640975 (c.5069C>T; p.Ala1690Val),

<footnote>**Abbreviations:** ACEi, Angiotensin-converting enzyme inhibitors; AER, Albumin excretion rate (mg/24 hours); ALB, Urinary albumin level (mg/L); ARBs, Angiotensin receptor blockers; CKD, Chronic kidney disease; CKD-EPI, CKD Epidemiology Collaboration; CUBN, The gene encoding cubilin; DM, Diabetes mellitus; eGFR, Estimated glomerular filtration rate (ml/min/1.73 m²); GRS, Genetic risk score; NDM, Non-diabetes; T1D, Type 1 diabetes; T2D, Type 2 diabetes; UACR, Urinary albumin-creatinine ratio (mg/mmol); UKBB, UK Biobank.</footnote>
rs144360241 (c.6469A>G; p.Asn2157Asp), rs45551835 (c.8741C>T; p.Ala2914Val), and rs1801239 (c.8950A>G, p.Ile2984Val)); these are functional (missense) variants that have been proposed to alter the function of cubilin, leading to a form of albuminuria that may reflect a lack of tubular reabsorption of albumin (i.e., tubular albuminuria) (8). *In silico* structural and damage prediction analyses of the variants indicate their potential to change secondary or even tertiary structure(s) in the cubilin protein and to have different degrees of damaging effects on protein function, disease, or both (8). Our recent study further suggests that the effect of some of these variants on urine albumin levels is 2-3 times higher in diabetes compared to non-diabetes (11).

However, the role of these *CUBN* variants in relation to estimated glomerular filtration rate (eGFR), a clinically used marker of kidney function, is largely unexplored, and most genetic studies have focused on the general population (8, 9, 11). Recent efforts to uncover the role of these variants specifically in diabetes – and to clearly separate the effect seen here from the effect in the non-diabetes-proportion of the general population – have been performed as relatively small secondary analyses without including *rs144360241* or diabetes subtypes (8). Thus far, only *rs45551835* has been connected to higher levels of eGFR in type 2 diabetes and *rs141640975* in non-diabetes (8). Therefore, we investigated the relationship between the four *CUBN* variants and eGFR in different contexts: First, we meta-analyzed studies of SNV-eGFR<sub>creatinine</sub> regressions in Europeans with type 1 (T1D) or type 2 diabetes mellitus (T2D). We then examined single- and aggregate-variant associations separately in diabetes and non-diabetes populations of a large, nationally representative cohort facilitating

application of identical phenotype definitions, including the
dependency of albuminuria-stage in SNV-eGFR<sub>creatinine</sub>
associations, generation of a *CUBN*-specific genetic risk score
(GRS), and identification of associations between individual SNVs
and cystatin C-based measures of kidney function. Together, these
analyses both seek to replicate previous associations in DM and
NDM populations and to provide novel insights into the link
between *CUBN* and eGFR.

2 Methods

2.1 Study design and cohorts

For the genetic association meta-analysis in diabetes mellitus (DM), we included data collected *via* three approaches (Figure 1): First, we acquired summary statistics from up to 15,200 individuals of European origin with either type 1 diabetes (T1D) or type 2 diabetes (T2D) subsetted from six cohorts: AfterEU (T1D) (15–18), Rotterdam (T2D) (19), DiaGene (T2D) (20), UK-ROI (T1D) (21), Genesis (T1D) (22) and ANDIS (T2D) (23). These studies (hereafter referred to as “DM cohorts”) were invited to the study and given a harmonized analysis plan provided that any subset of the requested genetic variants was available. A description of each cohort can be found in the *Supplemental text*.

Second, we applied the same analysis plan to a subset of
individuals with T2D (n ~ 14,860) from the UK Biobank (24)
(henceforth referred to as “UKBB-T2D”). The approach we used to
extract the T2D subset has been described previously (25, 26).

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Third, we did a lookup in a subset of an exome-wide association study (henceforth referred to as “ExWas”) that included 3,990 individuals with T2D from three Danish studies (Inter99, Vejle biobank and Addition-DK) described previously (11).

We also searched the Type 2 Diabetes Knowledge Portal [at time of search: www.type2diabetesgenetics.org, now: https://t2d.hugeamp.org/ (27)] for large-scale studies with publicly available summary statistics fulfilling the following criteria: Summary statistics should a) be readily available through the knowledge portal or a direct link to a study website; b) be available for diabetes-stratified and European-only populations; c) include at least one target genotype; d) be based on natural log-transformed eGFR values rather than non-transformed eGFR values; and e) be based on regression models with covariate adjustments comparable to those in the other cohorts in this study. However, as of 10 July 2020, no studies in the portal fulfilled our criteria, and no additional studies were included.

For additional analyses, we used 1) a group of individuals without diabetes from UKBB (n ~ up to 370,000 individuals), henceforth referred to as “UKBB-NDM”) and 2) the UKBB-T2D group, which was also part of the meta-analysis (Supplementary Figure 1). 127,090 non-diabetes individuals from the Icelandic study deCODE participated as the replication cohort (Supplemental text).

This research work was conducted in accordance with the Helsinki Declaration. Ethical approval was previously obtained locally for individual studies. All participants gave written informed consent before participating.

## 2.2 Phenotype details

For the DM cohorts and UKBB (both NDM and T2D groups), we calculated the creatinine-based estimated glomerular filtration rate (eGFR<sub>creatinine</sub>) with the Chronic Kidney Disease Epidemiology Collaboration creatinine equation (CKD-EPI<sub>creatinine(2012)</sub>), ml/min/1.73 m² (28), natural log-transformed). We included it here as a continuous variable. Other measures of kidney function were also calculated for UKBB; see section 2.4.2.4.

## 2.3 Genotyping, imputation, quality control and variant selection

We obtained information on genotyping, imputation, and quality control of each cohort and summarized it in Supplementary Tables 1, 2.

Four variants were selected for further analysis: rs141640975 (Chromosome (chr) 10, position (pos) 16992011 (genome-build GRCh37.p13)) with minor allele frequency (MAF) 0.002-0.009; rs144360241 (chr 10, pos 16967417) with MAF 0.006-0.010; rs45551835 (chr 10, pos 16932384) with MAF 0.016-0.021; and rs1801239 (chr 10, pos 16919052) with MAF 0.097-0.114. For the deCODE study, the MAFs were in the same range except rs144360241 (MAF: 0.002). The minor alleles of these variants (A, C, A, and C, respectively) were used as effect alleles.

We used LDlink version 5.1 (29) with the European (CEU + GBR) reference panel to confirm the independent relationship (Linkage Disequilibrium (LD) r²< 0.1) between these SNVs.

The SNVs were first used in single-variant analyses and were then combined into a genetic risk score (GRS; see description below).

## 2.4 Statistical methods

A flow chart of the meta-analyses is shown in Figure 1, and one of the additional analyses is shown in Supplementary Figure 1.

### 2.4.1 Study-level SNV-eGFR<sub>creatinine</sub> association analysis in diabetes and subsequent meta-analysis

In each DM cohort and UKBB-T2D, associations between eGFR<sub>creatinine</sub> and genetic variants were assessed assuming an additive genetic model. We used natural log-transformed eGFR<sub>creatinine</sub> in a linear regression model (model 1) adjusted for traditional clinical and genetic factors, i.e. age, gender, and study-specific covariates (i.e., 0-10 principal components of population structure to account for population stratification). To control for potential bias on kidney function in the diabetes population, another model was further adjusted for HbA<sub>1c</sub>, systolic blood pressure (a proxy for medication with Angiotensin receptor blockers (ARBs) or Angiotensin-converting enzyme inhibitor (ACEi) frequently used in diabetes treatment) and diabetes duration (model 2). Some of the cohorts used summary statistics calculated prior to our query, so we allowed minor deviations in the included covariates (Supplementary Table 3). A list of software used for association analysis can be found in Supplementary Table 1. Each study dealt with missing data separately. Once all summary results were collected, we performed study-level quality control. Summary results were meta-analyzed using a fixed-effect inverse-variance method in the “Metagen” package in R (version 3.6.3). We report results in any diabetes mellitus subtype (denoted “combined”) and in T1D and T2D subsets. Significant heterogeneity (P<0.05) indicated variation across studies. Effect sizes (betas) are presented with 95% confidence intervals. We evaluate statistical significance at an FDR-corrected level of 0.05/4 = 0.0125 considering the number of tested SNVs.

### 2.4.2 Additional analyses in UKBB populations with diabetes and non-diabetes

To explore the interplay between CUBN-variants and kidney-related traits in more detail, we did a range of additional linear regressions in the UKBB NDM and T2D groups. Further, we also applied a combined genetic risk score (GRS). We based the analyses on model 1 and model 3. The latter was very similar to model 2, in that it included adjustment for model 1 and SBP but not HbA<sub>1c</sub> and diabetes duration. The last two adjustments were absent from this model because they are less relevant in non-diabetes. We applied the same models in DM and NDM to provide consistency. Individuals were excluded if they had missing data for any variable.
### 2.4.2.1 SNV-eGFR<sub>creatinine</sub> association analysis in the UKBB population without diabetes and replication in the deCODE study

We examined SNV-eGFR<sub>creatinine</sub> associations in the UKBB NDM and T2D populations. It was advantageous to use the UKBB dataset here as it is a well-powered, phenotypically homogenous dataset (n ~ up to 370,000 individuals without diabetes). Since effects are based on natural log-transformed eGFR (trait) values, we also calculated the percental difference in mean, non-transformed eGFR per added effect allele for significant effects as follows: % difference = (e<sup>beta-1</sup>)\*100%. Again, we evaluated statistical significance at an FDR-corrected level of 0.0125.

SNV-eGFR<sub>creatinine</sub> associations identified in the UKBB NDM group were also examined in the Icelandic deCODE study (n<sub>NDM</sub>=127,090) applying model 3.

### 2.4.2.2 Interaction with albuminuria

In order to examine whether the SNVs associated with eGFR<sub>creatinine</sub> in an albuminuria-dependent fashion, we assessed albuminuria-SNV interactions in SNV-eGFR<sub>creatinine</sub> regression models in individuals with T2D (n<sub>T2D</sub> = 7,777) and without DM (n<sub>NDM</sub> = 107,276) for whom continuous urine albumin levels were available (derived from the UKBB "microalbumin" field). The interaction term in the regression models included albuminuria groups as a factor defined from these albumin levels as follows: i) *normoalbuminuria*: <= 30 mg/L (n<sub>DM</sub> = 5,566, n<sub>NDM</sub> = 93,728), ii) *microalbuminuria*: 30-300 mg/L (incl. lower but not upper threshold, n<sub>NDM</sub> = 1,954, n<sub>NDM</sub> = 12,690), and iii) *macroalbuminuria*: >300 mg/L (incl. lower threshold, n<sub>DM</sub> = 257, n<sub>NDM</sub> = 858). We used regression models based on model 1 and 3 (i.e., model 1: ln(eGFR<sub>creatinine</sub>) ~ SNV + albuminuria group + age + sex + SNV\*albuminuria group and model 3: model 1 + SBP). A significant p-value (< 0.05) for the SNV\*albuminuria interaction term was considered evidence for interaction. Interaction analysis was done whenever primary SNV-eGFR<sub>creatinine</sub> analyses were well-powered.

### 2.4.2.3 Genetic risk score association with microalbuminuria and eGFR<sub>creatinine</sub>

We estimated an albuminuria genetic risk score (GRS) using the four albuminuria-associated CUBN missense SNVs. The GRS was generated for each study participant using the sum of individual SNV effect alleles in the UKBB dataset. We then examined the associations between GRS<sub>CUBN</sub> and continuous urine microalbumin levels (mg/L) and eGFR<sub>creatinine</sub>.

### 2.4.2.4 SNV vs. other kidney function-related traits in UKBB

We examined the associations between the study SNVs and 1) circulating serum Cystatin C levels (mg/L) and 2) the more recent eGFR<sub>creatinine-cystatin C</sub> equation (30) that uses both serum creatinine and cystatin C levels and applies to all ethnicities.

### 2.4.3 Power calculations

We used Quanto (version 1.2.4) (31) to calculate post-hoc power for main SNV-eGFR<sub>creatinine</sub> associations in DM and NDM groups.

For all power calculations in Quanto, we: a) chose a continuous design for independent individuals; b) assumed a gene-only hypothesis; c) assumed an additive inheritance mode; and d) set the two-sided type I error-rate to 0.05.

For the remaining options in Quanto, we typed in information specific to each variant and population (Supplementary Tables 13-14): For each variant, we used allele frequencies of the effect allele; for meta-analyses, this was done as a range of calculations spanning the frequencies reported by individual cohorts. We used effect sizes obtained through DM and NDM SNV-eGFR<sub>creatinine</sub> association analyses (main effect). Means and standard deviations of ln (eGFR<sub>creatinine</sub>) were derived from UKBB subsets. Unless otherwise specified, total DM sample sizes were used.

## 3 Results

### 3.1 Clinical characteristics

Up to 34,743 individuals with diabetes mellitus (type 1 diabetes (T1D), n ~ 3,588, or type 2 diabetes (T2D), n ~ 31,155) and up to 370,061 without diabetes participated in the current study (Figure 1 and Supplementary Figure 1). Clinical characteristics of participating studies can be found in Table 1 and Supplementary Tables 4-7.

### 3.2 CUBN variants are not associated with eGFR<sub>creatinine</sub> in a diabetes meta-analysis

The effect of rs144360241 on eGFR<sub>creatinine</sub> was studied in 32,904 individuals with diabetes. The variant was not available in UK-ROI (Supplementary Figures 2, 6). All eight studies contributed to the 34,050 individuals analyzed for rs45551835 (Supplementary Figures 3 and 7). The rs141640975 variant was available for 32,993 individuals and was unavailable in UK-ROI (Supplementary Figures 4, 8). The common variant, rs1801239, was available in all eight studies in 34,070 individuals (Supplementary Figures 2, 9).

After meta-analysis, none of the four CUBN variants were significantly positively associated with eGFR<sub>creatinine</sub> in the DM group, neither in the T1D or T2D subgroup [Table 2 (Model 1) and Table 3 (Model 2)]. However, the positive directionality of the effect for the T2D group was consistent with the directionality of effect for the combined group for all variants with non-zero effects. The T2D group carried the largest weight in the combined meta-analyses and UKBB carried the largest weight within the T2D group (Supplementary Figures 2-5). There was no evidence of heterogeneity across studies, except in model 2 for rs45551835 and rs1801239 (Table 3).
<table><caption>TABLE 1 Clinical characteristics of participating studies.</caption><thead><tr><th rowspan="2">Study name</th><th rowspan="2">DM type</th><th rowspan="2">Individuals (N)</th><th rowspan="2">Males (N, %)</th><th rowspan="2">Age<sup>##</sup> [years]</th><th rowspan="2">BMI [kg/m<sup>2</sup>]</th><th rowspan="2">eGFR<sub>creatinine</sub> [ml/min/ 1.73 m<sup>2</sup>]</th><th rowspan="2">SBP [mmHg]</th><th rowspan="2">Diabetes duration [years]</th><th colspan="3">Urinary albumin</th></tr><tr><th>AER [mg/ 24h]</th><th>UACR [mg/ mmol]</th><th>ALB [mg/ L]</th></tr></thead><tbody><tr><td>AfterEU</td><td>T1D</td><td>854</td><td>492 (57.60)</td><td>43.67 (11.15)</td><td>24.23 (3.21)</td><td>89.48 (26.61)</td><td>139.22 (20.90)</td><td>28.02 (9.50)</td><td>29.00 (7.00 - 618.00)</td><td>NR</td><td>NR</td></tr><tr><td>UK-ROI</td><td>T1D</td><td>1,410</td><td>716 (50.80)</td><td>45.09 (11.35)</td><td>26.30 (4.40)</td><td>54.30 (30.00)</td><td>135.02 (20.80)</td><td>30.45 (9.70)</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>GENESIS</td><td>T1D</td><td>1,324</td><td>700 (52.90)</td><td>41.37 (12.21)</td><td>22.21 (8.15)</td><td>80.87 (28.49)</td><td>129.41 (23.75)</td><td>24.91 (10.45)</td><td>9.00 (4.16- 37.25)</td><td>NR</td><td>NR</td></tr><tr><td>DiaGene</td><td>T2D</td><td>1,886</td><td>1,011 (53.60)</td><td>65.24 (10.57)</td><td>30.47 (5.43)</td><td>78.33 (20.55)</td><td>141.83 (18.72)</td><td>10.09 (8.45)</td><td>NR</td><td>5.85 (30.45)</td><td>NR</td></tr><tr><td>Rotterdam</td><td>T2D</td><td>1,022</td><td>487 (47.70)</td><td>68.10 (9.70)</td><td>29.40 (4.80)</td><td>78.30 (16.40)</td><td>147.10 (21.70)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>ANDIS</td><td>T2D</td><td>9,367</td><td>5,548 (59.22)</td><td>66.29 (13.29)</td><td>30.77 (5.70)</td><td>84.69 (30.92)</td><td>NA</td><td>8.07 (4.40)</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>ExWas**</td><td>T2D</td><td>3,990</td><td>2,370 (59.30)</td><td>61.00 (8.50)</td><td>NA</td><td>79.00 (1.28)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>UKBB- T2D*</td><td>T2D</td><td>14,890</td><td>9,703 (65.10)</td><td>60.97 (6.28)</td><td>31.90 (5.70)</td><td>87.86 (15.73)</td><td>144.50 (18.20)</td><td>NA</td><td>NR</td><td>NR</td><td>16.00 (10.00- 34.40)</td></tr><tr><td>UKBB- NDM*</td><td>NR*</td><td>370,061</td><td>166,976 (45.10)</td><td>56.73 (8.02)</td><td>27.10 (4.50)</td><td>90.81 (12.80)</td><td>139.90 (19.60)</td><td>NR</td><td>NR</td><td>NR</td><td>11.10 (8.30- 18.10)</td></tr></tbody></table>

<table><caption>TABLE 2 meta-analysis of SNV-eGFR<sub>creatinine</sub> summary data in diabetes mellitus and its subtypes (model 1).</caption><thead><tr><th>Genetic variant (EA)</th><th>Diabetes type</th><th>N</th><th>Effect (Beta [95% CI])</th><th>P<sub>HET</sub></th><th>P-value</th></tr></thead><tbody><tr><td rowspan="3">rs144360241 (C)</td><td>T1D</td><td>2,177</td><td>-0.14 [-0.32; 0.05]</td><td>0.38</td><td>0.15</td></tr><tr><td>T2D</td><td>30,727</td><td>0.01 [-0.01; 0.04]</td><td>0.62</td><td>0.40</td></tr><tr><td>Combined DM</td><td>32,904</td><td>0.01 [-0.02; 0.04]</td><td>0.42</td><td>0.53</td></tr><tr><td rowspan="3">rs45551835 (A)</td><td>T1D</td><td>3,236</td><td>-0.02 [-0.13; 0.08]</td><td>0.34</td><td>0.69</td></tr><tr><td>T2D</td><td>30,814</td><td>0.01 [0.00; 0.03]</td><td>0.08</td><td>0.09</td></tr><tr><td>Combined DM</td><td>34,050</td><td>0.01 [0.00; 0.02]</td><td>0.15</td><td>0.10</td></tr><tr><td rowspan="3">rs141640975 (A)</td><td>T1D</td><td>2,177</td><td>0.16 [-0.11; 0.44]</td><td>0.75</td><td>0.25</td></tr><tr><td>T2D</td><td>30,816</td><td>0.00 [-0.03; 0.03]</td><td>0.53</td><td>0.83</td></tr><tr><td>Combined DM</td><td>32,993</td><td>0.01 [-0.02; 0.03]</td><td>0.60</td><td>0.73</td></tr><tr><td rowspan="3">rs1801239 (C)</td><td>T1D</td><td>3,236</td><td>-0.01 [-0.06; 0.03]</td><td>0.20</td><td>0.57</td></tr><tr><td>T2D</td><td>30,834</td><td>0.00 [0.00; 0.01]</td><td>0.21</td><td>0.64</td></tr><tr><td>Combined DM</td><td>34,070</td><td>0.00 [0.00; 0.01]</td><td>0.23</td><td>0.59</td></tr></tbody></table>

<footnote>*Non-DM population. **The ExWas study comprises summary data from T2D individuals (discovery set). N, sample size; SD, standard deviation; BMI, Body-Mass Index; eGFR<sub>creatinine</sub>, estimated glomerular filtration rate based on the CKD-EPI<sub>2012</sub> equation (non-transformed); SBP, Systolic blood pressure; AER, albumin excretion rate; IQR, Interquartile range; UACR, urinary albumin-creatinine ratio; UKBB, UK Biobank; ALB, continuous baseline urinary albumin level; T2D, Type 2 diabetes; DM, diabetes mellitus; NDM; non-DM; T1D, type 1 diabetes. NR, not relevant; NA, not available. *The UK Biobank urinary albumin measures are based on n=7,777 in T2D and n=370,061 in the NDM group. **The time point for age assessment is NA for Genesis. Age at recruitment was used in all other studies. Age, BMI, eGFR, and SBP have been denoted as mean (SD), while Urinary albumin measures have been denoted as median (IQR).</footnote>

<footnote>SNV, single nucleotide variant; eGFR<sub>creatinine</sub>, log-transformed estimated glomerular filtration rate based on the CKD-EPI<sub>2012</sub> equation; EA, effect allele (i.e., minor allele); N, sample size; Beta, Beta coefficient; CI, confidence interval; P<sub>HET</sub>, P-value for heterogeneity across studies. P<sub>HET</sub> < 0.05 indicates variation; T1D: Type 1 diabetes; T2D: Type 2 diabetes; Combined DM: T1D and T2D combined.</footnote>
<table><caption>TABLE 3 meta-analysis of SNV-eGFR<sub>creatinine</sub> summary data in diabetes mellitus and its subtypes (model 2).</caption><thead><tr><th>Genetic variant (EA)</th><th>Population</th><th>N</th><th>Effect (Beta [95% CI])</th><th>P<sub>HET</sub></th><th>P-value</th></tr></thead><tbody><tr><td rowspan="3">rs144360241 (C)</td><td>T1D</td><td>1,916</td><td>-0.12 [-0.32; 0.08]</td><td>0.26</td><td>0.25</td></tr><tr><td>T2D</td><td>15,745</td><td>0.01 [-0.02; 0.04]</td><td>0.37</td><td>0.66</td></tr><tr><td>Combined DM</td><td>17,661</td><td>0.00 [-0.02; 0.03]</td><td>0.32</td><td>0.78</td></tr><tr><td rowspan="3">rs45551835 (A)</td><td>T1D</td><td>2,712</td><td>-0.05 [-0.16; 0.07]</td><td>0.25</td><td>0.43</td></tr><tr><td>T2D</td><td>15,724</td><td>0.01 [0.00; 0.03]</td><td>0.03*</td><td>0.14</td></tr><tr><td>Combined DM</td><td>18,436</td><td>0.01 [0.00; 0.03]</td><td>0.05</td><td>0.18</td></tr><tr><td rowspan="3">rs141640975 (A)</td><td>T1D</td><td>1,916</td><td>0.10 [-0.17; 0.38]</td><td>0.4</td><td>0.46</td></tr><tr><td>T2D</td><td>15,746</td><td>0.00 [-0.04; 0.05]</td><td>0.58</td><td>0.88</td></tr><tr><td>Combined DM</td><td>17,662</td><td>0.01 [-0.04; 0.05]</td><td>0.67</td><td>0.8</td></tr><tr><td rowspan="3">rs1801239 (C)</td><td>T1D</td><td>2,712</td><td>0.00 [-0.04; 0.05]</td><td>0.53</td><td>0.94</td></tr><tr><td>T2D</td><td>15,741</td><td>0.00 [-0.01; 0.01]</td><td>0.03*</td><td>0.77</td></tr><tr><td>Combined DM</td><td>18,453</td><td>0.00 [-0.01; 0.01]</td><td>0.15</td><td>0.76</td></tr></tbody></table>

SNV, single nucleotide variant; eGFR<sub>creatinine</sub>, log-transformed estimated glomerular filtration rate based on the CKD-EPI<sub>2012</sub> equation; EA, effect allele (i.e., minor allele); N, sample size; Beta, Beta coefficient; CI, confidence interval; P<sub>HET</sub>, P-value for heterogeneity across studies. P<sub>HET</sub> < 0.05 indicates variation; T1D: Type 1 diabetes; T2D: Type 2 diabetes; Combined DM: T1D and T2D combined.

## 3.3 CUBN variants are associated with higher eGFR<sub>creatinine</sub> in non-diabetes

In UKBB-NDM, we observed larger eGFR<sub>creatinine</sub>-levels for minor alleles compared to major alleles for all four CUBN variants in both models, except for rs1801239 in NDM, model 3 (Table 4 and Supplementary Table 8): The effect and standard deviation of rs144360241 was, for model 1 (model 3), 0.008 ± 0.002 (0.007 ± 0.002), corresponding to a difference of +0.8% (+0.7%) in mean eGFR<sub>creatinine</sub> (ml/min/1.73 m²) for each additional copy of the affect allele, C. For rs45551835, the effect was 0.005 ± 0.001 (0.004 ± 0.001), corresponding to a difference of +0.5% (+0.4%) in mean eGFR<sub>creatinine</sub> per copy of the A-allele. rs141640975 had the largest effect size, 0.02 ± 0.003 (0.02 ± 0.003), corresponding to a +2.02% (+2.02%) difference in mean

eGFR<sub>creatinine</sub> for each additional A-allele. The common variant, rs1801239, had the smallest effect size of 0.001 ± 0.0005, corresponding to a +0.1% difference in eGFR<sub>creatinine</sub> for each C-allele. We replicated the finding that rs141640975 was significantly associated with higher eGFR<sub>creatinine</sub> in non-diabetes in an Icelandic study (deCODE, n = 127,090, effect = 0.026, SE = 0.007, P<sub>eGFR</sub><sub>creatinine</sub> = 7.7 × 10<sup>-4</sup>, model 3, Supplementary Table 8). None of the other SNVs were replicated (data not shown). Meta-analysis for the rs141640975-eGFR-association in the NDM studies (UKBB and deCODE) is depicted in Supplementary Figure 10.

In UKBB-T2D, none of the variants had statistically significant associations with eGFR<sub>creatinine</sub>, although the effects of three of the variants (except rs141640975) were in the same direction as in NDM (Table 4 and Supplementary Table 8).

<table><caption>TABLE 4 Summary results for SNV-eGFR<sub>creatinine</sub> analyses in UKBB (model 1).</caption><thead><tr><th>Genetic variant (EA)</th><th>EAF</th><th>Population **</th><th>N</th><th>Effect (Beta [SE])</th><th>P-value</th></tr></thead><tbody><tr><td rowspan="3">rs144360241 (C)</td><td>0.004</td><td>NDM ***</td><td>369,832</td><td>0.008 (0.002)</td><td>0.0008*</td></tr><tr><td>0.004</td><td>T2D ****</td><td>14,882</td><td>0.02 (0.02)</td><td>0.23</td></tr><tr><td>0.014</td><td>NDM ***</td><td>369,028</td><td>0.005 (0.001)</td><td>0.0004*</td></tr><tr><td rowspan="3">rs45551835 (A)</td><td>0.014</td><td>T2D ****</td><td>14,860</td><td>0.01 (0.01)</td><td>0.13</td></tr><tr><td>0.003</td><td>NDM ***</td><td>369,987</td><td>0.02 (0.003)</td><td>2.2 × 10<sup>-9</sup>*</td></tr><tr><td>0.003</td><td>T2D ****</td><td>14,885</td><td>-0.01 (0.02)</td><td>0.71</td></tr><tr><td rowspan="3">rs141640975 (A)</td><td>0.10</td><td>NDM ***</td><td>369,849</td><td>0.001 (0.0005)</td><td>0.006*</td></tr><tr><td>0.10</td><td>T2D ****</td><td>14,880</td><td>0.00 (0.00)</td><td>0.42</td></tr><tr><td>0.10</td><td>T2D ****</td><td>14,880</td><td>0.00 (0.00)</td><td>0.42</td></tr></tbody></table>

SNV, single-nucleotide variant; eGFR<sub>creatinine</sub>, estimated glomerular filtration rate (natural log-transformed); EA, effect allele (i.e., minor allele); N, sample size; EAF, Effect allele frequency; Beta, Beta coefficient; SE, standard error; NDM, without Diabetes Mellitus; T2D, Type 2 diabetes. *Statistically significant (P< 0.05). ** For completeness, we also show the results for T2D, which were part of DM meta-analyses for model 1. *** out of total 370,061 individuals. **** out of total 14,892 individuals.
<table><caption>TABLE 5 Interaction with albuminuria in SNV-eGFR<sub>creatinine</sub> analyses in UKBB (model 1).</caption><thead><tr><th>Genetic variant (EA)</th><th>Population</th><th>N</th><th>P-value of interaction term<sup>#</sup></th></tr></thead><tbody><tr><td>rs144360241 (C)</td><td>NDM **</td><td>107,202</td><td>0.67</td></tr><tr><td>rs45551835 (A)</td><td>NDM **</td><td>106,964</td><td>0.88</td></tr><tr><td>rs141640975 (A)</td><td>NDM **</td><td>107,255</td><td>0.03*</td></tr><tr><td>rs1801239 (C)</td><td>NDM **</td><td>107,216</td><td>0.49</td></tr></tbody></table>

SNV, single-nucleotide variant; eGFR<sub>creatinine</sub>, estimated glomerular filtration rate (natural log-transformed); EA, effect allele (i.e., minor allele); N, sample size; NDM, without Diabetes Mellitus; *Statistically significant (P< 0.05). ** out of total 107,276 individuals with continuous urinary albumin levels. Albuminuria-SNV interaction was only tested when primary SNV-eGFR-creatinine associations were significant. # Interaction term is SNV*albuminuria groups (normo-, micro-, and macro albuminuria).

## 3.4 Associations of rs141640975 with eGFR<sub>creatinine</sub> depend on albuminuria-status in non-diabetes

To examine whether the SNVs are associated with eGFR<sub>creatinine</sub> in an albuminuria-dependent fashion, we included albuminuria*SNV interactions in two regression models. For the first model, we observed significant interaction for rs141640975 in UKBB-NDM (P<0.03, Table 5). This was also observed in the other model (P<0.04, Supplementary Table 9). An interaction plot showed that for the eGFR-SNV-association, the effect on eGFR was even higher for more elevated albuminuria-levels (Supplementary Figure 11).

## 3.5 A CUBN-based GRS for albuminuria is associated with eGFR<sub>creatinine</sub> in non-diabetes

We combined the four CUBN variants into a genetic risk score for albuminuria, verified its associations with continuous urine albumin levels and tested it against eGFR<sub>creatinine</sub> in UKBB-T2D and UKBB-NDM. The GRS was associated with higher levels of both traits, except for eGFR in T2D (Tables 6, 7).

<table><caption>TABLE 6 Summary results for GRS<sub>CUBN</sub>-eGFR<sub>creatinine</sub> and -ALB analyses in UKBB (model 1).</caption><thead><tr><th>Trait</th><th>Population</th><th>N</th><th>Effect (Beta [SE])</th><th>P-value</th></tr></thead><tbody><tr><td rowspan="3">ALB</td><td>NDM **</td><td>106,814</td><td>0.05 (0.004)</td><td rowspan="2">2 × 10<sup>-16*</sup></td></tr><tr><td>T2D ***</td><td>7,741</td><td>0.08 (0.02)</td></tr><tr><td>NDM</td><td>368,521</td><td>0.002 (0.0004)</td><td>2 × 10<sup>-6*</sup></td></tr><tr><td>eGFR<sub>creatinine</sub></td><td>T2D</td><td>14,837</td><td>0.004 (0.003)</td><td>0.2</td></tr></tbody></table>

GRS<sub>CUBN</sub>, A genetic risk score based on a combination of the four CUBN genetic variants (minor alleles); N, sample size; Beta, Beta estimate; SE, standard error; ALB, continuous urinary albumin (mg/L, natural log-transformed); eGFR<sub>creatinine</sub>, estimated glomerular filtration rate (natural log-transformed); NDM, without Diabetes Mellitus; T2D, Type 2 diabetes. *Statistically significant (P< 0.05). ** out of total 107,276 individuals with continuous urinary albumin levels. *** out of total 7,777 individuals with continuous urinary albumin levels.

<table><caption>TABLE 7 Summary results for GRS<sub>CUBN</sub>-eGFR<sub>creatinine</sub> and -ALB analyses in UKBB (model 3).</caption><thead><tr><th>Trait</th><th>Population</th><th>N</th><th>Effect (Beta [SE])</th><th>P-value</th></tr></thead><tbody><tr><td rowspan="3">ALB</td><td>NDM **</td><td>99,180</td><td>0.05 (0.004)</td><td>2 × 10<sup>-16*</sup></td></tr><tr><td>T2D ***</td><td>7,182</td><td>0.08 (0.02)</td><td>3 × 10<sup>-4</sup></td></tr><tr><td>NDM</td><td>343,988</td><td>0.002 (0.0004)</td><td>2 × 10<sup>-5*</sup></td></tr><tr><td>eGFR<sub>creatinine</sub></td><td>T2D</td><td>13,828</td><td>0.005 (0.003)</td><td>0.1</td></tr></tbody></table>

GRS<sub>CUBN</sub>, A genetic risk score based on a combination of the four CUBN genetic variants (minor alleles); N, sample size; Beta, Beta estimate; SE, standard error; ALB, continuous urinary albumin (mg/L, natural log-transformed); eGFR<sub>creatinine</sub>, estimated glomerular filtration rate (natural log-transformed); NDM, without Diabetes Mellitus; T2D, Type 2 diabetes. *Statistically significant (P< 0.05). ** out of total 107,276 individuals with continuous urinary albumin levels. *** out of total 7,777 individuals with continuous urinary albumin levels.

## 3.6 rs141640975 is associated with additional markers of kidney function in non-diabetes

We examined the associations between the study SNVs and two additional markers of kidney function. The SNV rs141640975 was associated with higher levels of eGFR<sub>creatinine-cystatin C</sub> [a more recent ethnicity-independent GFR-estimator (28)] and lower levels of cystatin C, both observed in NDM (Supplementary Tables 10–12). The eGFR<sub>creatinine-cystatin C</sub> association of rs144360241 was borderline significant in NDM.

## 3.7 Estimated power

### 3.7.1 Meta-analysis (diabetes mellitus)

Given the ranges of EAFs obtained from individual studies participating in meta-analyses, we reached a power level of 35-43% for rs45551835, 16-23% for rs1444360241, and 9-21% for rs141640975 in the DM group (Supplementary Table 14). Effect sizes were assumed from the individual meta-analysis eGFR<sub>creatinine</sub>-associations of each SNV. We did not calculate power for rs1801239 as the effect in the DM meta-analysis was 0.0.

### 3.7.2 Association of SNVs with eGFR (UKBB population without diabetes)

In NDM, the power for main eGFR<sub>creatinine</sub> analyses was between 70-99% for the four variants (Supplementary Table 15).

## 4 Discussion

Recently, we demonstrated that individuals carrying the minor allele of the CUBN missense variant rs141640975 had higher albuminuria-levels than non-carriers. The effect of this variant was stronger in individuals with diabetes (DM) compared to those without diabetes (NDM) (11). In continuation of these findings, Bedin et al. (8) performed secondary lookups for CUBN-variants in
the CKDGen eGFR GWAS study population, reporting that missense variants in *CUBN* may also be associated with higher levels of eGFR in the general population. Our current large-scale study aimed to examine the effect of minor alleles of three rare *CUBN* missense variants (*rs144360241* (*c.6469A>G*; *p.Asn2157Asp*), *rs45551835* (*c.8741C>T*; *p.Ala2914Val*) and *rs141640975* (*c.5069C>T*; *p.Ala1690Val*)) and one common variant (*rs1801239* (*c.8950A>G*; *p.Ile2984Val*)) on eGFR<sub>creatinine</sub> levels separately in people with and without diabetes (*n<sub>DM</sub>* ~ 34,000 individuals, *n<sub>NDM</sub>* ~ 370,000 individuals), including stratification for diabetes-type and supplemented by tests on circulating cystatin C levels, the recently updated eGFR-equation based on creatinine and cystatin C (30), and aggregate-variant tests. We were able to replicate the association between creatinine-based eGFR and *rs141640975* in NDM and report new insightful connections with the alternative measures of kidney function for all four SNVs.

Previously, a borderline association between rs45551835 and higher eGFR-levels has been reported in a smaller type 2 diabetes (T2D) population from Denmark (8, 11), a finding which we could not replicate in our meta-analysis of up to 34,432 individuals with diabetes and its subtypes. Like the initial study (8), we could not establish a link between eGFR and the three other variants within the diabetes group. As for rs45551835, it was surprising to be unable to replicate the earlier findings as the current study has a larger sample size compared to earlier efforts. Our *post-hoc* power assessment indicated that insufficient power might be at play, even with a larger sample size for the diabetes group (8). We also speculated whether the apparent lack of association between *CUBN* and eGFR in our diabetes meta-analysis could be due to use of Angiotensin receptor blockers (ARBs) or Angiotensin-converting enzyme inhibitor (ACEi) medication which is frequently used in diabetes treatment. As part of our sensitivity analyses, we included models adjusted for systolic blood pressure (a proxy for such medication) and did not find evidence that this could explain why no association was found in the diabetes group. Another reason could be the allele frequency of the variants may differ between Danish and UK populations. We need further validation in well-powered populations to confirm the relationship between the rs45551835 and eGFR in diabetes, especially in T2D. In case of a true lack of association, *CUBN* may be associated with higher levels of urine albumin (11) with no pleiotropic effect to eGFR in this population.

We proceeded to single- and aggregate-variant analyses in the UK Biobank (UKBB), shifting focus to non-diabetes populations. For all four *CUBN* variants, we report significantly higher eGFR<sub>creatinine</sub>-levels in individuals without diabetes harboring more copies of the minor alleles compared to individuals with fewer or no copies of the minor alleles in the same group. For rs141640975, we observed the strongest association with eGFR<sub>creatinine</sub> (P = 2.2 × 10<sup>-9</sup>) with replication in the Icelandic study (deCODE, P = 7.7 × 10<sup>-4</sup>), confirming what has previously been observed for this SNV in NDM (8) – but also a significant interaction between the SNV and albuminuria stages (P<sub>INT</sub>< 0.05). Taken together with the already known associations of the minor alleles with higher albuminuria (11), this not only demonstrates genetic pleiotropy of *CUBN* for albuminuria and eGFR in non-diabetes but also implies that these two associations are intertwined

for this SNV, where the effect on eGFR is even higher for more elevated albuminuria-levels. Here, *CUBN* demonstrates a classic genetic pleiotropy phenomenon where a DNA variant influences multiple traits, usually in the same domain with concordant or sometimes discordant effects as observed earlier in complex disorders (32). Further validation of independent biological or related causal effects might be required in additional follow up studies.

This finding is unusual as there is no obvious clinical or pathophysiological explanation for such an albuminuria-eGFR pattern in the context of non-diabetes. It has been suggested that the tubular albuminuria observed in presence of C-terminal variants in *CUBN* has a benign or even slightly protective effect on kidney function in chronic kidney disease if glomerular albuminuria is also present (8, 33, 34). Another recent study on chronic isolated proteinuria suggests that different C-terminal *CUBN* variants uncouple proteinuria from glomerular filtration barrier through declined cubilin expression accompanied by aberrant amnionless (AMN) localization in renal tubules. AMN is part of the receptor complex (along with cubilin and megalin) necessary for tubular reabsorption of albumin. This is suggested to create a benign condition, not requiring any further proteinuria lowering treatment (35). In non-diabetes, where the population can be assumed to consist mostly of healthy individuals, a concept of such protectiveness is less relevant. However, it is possible that an undetected subpopulation with relevant comorbidities exists in the non-diabetes group.

Our *CUBN* aggregate-variant method – which was defined as a genetic risk score (GRS) combining the four variants – showed that a higher number of C-terminal *CUBN* risk alleles is associated with higher urine albumin and eGFR<sub>creatinine</sub> levels and confirms both the single-variant association with higher urine albumin levels reported previously in diabetes and non-diabetes (11, 14), and the consistency of the overall effects on urine albumin levels being greater in diabetes compared to non-diabetes (10, 11). Through GRS<sub>CUBN</sub>, we also saw that a higher number of minor alleles across the four variants was associated with higher eGFR<sub>creatinine</sub>-levels in the UKBB population without diabetes, which is in line with our single-variant findings and the previous findings for rs45551835 (8). Using aggregate-variant methods is an optimal way to examine combined genetic effects and has been used extensively for polygenic traits (13, 36). Using GRS is highly relevant here as three of the four variants are rare and mostly present as heterozygous variants in our populations. This might substantiate with some additional power to detect effects and adds further certainty to the presence of a *CUBN*-eGFR relationship in non-diabetes. Nevertheless, we still do not find an association with eGFR in T2D, even when the variants are combined in a GRS.

Finally, we examined the association between the study SNVs and two alternative markers of kidney function. In non-diabetes, the minor alleles of *rs141640975* and *rs144360241* were associated with higher levels of eGFR<sub>creatinine-cystatin C</sub>. This measure was estimated using a recent update to the equation, CKD-EPI<sub>2021</sub>, which does not include ethnicity and is a more precise indicator of kidney function in comparison to the CKD-EPI<sub>creatinine(2012)</sub> equation which is based only on creatinine. Our results using the
conventional eGFR<sub>creatinine</sub> equation are concordant with our results from the updated equation in terms of directionality of effect and with our finding that rs141640975 is associated with lower cystatin C levels, which is another indicator of kidney function. It should be noted, though, that considering **Table 1** and **Supplementary Tables 4–6**, the 0.1% – 2.02% higher mean eGFR we report for each minor allele is modest and may reflect that individual harboring these genetic variants have normal kidney function rather than a better kidney function.

A strength of our study is the restriction to specifically diabetes-
and non-diabetes-only subgroups so that effects from mixed diabetes-
status are minimized. Heterogeneity is likely to be present in meta-
analyses of a diverse set of cohorts originally used for different
research purposes. Indeed, some of the cohorts included in our
meta-analyses differ regarding available covariates and/or kidney
disease status. However, we did not observe heterogeneity in our
meta-analyses. In addition to this, we could minimize heterogeneity
in the remainder of our analyses by using data from the UKBB, which
is a nationally representative cohort facilitating application of
identical phenotype definitions across subgroups. Another strength
is the broad spectrum of additional analyses that we explored in the
UKBB population to nuance our findings on the relationship between
eGFR and CUBN. The judicious use of UKBB leveraging individual-
level genotype information to investigate interaction-analyses based
on albuminuria groupings is a great strength of the current study,
especially for rare variants.

A major limitation is that we did not have sufficient statistical
power for our meta-analyses in the diabetes group due to the limited
availability of suitable datasets. Consequently, interpretations of
T2D findings should not be overstated and we thus could not
demonstrate, nor disprove, the presence of a CUBN-eGFR
relationship in this population. Although we demonstrate that C-
terminal missense variants in CUBN are associated with different
measures of normal (or even higher) kidney function in non-
diabetes, we emphasize that the current study is insufficient to
establish causality. Finally, using multiple-testing-corrected
significance thresholds might be too conservative when testing a
very small number of variants from the same locus as it may remove
true associations. In genome-wide studies, a conservative threshold
of 5 × 10⁻⁸ is generally agreed upon for novel associations. There is
less consensus on when and how to appropriately apply multiple
testing correction in smaller-scale genetic studies dealing with a
mixture of new and known associations. Nevertheless, we deemed
that it would be fair to apply FDR-correction of the significance
threshold to our primary analyses in DM and NDM.

In conclusion, the current study identifies the existence of
pleiotropic genetic effects of *CUBN* on two facets of kidney function
– albuminuria and eGFR – by reporting SNV-eGFR associations in a
large study population without diabetes. The interaction between
rs141640975 and albuminuria-status on eGFR<sub>creatinine</sub> in this
population and its associations with lower cystatin C and higher
levels of eGFR<sub>creatinine-cystatin C</sub> expands our knowledge of these
variants in relation to measures of kidney function. The
demonstration of a *CUBN*-focused GRS in relation to albuminuria
and eGFR<sub>creatinine</sub> further suggests an important role of *CUBN*-variants
in the future personalization of chronic kidney disease management.

Data availability statement

The original contributions presented in the study are included
in the article/Supplementary Material. Further inquiries can be
directed to the corresponding author.

Ethics statement

The studies involving human participants were reviewed and
approved by Ethical approval has previously been obtained
locally for each individual study. The patients/participants
provided their written informed consent to participate in
this study.

Author contributions

NU, MS, PR, and TA contributed to conception and design of the study. NU wrote the first draft of the manuscript.NU, MC-G, CH, AN, AO, SS, D-AT, EA, MH, AM, EJS, MS, PR, and TA contributed to manuscript revision. D-AT, VS, KS, EA, MH, AM, PR and TA acquired data. NU, FA, MC-G, CH, AN, SS, LS, D-AT, and TA performed statistical analysis. NU, MC-G, LS, D-AT, AM, MS, PR, and TA contributed to interpretation of data. TA and MS acquired funding and TA administered this project. PR and TA supervised the project. LC and MG had other roles. All authors contributed to the article and approved the submitted version.

Funding

NU, MS, and TA were supported by the Novo Nordisk
Foundation, Steno Collaborative Grant (NNF18OC0052457). TA
and PR were supported by Steno Diabetes Center Copenhagen,
Herlev, Denmark. Funding of individual studies contributing to this
project can be found in *Supplementary Table 16*.

Acknowledgments

This research has been conducted using data from UK Biobank
database (www.ukbiobank.ac.uk), project ID numbers, 32683 and
71699. Acknowledgements of individual studies can be found in
*Supplementary Table 16*.

Conflict of interest

Author MC-G was employed by Pfizer-University of Granada-Andalusian Regional Government. Authors AO, VS, and KS were employed by Amgen, Inc. PR reports personal fees from Bayer during the conduct of the study. He has received research support and personal fees from AstraZeneca and Novo Nordisk, and personal fees from Astellas Pharma, Boehringer Ingelheim, Eli
Lilly, Gilead Sciences, Mundipharma, Sanofi, and Vifor Pharma. All fees are given to Steno Diabetes Center Copenhagen.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

## Publisher's note

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## Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fendo.2023.1081741/full#supplementary-material

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