Azilsartan as a novel anti-ferriptotic agent via the upregulation of the Nrf2/HO-1/SLC7A11/GPX4 axis and downregulation of inflammatory pathways in folic acid-induced acute kidney injury in male mice

Azilsartan, a unique angiotensin II receptor blocker (ARB) with an oxo-oxadiazole ring, exhibits antioxidant and anti-inflammatory properties, but its role in ferroptosis-mediated AKI remains unexplored. This study investigates whether azilsartan protects against FA-induced AKI in male mice by attenuating ferroptosis, modulating iron metabolism, and suppressing inflammatory signaling. 42 male C57BL/6 J mice were randomized into six groups: control, FA-induced AKI, three azilsartan doses (1, 3, 5 mg/kg), and ferrostatin-1 (Fer-1) as a positive control. Azilsartan or Fer-1 was administered for 7 days before FA injection (250 mg/kg, i.p.) and continued for 3 days post-induction. Renal function (serum urea, creatinine), ferroptosis markers (GPX4, MDA, Nrf2, SLC7A11, HO-1), iron-handling proteins (ferritin, TfR1), inflammatory mediators (TNF-α, NF-κB p65), and histopathology were assessed. FA-AKI caused marked renal dysfunction, elevated KIM-1, lipid peroxidation, depletion of GPX4, downregulation of Nrf2/HO-1/SLC7A11 and TfR1, reduction of transferrin levels, and inflammatory activation. Azilsartan improved renal function and histology in a dose-dependent manner, restored GPX4, reduced MDA, upregulated Nrf2/HO-1/SLC7A11 and TfR1, increased ferritin levels, and suppressed TNF-α/NF-κB. High-dose azilsartan achieved effects comparable to those of Fer-1. Azilsartan confers potent protection against FA-induced AKI by activating the Nrf2/HO-1/SLC7A11/GPX4 axis, reducing lipid peroxidation, normalizing iron metabolism, and attenuating inflammation. These findings support azilsartan’s potential as a repurposed therapy for ferroptosis-driven renal injury. • Azilsartan protects against folic acid–induced acute kidney injury in mice • Activates Nrf2/HO-1/SLC7A11/GPX4 axis to suppress ferroptosis and lipid peroxidation • Normalizes iron metabolism via ferritin restoration and normalization of TfR1 expression • Attenuates NF-κB/TNF-α–mediated renal inflammation in acute kidney injury • Repurposes azilsartan as a novel anti-ferroptotic therapy for renal protection