Kidney Cancer Metabolic Modulation of Clear-cell Renal Cell Carcinoma with Dichloroacetate, an Inhibitor of Pyruvate Dehydrogenase Kinase Adam Kinnaird a,b , Peter Dromparis b , Bruno Saleme b , Vikram Gurtu b , Kristalee Watson c , Roxane Paulin b , Sotirios Zervopoulos b , Trevor Stenson b , Gopinath Sutendra b , Desmond B. Pink d , Katia Carmine-Simmen d , Ronald Moore a , John D Lewis d , Evangelos D. Michelakis b, * a Division of Urology, University of Alberta, Edmonton, Alberta, Canada; b Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; c Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; d Department of Oncology, University of Alberta, Edmonton, Alberta, Canada E U R O P E A N U R O L O G Y X X X ( 2 0 1 5 ) X X X – X X X ava ilable at www.sciencedirect.com journa l homepage: www.europea nurology.com Article info Article history: Accepted September 10, 2015 Associate Editor: James Catto Keywords: Metabolic modulation Pyruvate dehydrogenase kinase Warburg effect Dichloroacetate Abstract Background: Clear-cell renal cell carcinoma (ccRCC) exhibits suppressed mitochondrial function and preferential use of glycolysis even in normoxia, promoting proliferation and suppressing apoptosis. ccRCC resistance to therapy is driven by constitutive hypoxia-inducible factor (HIF) expression due to genetic loss of von Hippel-Lindau factor. In addition to promoting angiogenesis, HIF suppresses mitochondrial function by inducing pyruvate dehydrogenase kinase (PDK), a gatekeeping enzyme for mitochon- drial glucose oxidation. Objective: To reverse mitochondrial suppression of ccRCC using the PDK inhibitor dichloroacetate (DCA). Design, setting, and participants: Radical nephrectomy specimens from patients with ccRCC were assessed for PDK expression. The 786-O ccRCC line and two animal models (chicken in ovo and murine xenografts) were used for mechanistic studies. Outcome measurements and statistical analysis: Mitochondrial function, proliferation, apoptosis, HIF transcriptional activity, angiogenesis, and tumor size were measured in vitro and in vivo. Independent-sample t-tests and analysis of variance were used for statistical analyses. Results: PDK was elevated in 786-O cells and in ccRCC compared to normal kidney tissue from the same patient. DCA reactivated mitochondrial function (increased respiration, Krebs cycle metabolites such as a-ketoglutarate [cofactor of factor inhibiting HIF], and mitochondrial reactive oxygen species), increased p53 activity and apoptosis, and decreased proliferation in 786-O cells. DCA reduced HIF transcriptional activity in an FIH-dependent manner, inhibiting angiogenesis in vitro. DCA reduced tumor size and angiogenesis in vivo in both animal models. Conclusions: DCA can reverse the mitochondrial suppression of ccRCC and decrease HIF transcriptional activity, bypassing its constitutive expression. Its previous clinical use in humans makes it an attractive candidate for translation to ccRCC patients. Patient summary: We show that an energy-boosting drug decreases tumor growth and tumor blood vessels in animals carrying human kidney cancer cells. This generic drug has been used in patients for other conditions and thus could be tested in kidney cancer that remains incurable. # 2015 Published by Elsevier B.V. on behalf of European Association of Urology. * Corresponding author. Department of Medicine, University of Alberta, Edmonton T6G 2B7, Canada. Tel. +1 780 4071576. E-mail address: em2@ualberta.ca (E. Michelakis). EURURO-6432; No. of Pages 11 Please cite this article in press as: Kinnaird A, et al. Metabolic Modulation of Clear-cell Renal Cell Carcinoma with Dichloroacetate, an Inhibitor of Pyruvate Dehydrogenase Kinase. Eur Urol (2015), http://dx.doi.org/10.1016/j.eururo.2015.09.014 http://dx.doi.org/10.1016/j.eururo.2015.09.014 0302-2838/# 2015 Published by Elsevier B.V. on behalf of European Association of Urology.