Diabetic kidney disease (DKD) is a heritable but poorly understood complication of diabetes. To identify genetic variants predisposing to DKD, we performed genome-wide association analyses in 19,406 individuals with type 1 diabetes (T1D) using a spectrum of DKD definitions based on albuminuria and renal function. We identified 16 genome-wide significant loci. The variant with the strongest association (rs55703767) is a common missense mutation in the collagen type IV alpha 3 chain (COL4A3) gene, which encodes a major structural component of the glomerular basement membrane (GBM) implicated in heritable nephropathies. The rs55703767 minor allele (Asp326Tyr) is protective against several definitions of DKD, including albuminuria and end-stage renal disease. Three other loci are in or near genes with known or suggestive involvement in DKD (BMP7) or renal biology (COLEC11 and DDR1). The 16 DKD-associated loci provide novel insights into the pathogenesis of DKD, identifying potential biological targets for prevention and treatment.The devastating diabetic complication of DKD is the major cause of end-stage renal disease (ESRD) worldwide 1,2 . Current treatment strategies at best slow the progression of DKD, and do not halt or reverse the disease. Although improved glycemic control influences the rate of diabetic complications, a large portion of the variation in DKD susceptibility remains unexplained: one third of people with T1D develop DKD despite adequate glycemic control, while others maintain normal renal function despite long-term severe chronic hyperglycemia 3 .Though DKD demonstrates both familial clustering 4-6 and single nucleotide polymorphism (SNP) heritability 7 , the specific genetic factors influencing DKD risk remain largely unknown. Recent genome-wide association studies (GWAS) have only identified a handful of loci for DKD, albuminuria, or estimated glomerular filtration rate (eGFR) in individuals with diabetes 7-13 .Potential reasons for the limited success include small sample sizes, modest genetic effects, and lack of consistency of phenotype definitions and statistical analyses across studies.Through collaboration within the JDRF Diabetes Nephropathy Collaborative Research Initiative (DNCRI), we adopted three approaches to improve our ability to find new genetic risk factors for DKD: 1) assembling a large collection of T1D cohorts with harmonized DKD phenotypes, 2) creating a comprehensive set of detailed DKD definitions, and 3) augmenting genotype data with low frequency and exome array variants.
RESULTS
Phenotypic comparisonsWe investigated a broad spectrum of DKD definitions based on albuminuria and renal function criteria, defining a total of 10 different case-control comparisons to cover the different aspects of disease progression (Figure 1). Seven comparisons were based on albuminuria and/or ESRD (including diabetic nephropathy [DN], defined as either macroalbuminuria or ESRD); two were defined based on eGFR (used to classify severity of chronic kidney disease [CKD]); and one combined both...