# Spatial Distribution of K13-Positive Airway Epithelial Cells in Idiopathic Pulmonary Fibrosis

## TL;DR

This study shows that K13+ cells in the lungs of IPF patients become active and contribute to disease progression by changing the airway structure and signaling with other cells.

## Contribution

The study identifies K13+ cell activation as a key driver of airway proximalization and fibrosis in IPF.

## Key findings

- K13+ cells in IPF lungs show a proximal-like pseudostratified phenotype with overlapping expression of K5, CC10, ACE-TUB, and MUC5AC.
- K13+ subclusters are associated with profibrotic markers and signaling pathways like TGF-β and SEMA3.
- K13+ cell activation is linked to epithelial-mesenchymal crosstalk and airway remodeling in IPF.

## Abstract

Background: The progression of idiopathic pulmonary fibrosis (IPF) involves distal airway remodeling and bronchiolization; however, the mechanisms driving these changes, particularly the contributions of epithelial stem cells, are not fully understood. K13+ hillock cells, normally quiescent in proximal airways, were examined for their potential contribution to IPF pathogenesis. Methods: Spatial immunofluorescence was used to profile K13 expression along the airway axes in IPF and control lungs. Multiplex staining complemented by ex vivo culture assays was used to test expression stability. Single-cell RNA-sequencing (scRNA-seq) data were re-analyzed to identify cell subclusters and pathway enrichments. Meanwhile, cell–cell communication was inferred by using CellChat. Results: K13 was ectopically upregulated in IPF honeycomb cysts, triggering a proximal-like pseudostratified phenotype. This shift was marked by surges in K13+ regionally overlapping expression patterns (K5+, ~9%; CC10+, ~53%; ACE-TUB+, ~44%; MUC5AC+, ~23%) and a decline in SOX2 expression (~95% to ~64%), with ~70% of residual SOX2low cells exhibiting elevated K13. Accompanying the expansion of K13+ subclusters (basal: 1.8% to 41.5%; club: 10.7% to 31.5%), it was observed that the profibrotic markers (K17, S100A2, LGALS7, IGFBP6) and ontologies related to RNA processing, stress response, and senescence were also enriched. These subclusters also amplified pro-fibrotic signaling (e.g., TGF-β, SEMA3, and GALECTIN-9) associated with epithelial subtypes and HAS1high fibroblasts. Conclusions: Here, we demonstrate that K13+ cell activation is a pivotal event, driving the dysregulated proximalization of distal airways in IPF through fate reprogramming and epithelial-mesenchymal crosstalk. Thus, elucidating these K13-mediated fate dynamics provides a critical framework for understanding IPF pathogenesis.