Nitric oxide deficiency in chronic kidney disease

Guanidino compound levels in blood, cerebrospinal fluid, and post-mortem brain material of patients with argininemia

The paucity of hyperammonemic crises together with spasticity, only seen in human arginase I deficient patients and not in patients with other urea cycle disorders, forces a search for candidates other than ammonia to associate with the pathophysiology and symptomatology. Therefore, we determined arginine together with some catabolites of arginine in blood and cerebrospinal fluid of these patients as well as in extremely rare post-mortem brain material of two patients with argininemia. The levels of alpha-keto-delta-guanidinovaleric acid, argininic acid and alpha-N-acetylarginine correlate with the arginine levels in blood and cerebrospinal fluid of patients with imposed or spontaneous protein restriction. The levels in blood are higher than the upper limit of normal in all studied patients. In addition to the highly increased levels of these same compounds in blood of a child with argininemia, the increase of guanidinoacetic acid, 24h before death, is remarkable. However, the manifest increases of these studied catabolites of arginine are not seen in post-mortem brain material of the same pediatric patient. Otherwise a clear increase of guanidinoacetic acid in post-mortem brain material of an adult patient was shown. A similar, comparable increase of homoarginine in both studied post-mortem brain materials is observed. Therefore the study of the pathobiochemistry of arginine in argininemia must be completed in the future by the determination of the end catabolites of the nitric oxide and agmatine biosynthesis pathways in the knockouts as well as in the patients to evaluate their role, together with the here studied catabolites, as candidates for association with pathophysiology and symptomatology.

Asymmetric dimethylarginine in angiotensin II-induced hypertension

Recent studies have shown that asymmetric dimethylarginine (ADMA), a nitric oxide synthase inhibitor, is increased in hypertension and chronic kidney disease. However, little is known about the effects of hypertension per se on ADMA metabolism. The purpose of this study was to test the hypothesis that ANG II-induced hypertension, in the absence of renal injury, is associated with increased oxidative stress and plasma and renal cortex ADMA levels in rats. Male Sprague-Dawley rats were treated with ANG II at 200 ng.kg(-1).min(-1) sc (by minipump) for 1 or 3 wk or at 400 ng.kg(-1).min(-1) for 6 wk. Mean arterial pressure was increased after 3 and 6 wk of ANG II; however, renal injury (proteinuria, glomerular sclerosis, and interstitial fibrosis) was only evident after 6 wk of treatment. Plasma thiobarbituric acid reactive substances concentration and renal cortex p22(phox) protein abundance were increased early (1 and 3 wk), but urinary excretion of isoprostane and H(2)O(2) was only increased after 6 wk of ANG II. An increased in plasma ADMA after 6 wk of ANG II was associated with increased lung protein arginine methyltransferase-1 abundance and decreased renal cortex dimethylarginine dimethylaminohydrolase activity. No changes in renal cortex ADMA were observed. ANG II hypertension in the absence of renal injury is not associated with increased ADMA; however, when the severity and duration of the treatment were increased, plasma ADMA increased. These data suggest that elevated blood pressure alone, for up to 3 wk, in the absence of renal injury does not play an important role in the regulation of ADMA. However, the presence of renal injury and sustained hypertension for 6 wk increases ADMA levels and contributes to nitric oxide deficiency and cardiovascular disease.

Exercise and possible molecular mechanisms of protection from vascular disease and diabetes: the central role of ROS and nitric oxide

It is now widely accepted that hypertension and endothelial dysfunction are associated with an insulin-resistant state and thus with the development of T2DM (Type 2 diabetes mellitus). Insulin signalling is impaired in target cells and tissues, indicating that common molecular signals are involved. The free radical NO* regulates cell metabolism, insulin signalling and secretion, vascular tone, neurotransmission and immune system function. NO* synthesis is essential for vasodilation, the maintenance of blood pressure and glucose uptake and, thus, if levels of NO* are decreased, insulin resistance and hypertension will result. Decreased blood levels of insulin, increased AngII (angiotensin II), hyperhomocysteinaemia, increased ADMA (asymmetric omega-NG,NG-dimethylarginine) and low plasma L-arginine are all conditions likely to decrease NO* production and which are associated with diabetes and cardiovascular disease. We suggest in the present article that the widely reported beneficial effects of exercise in the improvement of metabolic and cardiovascular health are mediated by enhancing the flux of muscle- and kidney-derived amino acids to pancreatic and vascular endothelial cells aiding the intracellular production of NO*, therefore resulting in normalization of insulin secretion, vascular tone and insulin sensitivity. Exercise may also have an impact on AngII and ADMA signalling and the production of pro- and anti-inflammatory cytokines in muscle, so reducing the progression and development of vascular disease and diabetes. NO* synthesis will be increased during exercise in the vascular endothelial cells so promoting blood flow. We suggest that exercise may promote improvements in health due to positive metabolic and cytokine-mediated effects.

Renal NOS activity, expression, and localization in male and female spontaneously hypertensive rats

The goal of this study was to examine the status of the renal nitric oxide (NO) system by determining NO synthase (NOS) isoform activity and expression within the three regions of the kidney in 14-wk-old male and female spontaneously hypertensive rats (SHR). NOS activity, and NOS1 and NOS3 protein expressions and localization were comparable in the renal cortex and outer medulla of male and female SHR. In contrast, male SHR had significantly less NOS1 and NOS3 enzymatic activity (0 +/- 5 and 53 +/- 7 pmol.mg(-1).30 min(-1), respectively) compared with female SHR (37 +/- 16 and 172 +/- 40 pmol.mg(-1).30 min(-1), respectively). Lower levels of inner medullary NOS1 activity in male SHR were associated with less NOS1 protein expression [45 +/- 7 relative densitometric units (RDU)] and fewer NOS1-positive cells in the renal inner medulla compared with female SHR (79 +/- 12 RDU). Phosphorylation of NOS3 is an important determinant of NOS activity. Male SHR had significantly greater phosphorylation of NOS3 on threonine 495 in the renal cortex compared with females (0.25 +/- 0.05 vs. 0.15 +/- 0.06 RDU). NOS3 phosphorylation was comparable in males and females in the other regions of the kidney. cGMP levels were measured as an indirect index of NO production. cGMP levels were significantly lower in the renal cortex (0.08 +/- 0.01 pmol/mg) and inner medulla (0.43 +/- 0.02 pmol/mg) of male SHR compared with females (cortex: 0.14 +/- 0.02 pmol/mg; inner medulla: 0.56 +/- 0.02 pmol/mg). Our data suggest that the effect of the sex of the animal on NOS activity and expression is different in the three regions of the SHR kidney and supports the hypothesis that male SHR have lower NO bioavailability compared with females.

Haemodialysis acutely reduces the plasma levels of ADMA without reversing impaired NO-dependent vasodilation

End-stage renal disease patients have endothelial dysfunction and high plasma levels of ADMA (asymmetric ω-NG,NG-dimethylarginine), an endogenous inhibitor of NOS (NO synthase). The actual link between these abnormalities is controversial. Therefore, in the present study, we investigated whether HD (haemodialysis) has an acute impact on NO-dependent vasodilation and plasma ADMA in these patients. A total of 24 patients undergoing maintenance HD (HD group) and 24 age- and gender-matched healthy controls (Control group) were enrolled. The increase in forearm SkBF (skin blood flow) caused by local heating to 41 °C (SkBF41), known to depend on endothelial NO production, was determined with laser Doppler imaging. SkBF41 was expressed as a percentage of the vasodilatory reserve obtained from the maximal SkBF induced by local heating to 43 °C (independent of NO). In HD patients, SkBF41 was assessed on two successive HD sessions, once immediately before and once immediately after HD. Plasma ADMA was assayed simultaneously with MS/MS (tandem MS). In the Control group, SkBF41 was determined twice, on two different days, and plasma ADMA was assayed once. In HD patients, SkBF41 was identical before (82.2±13.1%) and after (82.7±12.4%) HD, but was lower than in controls (day 1, 89.6±6.1; day 2, 89.2±6.9%; P<0.01 compared with the HD group). In contrast, plasma ADMA was higher before (0.98±0.17 μmol/l) than after (0.58±0.10 μmol/l; P<0.01) HD. ADMA levels after HD did not differ from those obtained in controls (0.56±0.11 μmol/l). These findings show that HD patients have impaired NO-dependent vasodilation in forearm skin, an abnormality not acutely reversed by HD and not explained by ADMA accumulation.

Cellular ADMA: regulation and action

Asymmetric (N(G),N(G)) dimethylarginine (ADMA) is present in plasma and cells. It can inhibit nitric oxide synthase (NOS) that generates nitric oxide (NO) and cationic amino acid transporters (CATs) that supply intracellular NOS with its substrate, l-arginine, from the plasma. Therefore, ADMA and its transport mechanisms are strategically placed to regulate endothelial function. This could have considerable clinical impact since endothelial dysfunction has been detected at the origin of hypertension and chronic kidney disease (CKD) in human subjects and may be a harbinger of large vessel disease and cardiovascular disease (CVD). Indeed, plasma levels of ADMA are increased in many studies of patients at risk for, or with overt CKD or CVD. However, the levels of ADMA measured in plasma of about 0.5micromol.l(-1) may be below those required to inhibit NOS whose substrate, l-arginine, is present in concentrations many fold above the Km for NOS. However, NOS activity may be partially inhibited by cellular ADMA. Therefore, the cellular production of ADMA by protein arginine methyltransferase (PRMT) and protein hydrolysis, its degradation by N(G),N(G)-dimethylarginine dimethylaminohydrolase (DDAH) and its transmembrane transport by CAT that determines intracellular levels of ADMA may also determine the state of activation of NOS. This is the focus of the review. It is concluded that cellular levels of ADMA can be 5- to 20-fold above those in plasma and in a range that could tonically inhibit NOS. The relative importance of PRMT, DDAH and CAT for determining the intracellular NOS substrate:inhibitor ratio (l-arginine:ADMA) may vary according to the pathophysiologic circumstance. An understanding of this important balance requires knowledge of these three processes that regulate the intracellular levels of ADMA and arginine.

Erythropoietin and renoprotection

In the haematopoietic system, the principal function of erythropoietin (EPO) is the regulation of RBC production. Consequently, following the cloning of the EPO gene, recombinant human EPO (rHuEPO) forms have been widely used for treatment of anaemia in chronic kidney disease and chemotherapy-induced anaemia in cancer patients. However, a steadily growing body of evidence indicates that the therapeutic benefits of rHuEPO could be far beyond the correction of anaemia. Several articles have been recently published on the tissue-protective, nonhaematological effects of rHuEPO that prevent ischaemia-induced tissue damage in several organs including the kidney.In this review, we focus on nonhaematological effects of rHuEPO in various experimental settings of acute and chronic kidney injury. Because this tissue-protective action of rHuEPO is not the result of correction of anaemia-related tissue hypoxia, we will also discuss potential molecular pathways involved. Finally, we will review the current literature on clinical studies with rHuEPO or analogous substances and progression of chronic kidney disease, and propose possible clinical renoprotective strategies.

Drug discovery for overcoming chronic kidney disease (CKD): the endothelin ET B receptor/nitric oxide system functions as a protective factor in CKD

Accelerated cardiovascular disease (CVD) is a frequent complication of renal disease. Chronic kidney disease (CKD) develops hypertension and dyslipidemia, which in turn can contribute to the progression of renal failure. There is general agreement that endothelin-1 (ET-1), which acts through the two subtypes of receptor ET(A) and ET(B), plays important physiological roles in the regulation of normal cardiovascular function and that excessive ET-1 production is linked to CVD and CKD. Although selective ET(A) or nonselective ET(A)/ET(B) receptor antagonisms have been recognized as a potential strategy for treatment of several cardiovascular disease, it remains unclear which of the antagonisms is suitable for the individuals with CKD because upregulation of the nitric oxide (NO) system via ET(B) receptor is responsible for renal function such as natriuresis, diuresis, and glomerular hemodynamics. Our findings clearly indicate that the blockade of ET receptors, in particular ET(A)-receptor antagonism, not only produces a potential renoprotective effect in CKD but also reduces the risk of CVD. In contrast, pharmacological blockade or genetic deficiency of ET(B) receptor seems to aggravate CKD and CVD in several experimental models of rats. Moreover, preliminary evidence in patients with CKD also suggests that both selective ET(A)- and nonselective ET(A)/ET(B)-receptor blockade decreases blood pressure but that selective ET(A) blockade has additional desirable effects on renal hemodynamics. Thus, at least in CKD, these findings support the notion that ET(B) receptor-mediated actions produce a renoprotective effect and that nonselective ET(A)/ET(B)-receptors blockade seem to offer no advantage over selective ET(A) antagonism, and if anything may potentially reduce the benefits.

Purification and mechanism of action of "cortexin," a novel antihypertensive protein hormone from kidney and its role in essential hypertension in men

Because kidney tissue damage is associated with both hypertension and impaired nitric oxide (NO) production, we investigated the possibility whether the kidney tissue contains any activator of endothelial NO synthase (eNOS) that could be important in essential hypertension. An activator protein of M(r) 43000 Da for eNOS from the goat kidney cortex homogenate was purified to homogeneity by chromatographic techniques. This activator trivially, called "cortexin," was determined by enzyme-linked immunosorbent assay using anticortexin antibody. NO was determined by the formation of methemoglobin. Injection of 0.5 nmol cortexin/kg body weight to rabbit pretreated with l-epinephrine that increased the systolic and diastolic pressures to 195 +/- 3.40 mm Hg and 98.14 +/- 6.64 mm Hg, respectively, reduced and kept the elevated pressures at normal ranges of 133.57 +/- 12.14 (systolic) and 51.03 +/- 3.21 (diastolic) for 45 hours with simultaneous increase of plasma NO level. The inhibition of cortexin-induced NO synthesis nullified the antihypertensive effect of cortexin. The plasma cortexin level in newly diagnosed persons with essential hypertension was 0 pmol/mL (median), which contrasted with 218.94 pmol cortexin/mL (median), in normotensive persons (P < .0005; n = 25). We concluded that the impaired production of cortexin in the cortex of kidney might lead to essential hypertension.

Asymmetric dimethylarginine: a novel marker of risk and a potential target for therapy in chronic kidney disease

PURPOSE OF REVIEW

Asymmetric dimethylarginine (ADMA) is a naturally occurring amino acid that reduces the bioavailability of nitric oxide. ADMA opposes important antiatherosclerotic effects of nitric oxide. ADMA not only correlates with traditional and nontraditional risk factors but is also considered a common pathway mediating the adverse vascular effects of traditional and nontraditional risk factors. Over the past 15 years, ADMA has generated increasing interest from both clinical scientist and basic researchers. The present study summarizes the latest developments in the field.

RECENT FINDINGS

Modulating (increasing) activity of dimethylamine dimethylaminohydrolase, the main enzyme metabolizing ADMA, emerges as a possible therapeutic option to lower ADMA and favorably influence organ dysfunction. These preclinical findings are thought to be of major importance as ADMA predicts cardiovascular events and mortality in the general population and in patients with chronic kidney disease. Also, ADMA uniformly predicts the progression of moderate and severe chronic kidney disease. Symmetrical dimethylarginine, the structural isomer of ADMA, which was mistakenly thought to be without biological relevance, indicates the degree of renal impairment.

SUMMARY

ADMA also beautifully explains many facets of the pathophysiology of chronic kidney disease. Future preclinical and especially clinical studies are required to prove the importance of ADMA in renal and cardiovascular disease.

Splice variants of neuronal nitric oxide synthase are present in the rat kidney

BACKGROUND

Decreased renal cortical neuronal NO synthase (nNOS) abundance/activity correlates with progression of chronic kidney disease (CKD) in a number of animal models.

METHODS

Western blotting with both N-terminal and C-terminal antibodies, immunoprecipitation, proteomics, RT-PCR and in situ hybridization were used to identify nNOS splice variants in the rat kidney.

RESULTS

We have identified two nNOS proteins and transcripts in the rat kidney; nNOSalpha (approximately 160 kDa) and nNOSbeta (approximately 140 kDa), a catalytically active exon-2 deletion variant, lacking both the PDZ and protein inhibitor of nNOS (PIN) domains. We also report that nNOSbeta protein abundance is increased in the kidney at 11 weeks following 5/6th nephrectomy (5/6NX)-induced CKD while nNOSalpha protein abundance is diminished. The transcript data parallel the protein data in 5/6NX. By in situ hybridization, there is abundant nNOSalpha mRNA widely distributed throughout the normal kidney cortex, with very sparse nNOSbeta mRNA confined to a few proximal tubules. In a second injury model (6 weeks after 5/6 renal mass reduction by combined right kidney ablation and infarction of approximately 2/3 of the left kidney; 5/6 A/I), nNOSalpha mRNA almost disappears from the kidney cortex while nNOSbeta mRNA abundance increases in tubules and tubulo-interstitium.

CONCLUSION

The renal cortical nNOSbeta protein is present in low abundance in the normal kidney and increases with injury, in an inverse pattern of change with the nNOSalpha.

Arginine metabolism and nutrition in growth, health and disease

L-Arginine (Arg) is synthesised from glutamine, glutamate, and proline via the intestinal-renal axis in humans and most other mammals (including pigs, sheep and rats). Arg degradation occurs via multiple pathways that are initiated by arginase, nitric-oxide synthase, Arg:glycine amidinotransferase, and Arg decarboxylase. These pathways produce nitric oxide, polyamines, proline, glutamate, creatine, and agmatine with each having enormous biological importance. Arg is also required for the detoxification of ammonia, which is an extremely toxic substance for the central nervous system. There is compelling evidence that Arg regulates interorgan metabolism of energy substrates and the function of multiple organs. The results of both experimental and clinical studies indicate that Arg is a nutritionally essential amino acid (AA) for spermatogenesis, embryonic survival, fetal and neonatal growth, as well as maintenance of vascular tone and hemodynamics. Moreover, a growing body of evidence clearly indicates that dietary supplementation or intravenous administration of Arg is beneficial in improving reproductive, cardiovascular, pulmonary, renal, gastrointestinal, liver and immune functions, as well as facilitating wound healing, enhancing insulin sensitivity, and maintaining tissue integrity. Additionally, Arg or L-citrulline may provide novel and effective therapies for obesity, diabetes, and the metabolic syndrome. The effect of Arg in treating many developmental and health problems is unique among AAs, and offers great promise for improved health and wellbeing of humans and animals.

Breath analysis in patients with end-stage renal disease: effect of haemodialysis

BACKGROUND

There is no agreement about exhaled nitric oxide (FE(NO)) and its change after haemodialysis (HD) in end-stage renal disease (ESRD) patients. To comprehensively assess NO production in the respiratory system, NO metabolites in exhaled breath condensate (EBC) needs to be measured in addition to FE(NO), taking into account the influence on these markers of airway pH, which may be regulated by ammonia (NH3+), present in large amounts in the breath of ESRD patients and removed by HD.

STUDY DESIGN

FE(NO) and NO metabolites (NOx, NO2-,NO3- ), pH and NH3+ in EBC were measured in 12 ESRD patients, before and after HD. Twelve healthy subjects acted as controls.

RESULTS

FE(NO )values of ESRD patients were similar to normals, while EBC-NOx, NO2-, NH3+ and pH were significantly higher in ESRD patients compared to normals (EBC-NOx 12.3, range 11.1-41.9 microm vs. 9.4, range 4.6-10.9 microm, P = 0.007; NO2- 4.70, range 1.17-8.22 microm vs. 0.90, range 0.72-1.17 microm, P = 0.023; NH3+ 2340, range 1325-3922 microm vs. 660, range 406-872 microm, P < 0.001; pH 7.16, range 6.82-7.44 vs. 6.60, range 6.42-6.76, P = 0.004, respectively). HD caused a mild significant decrease of FE(NO), and normalization of NH3+, NOx, NO2- and pH. A significant positive relationship between EBC-pH and EBC-NH3+ before and after HD (r(2) = 0.65, P = 0.000) was observed, explaining higher than normal EBC-pH before HD, while no relationship was found between EBC-pH and FE(NO) or NO metabolites.

CONCLUSION

Oxidative stress, and not EBC-pH, is the most probable cause of increased NO metabolites in ESRD patients before HD.

Regulation of oxygen utilization by angiotensin II in chronic kidney disease

Angiotensin II blockade delays progression of chronic kidney disease by modifying intrarenal hemodynamics, but the effects on metabolic adaptations are unknown. Using the remnant kidney model of chronic kidney disease in rats, we measured the effects of combined angiotensin II blockade with captopril and losartan on renal oxygen consumption (QO(2)) and factors influencing QO(2). Remnant kidneys had proteinuria and reductions in the glomerular filtration rate (GFR), renal blood flow (RBF) and nitric oxide synthase-1 protein expression while QO(2), factored by sodium reabsorption (QO(2)/TNa), was markedly increased. Combined blockade treatment normalized these parameters while increasing sodium reabsorption but, since QO(2) was unchanged, QO(2)/TNa also normalized. Triple antihypertensive therapy, to control blood pressure, and treatment with lysine, to increase GFR and RBF, did not normalize QO(2)/TNa, suggesting a specific effect of angiotensin II in elevating QO(2)/TNa. Inhibition of nitric oxide synthase increased QO(2) in the kidney of sham-operated rats but not in the remnant kidney of untreated rats. Our study shows that combined captopril and losartan treatment normalized QO(2)/TNa and functional nitric oxide activity in the remnant kidney independent of blood pressure and GFR effects, suggesting that other mechanisms in addition to hemodynamics underlie the benefits of angiotensin II blockade.

Renoprotective mechanisms of soy protein intake in the obese Zucker rat

We previously showed that long-term consumption of a soy protein diet (SoyP) reduces renal damage in obese Zucker (ObeseZ) rats by restoring urinary NO2 and NO3 excretion (UNO2/NO3V), suggesting that nitric oxide (NO) deficiency may contribute to the renal progression observed in this model. In addition, there is compelling evidence that hyperleptinemia produced deleterious effects on the kidney through its interaction with the short leptin receptor (ObRa). This study was designed to evaluate the contribution of the NO/endothelial NO synthase (eNOS) system, renal oxidative stress, and ObRa expression to the renoprotection conferred by the consumption of a SoyP in ObeseZ rats. Ten lean and ten male ObeseZ rats were included. One-half of each group was fed with a 20% SoyP and the other half with a 20% casein protein diet (CasP) over the course of 160 days. eNOS protein levels and phosphorylation, renal lipoperoxidation (rLPO), and antioxidant enzyme activity were assessed. In addition, renal ObRa, TGF-beta, and kidney injury molecule (Kim-1) mRNA levels, as well as urinary Kim-1 levels, were measured. Renal injury observed in ObeseZ rats fed with CasP was not associated with changes in eNOS expression or phosphorylation. However, this group did present with increased rLPO, reduced catalase activity, and upregulation of ObRa, TGF-beta1, and Kim-1. In contrast, ObeseZ rats fed with a SoyP exhibited a reduction in NOS-Thr495 phosphorylation and rLPO, as well as an enhanced catalase activity. These findings were associated with a significant reduction of ObRa, TGF-beta1, and Kim-1 mRNA levels and urinary Kim-1 protein. Our results show that renoprotection by SoyP in ObeseZ rats is in part mediated by increased NO availability secondary to a reduction in eNOS-T495 phosphorylation and oxidative stress, together with a significant reduction in ObRa and TGF-beta expression.

Ischemic injury underlies the pathogenesis of aristolochic acid-induced acute kidney injury

Aristolochic acid nephropathy (AAN) is a progressive tubulointerstitial renal disease caused by aristolochic acid intake. To determine the contribution of renal ischemia to the pathogenesis of AAN, we characterized changes in the expression of angiogenic factors and vasoactive substances, and then we evaluated the expression of a marker of hypoxia in an acute AAN rat model. Rats were orally administrated either a decoction of Aristolochiae manshuriensis that contained 20 mg/kg of aristolochic acid-I or an equal volume of distilled water (control group) once daily for 4 days or 7 days. Renal histology and serum creatinine were assessed. Expression of endothelin-1 (ET-1) and hypoxia inducible factor-1 alpha (HIF-1alpha) mRNA within renal cortex were determined by semiquantitative reverse-transcription polymerase chain reaction. Levels of ET-1, nitric oxide (NO), vascular endothelial growth factor (VEGF), and HIF-1alpha in kidneys were determined by radioimmunoassay, Griess method, Western blot, and immunohistochemistry, respectively. Tubular injury scores and ET-1 mRNA expression were increased in the AA-treated rats at both days 4 and 8, whereas serum creatinine level and ET-1 protein expression was increased only at day 4. In contrast, NO production in AA-treated rats was decreased at day 8 compared with the control group. Similarly, VEGF protein expression was reduced in the AA-treated rats at both days 4 and 8. A dramatic increase in nuclear staining for HIF-1alpha was observed mainly in the tubular cells of tubulointerstitial damage area in the AA-treated rats at day 8. The observed increase in HIF-1alpha protein expression, decrease in VEGF protein expression, and imbalance of vasoactive substances after induction of acute kidney injury by AA suggests that ischemic injury contributes to the pathogenesis of AAN.