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Chawla LS, Kimmel PL. Acute kidney injury and chronic kidney disease: an integrated clinical syndrome. Kidney Int 2012; 82:516-24. [PMID: 22673882 DOI: 10.1038/ki.2012.208] [Citation(s) in RCA: 558] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The previous conventional wisdom that survivors of acute kidney injury (AKI) tend to do well and fully recover renal function appears to be flawed. AKI can cause end-stage renal disease (ESRD) directly, and increase the risk of developing incident chronic kidney disease (CKD) and worsening of underlying CKD. In addition, severity, duration, and frequency of AKI appear to be important predictors of poor patient outcomes. CKD is an important risk factor for the development and ascertainment of AKI. Experimental data support the clinical observations and the bidirectional nature of the relationships between AKI and CKD. Reductions in renal mass and nephron number, vascular insufficiency, cell cycle disruption, and maladaptive repair mechanisms appear to be important modulators of progression in patients with and without coexistent CKD. Distinction between AKI and CKD may be artificial. Consideration should be given to the integrated clinical syndrome of diminished GFR, with acute and chronic stages, where spectrum of disease state and outcome is determined by host factors, including the balance of adaptive and maladaptive repair mechanisms over time. Physicians must provide long-term follow-up to patients with first episodes of AKI, even if they presented with normal renal function.
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Affiliation(s)
- Lakhmir S Chawla
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC, USA
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Prunotto M, Gabbiani G, Pomposiello S, Ghiggeri G, Moll S. The kidney as a target organ in pharmaceutical research. Drug Discov Today 2011; 16:244-59. [DOI: 10.1016/j.drudis.2010.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 11/11/2010] [Accepted: 11/24/2010] [Indexed: 02/07/2023]
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Venkatachalam MA, Griffin KA, Lan R, Geng H, Saikumar P, Bidani AK. Acute kidney injury: a springboard for progression in chronic kidney disease. Am J Physiol Renal Physiol 2010; 298:F1078-94. [PMID: 20200097 DOI: 10.1152/ajprenal.00017.2010] [Citation(s) in RCA: 387] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Recently published epidemiological and outcome analysis studies have brought to our attention the important role played by acute kidney injury (AKI) in the progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD). AKI accelerates progression in patients with CKD; conversely, CKD predisposes patients to AKI. This research gives credence to older, well-thought-out wisdom that recovery from AKI is often not complete and is marked by residual structural damage. It also mirrors older experimental observations showing that unilateral nephrectomy, a surrogate for loss of nephrons by disease, compromises structural recovery and worsens tubulointerstitial fibrosis after ischemic AKI. Moreover, review of a substantial body of work on the relationships among reduced renal mass, hypertension, and pathology associated with these conditions suggests that impaired myogenic autoregulation of blood flow in the setting of hypertension, the arteriolosclerosis that results, and associated recurrent ischemic AKI in microscopic foci play important roles in the development of progressively increasing tubulointerstitial fibrosis. How nutrition, an additional factor that profoundly affects renal disease progression, influences these events needs reevaluation in light of information on the effects of calories vs. protein and animal vs. vegetable protein on injury and progression. Considerations based on published and emerging data suggest that a pathology that develops in regenerating tubules after AKI characterized by failure of differentiation and persistently high signaling activity is the proximate cause that drives downstream events in the interstitium: inflammation, capillary rarefaction, and fibroblast proliferation. In light of this information, we advance a comprehensive hypothesis regarding the pathophysiology of AKI as it relates to the progression of kidney disease. We discuss the implications of this pathophysiology for developing efficient therapeutic strategies to delay progression and avert ESRD.
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Affiliation(s)
- Manjeri A Venkatachalam
- Dept. of Pathology, Univ. of Texas Health Science Center, 7703 Floyd Curl Dr., San Antonio, TX 78229, USA.
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Abstract
Animal models of renal disease have provided valuable insights into the pathogenesis of acute and chronic kidney disease. Extension of these models to the mouse has become an increasingly important with the development of gene knockout and transgenic animals. In this review we discuss a range of models that can be used to mimic the mechanisms of human renal disease. While not perfect, the careful and ethical use of these models offers the opportunity to examine individual mechanisms in an accelerated time frame.
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Affiliation(s)
- Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Grenz A, Baier D, Petroktistis F, Wehrmann M, Köhle C, Schenk M, Sessler M, Gleiter CH, Fandrich F, Osswald H. Theophylline Improves Early Allograft Function in Rat Kidney Transplantation. J Pharmacol Exp Ther 2006; 317:473-9. [PMID: 16410406 DOI: 10.1124/jpet.105.096917] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Several previous studies have demonstrated a beneficial effect of the adenosine receptor (AdoR) antagonist theophylline in different forms of acute renal failure in laboratory animals and in humans. Therefore, we wanted to test whether theophylline can also improve impaired allograft function following ischemia reperfusion injury in experimental kidney transplantation (KT). Orthotopic transplantation of the left kidney was performed from Fisher 344 into Lewis rats. All transplanted rats received daily cyclosporine (5 mg/kg). The effect of theophylline treatment (10 mg/kg) on graft function was compared with appropriate controls on day 5 after KT by assessment of glomerular filtration rate (GFR) (inulin clearance). On day 5, GFR of allografts in control rats was 0.23 +/- 0.05 ml/min/g kidney weight (n = 10) compared with 0.50 +/- 0.09 ml/min/g in rats receiving theophylline (n = 9, p < 0.01), representing a 2-fold increase in GFR. Renal AdoR A(1) mRNA content was significantly increased in both KT groups compared with their respective control groups, whereas mRNA of AdoR A(2a), A(2b), and A(3) were found to be unchanged. Theophylline did not affect significantly interstitial infiltration of the graft by monocytes/macrophages and T-cells. Likewise, serum cytokines [interleukin (IL)-2, IL-6, IL-10, tumor necrosis factor-alpha] and erythropoietin plasma levels were not different among the allograft groups. The present study demonstrates that theophylline remarkably improved early renal allograft function in rats undergoing KT without influencing cytokine serum patterns or tissue inflammation. Since theophylline is a commonly used medication in humans, clinical studies in patients undergoing KT are warranted.
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Affiliation(s)
- Almut Grenz
- Institute of Pharmacology and Toxicology, Wilhelmstrasse 56, D-72074 Tuebingen, Germany
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Bolad IA, Robinson DR, Webb C, Hamour I, Burke MM, Banner NR. Impaired left ventricular systolic function early after heart transplantation is associated with cardiac allograft vasculopathy. Am J Transplant 2006; 6:161-8. [PMID: 16433770 DOI: 10.1111/j.1600-6143.2005.01138.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiac allograft vasculopathy (CAV) is a major cause of death more than 1 year after heart transplantation. We evaluated the role and possible predictive value of different etiological factors on development of CAV as diagnosed by quantitative coronary angiography (QCA). A total of 121 patients were studied with baseline QCA and 117 had a follow-up study at 1 year to assess the relationship of mean lumen diameter loss (MLDL) in main coronary arteries to immunological and non-immunological factors potentially affecting long-term survival. Out of them, 103 patients were males (85%), 114 (94%) patients were Caucasians and mean age was 48.5 +/- 10 years. Univariate analysis showed that MLDL at 1 year was inversely related to echocardiographic fractional shortening (FS) measured within the first week after transplantation (p = 0.0098) and to intracranial hemorrhage as cause of donor death (p = 0.04) and was directly related to male donors (p = 0.0008), domino transplants (p = 0.037) and donor negative cytomegalovirus (CMV) status (p = 0.022). Multivariate analysis showed that initial FS (p = 0.006) and donor intracranial hemorrhage as a cause of death (p = 0.042) were inversely related to MLDL whereas donor male sex (p = 0.003) and prednisolone treatment throughout the first year (p = 0.012) were directly related. Thus, left ventricular systolic dysfunction early after heart transplantation was associated with subsequent development of CAV.
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Affiliation(s)
- I A Bolad
- Transplant Unit, Harefield Hospital, Royal Brompton and Harefield NHS Trust, Hill End Road, Harefield, Middlesex UB9 6JH, UK
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Ahmed A, El Kossi M, Karim M, Raftery A, El Nahas AM, Haylor J. Extracellular matrix changes following renal warm ischemic injury in rats. Transplant Proc 2003; 35:101-2. [PMID: 12591325 DOI: 10.1016/s0041-1345(02)03964-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A Ahmed
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK
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He H, Stone JR, Perkins DL. Analysis of robust innate immune response after transplantation in the absence of adaptive immunity. Transplantation 2002; 73:853-61. [PMID: 11923683 DOI: 10.1097/00007890-200203270-00005] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Both animal models and clinical outcomes studies of transplantation suggest that antigen-independent mechanisms can alter graft survival and function. It has been suggested that antigen-independent processes interact with alloantigen-specific responses to augment the rejection reaction. A major link between antigen-specific adaptive immunity and pro-inflammatory stimuli is innate immunity. During transplantation, innate immunity may be stimulated by multiple factors, including ischemia, reperfusion, sterile injury, systemic stress, and cell death. METHODS We investigated the hypothesis that transplantation induces a potent innate immune response in a murine model of vascularized solid organ transplantation. In our studies, we analyzed three experimental groups: (a) alymphoid group in which both the donor and recipients strains lacked an adaptive immune response due to deletion of the recombinase activating gene, thus blocking production of both T cell and B cell antigen receptors; (b) syngeneic group in which the donors and recipients were genetically identical; and (c) allogeneic group in which the donors and recipients had a complete MHC mismatch. To analyze a large number of parameters we determined the level of expression of a panel of cytokines, chemokines, receptors, and cell surface markers by RNase protection assays. In addition, serum cytokines were determined by ELISA and the infiltration of inflammatory cells was assessed by histology. RESULTS Our results showed macrophage infiltration and up-regulation of multiple cytokines, chemokines, and chemokine receptors within the first day after transplantation in all groups, including the syngeneic and alymphoid recipients. CONCLUSIONS Our study demonstrated a robust innate immune response that is independent of adaptive immunity and natural killer cell responses.
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MESH Headings
- Animals
- Chemokines/immunology
- Cytokines/genetics
- Cytokines/immunology
- Gene Deletion
- Gene Expression Regulation/immunology
- Heart Transplantation/immunology
- Histocompatibility Testing
- Interleukin-1/blood
- Interleukin-6/immunology
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, Inbred Strains
- Models, Animal
- Receptors, Antigen, B-Cell/immunology
- Receptors, Antigen, T-Cell/immunology
- Receptors, Chemokine/immunology
- Ribonucleases
- Transplantation, Homologous
- Transplantation, Isogeneic
- Tumor Necrosis Factor-alpha/analysis
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Affiliation(s)
- Hongzhen He
- Laboratory of Molecular Immunology, Renal Division, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Weight SC, Waller JR, Bradley V, Whiting PH, Nicholson ML. Interaction of eicosanoids and nitric oxide in renal reperfusion injury. Transplantation 2001; 72:614-9. [PMID: 11544419 DOI: 10.1097/00007890-200108270-00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Both the eicosanoids and nitric oxide are known to play an important role in the pathogenesis of postischemic injury. Recent evidence has suggested that the generation of each may affect the other via a feedback loop. This was investigated in an experimental model of renal warm ischemia reperfusion injury. METHODS Rats underwent bilateral renal warm ischemia (15-60 min) then reperfusion (20 or 80 min) followed by a unilateral nephrectomy to measure renal nitric oxide (as nitroxides) and eicosanoids. Renal function was measured on days 2 and 7 prior to terminal nephrectomy for tissue analysis. RESULTS Vasodilator eicosanoids (6-KPGF1alpha and PGE2) fell on reperfusion in line with the duration of warm ischemia with a concomitant rise in the vasoconstrictor TxA2. The ratio of vasodilator to vasoconstrictor eicosanoids fell from 8.22 (2.3) in the control to 0.82 (0.1) in the 60-min warm ischemia group (P<0.01). Renal levels of nitroxides rose on reperfusion demonstrating an inverse correlation with the eicosanoid ratio (r2=0.86). Renal function was impaired at both day 2 and day 7 and showed a positive correlation with the eicosanoid ratio (r2=0.67 and 0.62, respectively). CONCLUSIONS Renal warm ischemic injury is associated with a progressive fall in the ratio of vasodilator-to-vasoconstrictor eicosanoids from early in reperfusion through to day seven although nitric oxide was elevated throughout the same period. There was no evidence of coinduction of nitric oxide synthase and cyclooxygenase in this model.
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Affiliation(s)
- S C Weight
- University Department of Surgery, Leicester General Hospital, UK
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Forbes JM, Hewitson TD, Becker GJ, Jones CL. Simultaneous blockade of endothelin A and B receptors in ischemic acute renal failure is detrimental to long-term kidney function. Kidney Int 2001; 59:1333-41. [PMID: 11260394 DOI: 10.1046/j.1523-1755.2001.0590041333.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is growing evidence of long-term pathological consequences following renal ischemia. Endothelin (ET) receptor antagonists have proved beneficial in the treatment of ischemic acute renal failure (IARF); however, the long-term outcomes have not been assessed in this disease. METHODS Experimental IARF was induced in uninephrectomized female Sprague-Dawley rats (N = 8) by clamping of the renal pedicle. At 24-hours postischemia, a once-only administration of drug or vehicle was given. One ischemic group received saline only (saline ischemic), and two other ischemic groups received either SB 234551 (ETA receptor antagonist, ETA group) or SB 209670 (ETA and ETB receptor antagonist, ETA/ETB group). A uninephrectomized control group was sham operated to simulate operative conditions without ischemia and was given a once-only saline infusion (sham ischemic). All groups were sacrificed at six-months postischemia. Serum creatinine was assessed daily for one week and then every four weeks. Glomerular filtration rates (GFRs), systolic blood pressure, 24-hour urine collection, and creatinine clearance were performed just prior to sacrifice. Immunohistochemistry for monocytes and macrophages (Mo and Mphi), myofibroblasts (MF, alpha-SMA), collagen IV, and collagen III was also evaluated. Cell kinetics were studied by immunostaining for proliferating cell nuclear antigen (PCNA) and by TUNEL. RESULTS Urinalysis revealed significant increases in urinary protein and albumin in the ETA/ETB group when compared with all other groups. GFRs and creatinine clearance were also decreased significantly in the ETA/ETB group. Urine albumin, protein, GFR, and creatinine clearance in the ETA group, however, were not different from the sham ischemic and saline ischemic groups. Systolic blood pressure was increased in the saline ischemic group as compared with all other groups. Kidney weights were increased in all ischemic groups, but no differences were observed between the saline ischemic group and ETR antagonist-treated groups. Immunohistochemistry revealed relationships between Mo and Mphi, MF, and tubulointerstitial collagen III, where the saline ischemic and ETA/ETB groups were increased as compared with the sham ischemic and ETA groups. There was no change observed in tubulointerstitial collagen IV accumulation. The largest number of proliferating cells was demonstrated in the ETA/ETB group, whereas apoptotic cells were identified in small amounts in all groups, with the largest number being found in the saline ischemic group. CONCLUSIONS Renal ischemia appears to have long-term functional and pathological consequences that can be prevented by treatment with ETA receptor antagonists. Blockade of both ETA and ETB receptors, however, appears to be detrimental to long-term kidney function.
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Affiliation(s)
- J M Forbes
- Victorian Paediatric Renal Service, Department of Nephrology, Royal Children's Hospital, Parkville, Victoria, Australia
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Forbes JM, Hewitson TD, Becker GJ, Jones CL. Ischemic acute renal failure: long-term histology of cell and matrix changes in the rat. Kidney Int 2000; 57:2375-85. [PMID: 10844607 DOI: 10.1046/j.1523-1755.2000.00097.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The cellular infiltration and matrix accumulation accompanying acute renal ischemia and reperfusion have been frequently noted but poorly defined. The long-term consequences of ischemia may irreversibly damage the kidney. METHODS Female Sprague-Dawley rats (200 g) underwent unilateral nephrectomy. After five days, the left renal pedicle was occluded for 45 minutes. Animals were sacrificed at 0, 1, 2, 4, 8, 16, 32, 64, and 180 days postischemia (N = 6). Immunohistochemistry for monocytes/macrophages (Mo/Mphi, ED-1), myofibroblasts [alpha-smooth muscle actin (alpha-SMA)], collagen III and IV, matrix metalloproteinase-2 (MMP-2) and proliferating cell nuclear antigen (PCNA) and terminal dUTP nick end labeling (TUNEL) were performed. RESULTS Kidney weights of postischemic animals were increased at all time points (postischemic to controls, 1.47 +/- 0.21 to 0.94 +/- 0.12 g at day 8; 1.49 +/- 0.20 to 1.27 +/- 0.13 g at day 64; and 1.86 +/- 0.1 to 1. 24 +/- 0.2 g at day 180). Serum creatinine values increased to 0.42 +/- 0.10 mmol/L at day 2 but returned to control levels by day 8 (0. 05 mmol/L). Glomerular collagen IV was decreased from 2 to 16 days postischemia, which was accompanied by an increase in MMP-2. The fractional area of the interstitium was greatest at day 8 (19.55 +/- 0.91% compared with day 0 at 8.08 +/- 0.27%), with a second increase observed at day 180 (16.61 +/- 0.70%). Interstitial Mo/Mphi increased postischemia from days 2 through 8 (8.84 +/- 2.12 to 133. 32 +/- 14.04 per 0.91 mm2) and then decreased. Myofibroblasts proliferated locally (PCNA double labeling was demonstrated), and increased numbers were found from days 2 through 16 (maximal at day 8, 26.96 +/- 3.04%, compared with day 0, 0.88 +/- 0.11%). In the postischemic groups, collagen IV increased to day 8 (20.84 +/- 1. 30%), but then decreased to below control values at day 64 (2.22 +/- 0.15%) before returning to normal by day 180. Interstitial collagen III increased to 8 days (0.45 +/- 0.07% to 2.55 +/- 0.36%) and then decreased to control levels by day 32, but showed a marked increase to approximately 6% at days 64 and 180. Cellular proliferation (PCNA) was maximal at days 2 and 4 (affecting tubule cells and myofibroblasts but not macrophages). Apoptosis was maximal at day 8 (in both interstitial and tubule cells) in the postischemic groups. CONCLUSION Marked changes in the accumulation of Mo/Mphi, MF, and collagen IV were found in this model of ischemic acute renal failure. The reversibility of functional and structural changes is in marked contrast to that found in progressive disease. The increases observed for collagen III at 64 and 180 days postischemia suggest that in the long term, however, further chronic structural changes may be observed.
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Affiliation(s)
- J M Forbes
- Victorian Paediatric Renal Service, Royal Children's Hospital, and Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Vos IH, Govers R, Gröne HJ, Kleij L, Schurink M, De Weger RA, Goldschmeding R, Rabelink TJ. NFkappaB decoy oligodeoxynucleotides reduce monocyte infiltration in renal allografts. FASEB J 2000; 14:815-22. [PMID: 10744638 DOI: 10.1096/fasebj.14.5.815] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Monocyte influx secondary to ischemia-reperfusion conditions the renal allograft to rejection by presentation of antigens and production of cytokines. Monocyte influx depends on NFkappaB-dependent transcription of genes encoding adhesion molecules and chemokines. Here we demonstrate that cationic liposomes containing phosphorothioated oligodeoxynucleotides (ODN) with the kappaB binding site serving as competitive binding decoy, can prevent TNF-alpha-induced NFkappaB activity in endothelial cells in vitro. In an allogenic rat kidney transplantation model (BN to LEW), we show that perfusing the renal allograft with this decoy prior to transplantation abolishes nuclear NFkappaB activity in vivo and inhibits VCAM-1 expression in the donor endothelium (P<0.05). At 24 h postreperfusion, periarterial infiltration of monocytes/macrophages was significantly reduced in decoy ODN-treated allografts compared to control allografts (3.7+/-0.7 vs. 9.2+/-1.2 macrophages/vessel; P<0.01). At 72 h, there was a reduction of tubulointerstitial macrophage infiltration in decoy ODN-treated kidneys compared to controls (75.6+/-13.9 vs. 120.0+/-11.2 macrophages/tubulointerstitial area; P<0.05). In conclusion, perfusion of the renal allograft with NFkappaB decoy ODN prior to transplantation decreases the initial inflammatory response in a stringent, nonimmunosuppressed allogenic transplantation model. Therefore, the NFkappaB decoy approach may be useful to explore the role of endothelium and macrophages in graft rejection and may be developed into a graft-specific immunosuppressive strategy allowing reduction of systemic immunosuppression on organ transplantation.
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Affiliation(s)
- I H Vos
- Departments of Nephrology and Hypertension, University Medical Center, Utrecht, The Netherlands
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Cook NS, Zerwes HG, Rudin M, Beckmann N, Schuurman HJ. Chronic graft loss: dealing with the vascular alterations in solid organ transplantation. Transplant Proc 1998; 30:2413-8. [PMID: 9723522 DOI: 10.1016/s0041-1345(98)00703-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- N S Cook
- Research Department, Novartis Pharma AG, Basel, Switzerland
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