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      Acute-on-Chronic Renal Failure in the Rat: Functional Compensation and Hypoxia Tolerance

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          Background: We hypothesized that chronic renal parenchymal disease may predispose to acute renal failure (ARF), facilitating the induction of hypoxic medullary tubular injury. Methods: To induce chronic renal parenchymal injury, rats underwent sham operation (control) or bilateral 50-min clamping of the renal artery [ischemia-reperfusion (IR)]. One or 3 months later, both groups were subjected to an ARF protocol, consisting of radiocontrast and the inhibition of prostaglandin and nitric oxide synthesis. Renal function and morphology were determined 24 h later. Results: Chronic tubulointerstitial changes (fibrosis, atrophy and hypertrophy) in the IR group correlated with baseline tubular function, but glomerular function was preserved. Functional deterioration after the ARF protocol was only marginally more pronounced in the IR group, and the degree of medullary acute tubular necrosis (ATN) was unaffected by prior IR. The extent of both tubular necrosis and chronic tubulointerstitial changes independently predicted the acute decline in renal function. Immunostaining of IR kidneys disclosed critically low medullary pO<sub>2</sub> (determined by pimonidazole adducts), regional hypoxic cell response (hypoxia-inducible factors) and upregulation of endothelin-B receptors. Conclusions: Compensatory changes result in normal plasma creatinine 1 and 3 months after IR, despite diminished tubular function. Preexisting renal disease only marginally predisposes to ARF, and the extent of ATN is not significantly enhanced. These findings illustrate the complex interaction between chronic and acute renal injury and dysfunction and parallel the difficulty of their assessment in the clinical practice. Adaptive cellular responses to chronic hypoxia in conjunction with parenchymal loss and decreased oxygen demand might alleviate acute hypoxic injury.

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          Most cited references 23

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          Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention.

          In patients undergoing percutaneous coronary intervention (PCI) in the modern era, the incidence and prognostic implications of acute renal failure (ARF) are unknown. With a retrospective analysis of the Mayo Clinic PCI registry, we determined the incidence of, risk factors for, and prognostic implications of ARF (defined as an increase in serum creatinine [Cr] >0.5 mg/dL from baseline) after PCI. Of 7586 patients, 254 (3.3%) experienced ARF. Among patients with baseline Cr 2.0, all had a significant risk of ARF. In multivariate analysis, ARF was associated with baseline serum Cr, acute myocardial infarction, shock, and volume of contrast medium administered. Twenty-two percent of patients with ARF died during the index hospitalization compared with only 1.4% of patients without ARF (P 2.0 are at high risk for ARF. ARF was highly correlated with death during the index hospitalization and after dismissal.
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            Signal transduction to hypoxia-inducible factor 1.

            Hypoxia-inducible factor 1 (HIF-1) is a transcriptional activator that functions as a master regulator of O2 homeostasis. HIF-1 target genes encode proteins that increase O2 delivery and mediate adaptive responses to O2 deprivation. HIF-1 activity is regulated by the cellular O2 concentration and by the major growth factor-stimulated signal transduction pathways. In human cancer cells, both intratumoral hypoxia and genetic alterations affecting signal transduction pathways lead to increased HIF-1 activity, which promotes angiogenesis, metabolic adaptation, and other critical aspects of tumor progression.
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              Hypoxia of the renal medulla--its implications for disease.


                Author and article information

                Am J Nephrol
                American Journal of Nephrology
                S. Karger AG
                April 2006
                05 April 2006
                : 26
                : 1
                : 22-33
                aNephrology Unit, Bikur Holim Hospital, Jerusalem, bDepartment of Physiology, the Technion Medical School, Haifa, and cDepartment of Medicine, Hadassah-Hebrew University Hospital, Mt. Scopus, Jerusalem, Israel; dDepartment of Nephrology and Critical Care, Charité University Clinic, Berlin, and eDivision of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen-Nuremberg, Germany; fDepartment of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass., USA
                91783 Am J Nephrol 2006;26:22–33
                © 2006 S. Karger AG, Basel

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                Page count
                Figures: 6, Tables: 4, References: 31, Pages: 12
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                Original Report: Laboratory Investigation


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