Reviews

Evolving concepts in the pathogenesis

of uraemic cardiomyopathy
Xiaoliang Wang and Joseph I. Shapiro*
Abstract | The term uraemic cardiomyopathy refers to the cardiac abnormalities that are seen
in patients with chronic kidney disease (CKD). Historically , this term was used to describe
a severe cardiomyopathy that was associated with end-​stage renal disease and characterized
by severe functional abnormalities that could be reversed following renal transplantation. In a
modern context, uraemic cardiomyopathy describes the clinical phenotype of cardiac disease
that accompanies CKD and is perhaps best characterized as diastolic dysfunction seen in
conjunction with left ventricular hypertrophy and fibrosis. A multitude of factors may contribute
to the pathogenesis of uraemic cardiomyopathy , and current treatments only modestly improve
outcomes. In this Review , we focus on evolving concepts regarding the roles of fibroblast growth
factor 23 (FGF23), inflammation and systemic oxidant stress and their interactions with more
established mechanisms such as pressure and volume overload resulting from hypertension and
anaemia, respectively , activation of the renin–angiotensin and sympathetic nervous systems,
activation of the transforming growth factor-​β (TGFβ) pathway , abnormal mineral metabolism
and increased levels of endogenous cardiotonic steroids.

Endogenous cardiotonic
steroids
A class of steroid hormones
with important roles in health
and disease. Endogenous
cardiotonic steroids such as
cardenolide and bufadienolide
signal through the
Na+/K+-ATPase.
Joan C. Edwards School of
Medicine, Marshall
University, Huntington,
WV, USA.
*e-​mail: shapiroj@
marshall.edu
https://doi.org/10.1038/
s41581-018-0101-8
Chronic kidney disease (CKD) is a global public health
problem that shortens lifespan primarily by increasing
the risk of cardiovascular disease1. A wide range of car-
diovascular diseases are more common in patients with
end-​stage renal disease (ESRD) than in healthy individ-
uals, including coronary artery disease, heart failure,
valvular heart disease, stroke, atrial fibrillation, sudden
cardiac arrest and ventricular arrhythmias and vascular
calcification2–8. The major phenotype of fatal cardiac dis-
ease in patients with ESRD — uraemic cardiomyopathy9
— is characterized by diastolic dysfunction and marked
left ventricular hypertrophy (LVH) that is histologically
notable for profound fibrosis10.
LVH (Box 1) is the most commonly diagnosed cardio-
vascular abnormality and the strongest independent pre-
dictor of cardiovascular mortality in patients with CKD
or ESRD11–13. However, LVH does not itself result in
severe symptoms. Rather, the diastolic dysfunction that
seems to accompany if not antedate the development of
LVH produces the symptoms of heart failure. This dias-
tolic dysfunction seems to be related to a decrease in the
active reuptake of calcium into the sarcoplasmic retic-
ulum as well as to ventricular fibrosis, which impairs
passive relaxation14–16.
A potential explanation for the increased prevalence
of left ventricular diastolic dysfunction in patients with
CKD17 is that CKD facilitates the development of myo-
cardial fibrosis, which in turn impairs left ventricular pas-
sive relaxation6. The cause of this fibrosis is an excessive
accumulation of type I collagen within the interstitium,
in particular around the intramyocardial arteries18.
A number of mechanical and humoral factors that act
during the progression of CKD are involved in the devel-
opment of myocardial fibrosis, including haemodynamic
overload, insulin resistance, inflammation, transforming
growth factor-​β (TGFβ), endogenous cardiotonic steroids
(CTS) and uraemic toxins19.
The pathogenesis of uraemic cardiomyopathy in
patients with CKD seems to be multifactorial and to
involve mechanisms that are not unique to the CKD
milieu, such as hypertension, volume overload (for
example, as a result of anaemia or hypervolaemia), acti-
vation of the renin–angiotensin–aldosterone system
(RAAS), stimulation of the β-​adrenergic system, TGFβ
signalling and insulin resistance, as well as CKD-​specific
mechanisms and mediators such as hyperparathy-
roidism, hyperphosphataemia, 1,25-dihydroxy-​vitamin D
(vitamin D) deficiency, increased production of fibroblast
growth factor 23 (FGF23), Klotho deficiency, circulating
uraemic toxins and increases in the concentrations of
CTS. The Na+/K+-ATPase–reactive oxygen species (ROS)
amplification pathway might be involved in both CKD-​
specific (endogenous CTS) and non-​CKD-specific mech-
anisms (hypertension or insulin-​resistance-associated
oxidative stress)10,20–26. The relationships between the
different mechanisms and outcomes are still unclear.
Moreover, treatments that are effective in other car-
diomyopathic conditions, such as antihypertensive or

Nature Reviews | Nephrology

Reviews
Key points
• Patients with chronic kidney disease or end-​stage renal disease have an increased risk
of cardiovascular disease and mortality.
• Uraemic cardiomyopathy is characterized by diastolic dysfunction and marked left
ventricular hypertrophy with profound ventricular fibrosis.
• Factors that have been implicated in the development and progression of uraemic
cardiomyopathy include haemodynamic overload, alterations in mineral metabolism,
insulin resistance, circulating uraemic toxins and endogenous cardiotonic steroids.
• Oxidative stress seems to have a role in all of the putative molecular pathways that
are involved in the pathogenesis of uraemic cardiomyopathy.
• Treatments that are effective in other cardiomyopathic conditions such as
antihypertensive drugs improve clinical outcomes in uraemic cardiomyopathy only
modestly at best.
• The available data suggest that targeting oxidative stress might be a beneficial
therapeutic strategy for patients with uraemic cardiomyopathy.
lipid-​lowering therapy, improve clinical outcomes in
uraemic cardiomyopathy only modestly at best.
In this Review, we focus on the molecular mech-
anisms of uraemic cardiomyopathy that are directly
involved in the induction or progression of cardiac
hypertrophy, potential crosstalk between these mecha-
nisms and implications for therapy. Owing to space lim-
itations, some potentially important mechanisms, such as
inflammation and anaemia, are not extensively discussed.
Haemodynamic overload
Haemodynamic overload is a well-​known stimulus
for the development of LVH in patients with CKD or
ESRD27,28 (Fig. 1). Pressure overload frequently occurs as
a result of hypertension and arteriosclerosis, whereas
volume overload occurs as a result of the presence of
anaemia and hypervolaemia. Anaemia and hyperten-
sion are common comorbidities in patients with CKD.
Hypertension or hypervolaemia leads to the development
of LVH as a mechanism to maintain vascular wall stress.
However, continuing left ventricular overload results in
Pressure overload maladaptive cardiomyocyte hypertrophy and eventually
Refers to the pathological state fibrosis and cardiomyocyte apoptosis. Whether the initial
of cardiac muscle in which it stimulus for cardiac hypertrophy in CKD is mechanical
has to contract against
excessive pressure.
stress or humoral factors such as angiotensin II (Ang II),
catecholamines or TGFβ is unclear.
Volume overload
Refers to the pathological state Mechanical stress
of the heart in which an
Several in vitro studies have demonstrated that mechan-
abnormally large volume of
blood must be pumped. ical stress is sufficient to induce cardiac hypertrophy in
response to substantial haemodynamic overload29–33. For
Hypervolaemia example, stretching of neonatal cardiac cells grown in
Also known as fluid overload, serum-​free media stimulated the expression of skeletal
hypervolaemia is a pathological
condition in which there is too
α-​actinin, atrial natriuretic peptide (ANP) and myosin
much fluid in the blood. heavy chain-​β (β-​MHC) and induced proto-​oncogenes,
Hypervolaemia is common in such as fos, myc and jun, which are associated with car-
the setting of renal failure. diac hypertrophy, in cardiomyocytes and other cardiac
cells30,34. Similarly, stretching of cardiomyocytes in vitro
Aortocaval fistula
A surgically created resulted in increased protein synthesis and expression
arteriovenous fistula between of proto-​oncogenes without involvement of growth
the abdominal aorta and factors and hormones30–32. Mechanical stretch can also
inferior vena cava, distal to the induce cardiomyocytes to release Ang II, which acts
origin of the renal arteries.
Aortocaval fistula is used as an
as a mediator of the stretch-​induced hypertrophic
experimental model of volume response35–37. The role of Ang II in the pathogenesis of
overload. cardiac hypertrophy is discussed further below.
Evidence from in vivo studies that support the view
that mechanical stress is sufficient for cardiac hyper­
trophy in response to haemodynamic overload includes
the finding that rodents subjected to transverse aortic
constriction (resulting in pressure overload) exhibited
rapid expression of hypertrophic genes (for example,
fos and jun) and an increase in heart weight:body weight
ratio38. In a pig model of volume overload induced by
aortocaval fistula, LVH was observed only 96 h after
surgery39. Moreover, rodents subjected to 5/6 nephrec-
tomy (a model of renal failure) showed substantial
and persistent hypertension accompanied by LVH40,41.
Interestingly, the development of oxidative stress also
occurs in mechanical stress-induced cardiac hyper­
trophy. Mice under transverse aorta constriction pro-
duced significant increases in LVH and ROS production,
both of which were attenuated by antioxidant therapy42.
Oxidative stress was also apparent within hours of aor-
tocaval shunt surgery in a porcine model39. The resulting
volume overload induced multiple apo­ptotic and hyper-
trophic responses in cardiomyocytes through the acti-
vation of c-​Jun-terminal kinase (JNK) and extracellular
signal-​regulated kinase (ERK).
The cardiac hypertrophy response that is induced
by mechanical stress is characterized by two main sig-
nalling pathways: the mitogen-​activated protein kinase
(MAPK) pathway, which is activated by tyrosine and/
or threonine phosphorylation in the cytosol and ulti-
mately results in regulation of nuclear hypertrophic
factors43–45, and the Janus-​associated kinase (JAK)–signal
trans­ducer and activator of transcription (STAT) path-
way, which is activated by stretch-​induced binding of
cardiotrophin 1 and leads to phosphorylation of the
receptor–JAK complex (Fig. 1), which in turn promotes
the expression of proliferative genes46–48.
The renin–angiotensin–aldosterone system
The RAAS and its key mediator Ang II have impor-
tant roles in signalling pathways that are involved in
the pathogenesis of hypertension, CKD and cardiac
remodelling49,50. However, Ang II can also induce car-
diac hypertrophy independently of its effects on blood
pressure51,52 (Fig. 1). These hypertrophic effects of Ang II
are mediated by Ang II receptor type 1 (AT1R) on
cardiomyocytes53,54. Following stimulation by Ang II,
AT1R activates protein kinase C (PKC), which in turn
activates MAPKs. Activation of the MAPK family mem-
bers, ERK1 and/or ERK2, JNK and p38 kinases, has
been identified in cardiomyocytes involved in cardiac
remodelling55,56.
The generation of ROS might also have a role in the
pathogenesis of Ang-​II-mediated cardiac hypertrophy57,58
(Fig. 1). Specifically, Ang II can induce cardiomyocyte
hypertrophy and cardiac fibrosis via the upregulation
of NADPH oxidase 4 (NOX4)59. In a rat renovascular
model of cardiac hypertrophy, blocking Ang II signal-
ling by losartan attenuated LVH through downregulation
of oxidative stress59. In another study, Ang II infusion
into wild-​type mice increased cardiac NOX4 expression
and induced LVH and fibrosis, whereas in mice with
cardiac-​specific overexpression of NOX4, administra-
tion of Ang II resulted in exaggerated cardiac fibrosis
www.nature.com/nrneph

Box 1 | evaluation of left ventricular hypertrophy
Evaluation of the left ventricle involves the quantification of ventricular size, wall
thickness and function. Echocardiography is the most commonly used method to
determine ventricle function because of its noninvasive nature, general applicability
and fairly low cost310,311. Several echocardiographic methods can reproducibly measure
left ventricle mass (LVM), including 2D-​guided M-​mode, 2D linear measurement and 3D
echocardiography311,312.
LVM varies with gender, age and body size. However, the LVM index (LVMI), which is
calculated by dividing LVM by the body surface area, enables comparisons to be made
between patients with different body sizes312. The American Society of Echocardiography
(ASE) guidelines state that LVMI >115 g/m2 in men and >95 g/m2 in women are diagnostic
of left ventricular hypertrophy (LVH) in patients with end-​stage renal disease312. Changes
in left ventricle geometry, such as posterior and septal wall thickness <1.0 cm, also
suggest hypertrophy. The ventricular relative wall thickness (RWT; defined as either
posterior wall thickness multiplied by 2 or the sum of the septal and posterior wall
thicknesses divided by the left ventricle diastolic dimension) can be used to further
characterize changes in left ventricle geometry as concentric or eccentric. An RWT >0.42
together with an elevated LVMI suggest concentric LVH, whereas an RWT <0.42 in the
setting of increased LVMI indicates eccentric hypertrophy311,312.
The ASE guidelines state that Doppler echocardiographic measurements including
the annular eʹ velocity, average E/eʹ ratio (defined as the mitral valve (MV) E velocity
divided by the mitral annular eʹ velocity), left ventricle volume index (defined as the MV
E velocity divided by the A-​wave velocity) and peak tricuspid regurgitation (TR) velocity
can be used to assess diastolic function15. However, none of these clinical
measurements are perfect, and the clinical assessment of diastolic function using
echocardiography remains challenging313.
and hypertrophy together with the expression of cardiac
fetal genes and activation of the NF-​κB signalling path-
way60. Moreover, treatment of Ang-​II-infused mice
that overexpress NOX4 with a NOX4 inhibitor abol-
ished the increase in oxidative stress and attenuated
cardiac remodelling60.
Our understanding of the RAAS has deepened in the
past decade with the identification of novel angiotensin
peptides61,62. Angioprotectin is an endogenous octapep-
tide that is generated enzymatically from Ang II and has
been identified in the plasma of healthy people and
patients with ESRD63. Angioprotectin antagonizes the
contractile actions of Ang II in the isolated aortic ring
through its action on the Mas receptor63. Another novel
component of the RAAS, alamandine, was identified in
2013 (ref.64). Alamandine is a heptapeptide that is gen-
erated from decarboxylation of Ang (1–7) and induces
vasodilatation and antihypertensive and antihyper-
trophic effects in spontaneously hypertensive rats or
isoprenaline-​treated rats64,65.
The adrenergic system
Overactivity of the sympathetic nervous system (SNS) is
a common feature of CKD that might contribute to the
increased prevalence of cardiovascular diseases in this
population66,67. Moreover, epidemiological studies have
reported that SNS activity is associated with cardiovascular
mortality in patients with CKD68–70. The mechanisms that
underlie this association can be characterized into indirect
and direct effects of SNS overactivation on the heart.
Hypertension induced by α-​adrenergic vasoconstric-
tion indirectly causes LVH71, and SNS overactivation is
associated with the development and progression of
chronic heart failure67,72. Noradrenaline is an organic
chemical in the catecholamine family that functions
in the body as a hormone and neurotransmitter and
Nature Reviews | Nephrology
Reviews
exerts its effects by binding to and activating adrenergic
receptors. Consistent evidence indicates that high SNS
activity, as measured by plasma noradrenaline levels,
contributes to morbidity and mortality in a variety of
cardiovascular diseases, including chronic heart failure73.
Patients with CKD have elevated levels of plasma
noradrenaline74, and noradrenaline infusion has been
shown to induce LVH independently of changes in blood
pressure in animal models70,75.
Increased concentrations of catecholamines such
as noradrenaline in patients with CKD likely induce
sustained activation of β-​adrenergic receptors (β-​ARs),
which may contribute to the development of the urae-
mic cardiomyopathy phenotype76 (Fig. 1). Activation
of β-​AR in the mouse heart has been shown to lead
to phosphorylation of ERK1 and ERK2 and nuclear
accumulation of ERK, which ultimately results in car-
diomyocyte hypertrophy77. Overexpression of β-​AR in
the mouse heart also results in cardiomyocyte hyper-
trophy and progressive heart failure72. These findings
indicate that increases in circulating catecholamines
and increased expression of β-​ARs can produce similar
pathological phenotypes.
Interestingly, cardiac β-​AR signalling also has a role
in the generation of intracellular ROS78 (Fig. 1). In mice,
overexpression of β-​AR led to increased generation of
NOX-​derived ROS, which activated the p38 MAPK
pathway and induced the expression of proliferative and
profibrotic genes72. Furthermore, in rabbit ventricular
myocytes β-AR stimulation increased the production
of mitochondrial ROS, which resulted in oxidation of
the ryanodine receptor (which has a role in calcium
release from the endoplasmic reticulum) and impaired
calcium cycling79.
Transforming growth factor-​β
Pressure-​overload-induced cardiac hypertrophy is
accompanied by increases in the expression of TGFβ and
the deposition of extracellular matrix proteins including
fibronectin and collagen80,81. Additionally, TGFβ has been
increasingly recognized as an important contributor to the
progression of CKD82. TGFβ is a multifunctional cytokine
and important profibrotic factor that is also upregulated in
dilated cardiomyopathy and pressure-​overloaded human
heart83,84. Several investigations have demonstrated that
the fibrogenic and hypertrophic actions of TGFβ may be
involved in the pathogenesis of cardiomyopathic condi-
tions. In the pressure-​overloaded heart, administration
of anti-​TGFβ antibody prevented collagen accumulation
and attenuated diastolic dysfunction85. Mechanistically,
upregulation of TGFβ in CKD induces the expression of
fibrosis genes such as collagen I and II in cardiac tissue
via activation of the serine/threonine kinase receptor and
phosphorylation of SMAD85.
Interestingly, TGFβ-​mediated cardiac fibrosis may
interact with other signalling pathways. Ang-​II-induced
induction of TGFβ in cultured cardiomyocytes was
reduced in the presence of an antioxidant or NOX
inhibitor, indicating a role for ROS in TGFβ signalling86.
Our laboratory found that stimulation of rat cardiac
fibroblasts with CTS led to increases in collagen pro-
duction but had no effect on the expression of TGFβ or
Reviews

↑ Mechanical stress ↑ Ang II ↑ Catecholamines ↑ TGFβ patients with ESRD have confirmed a positive association
Cytokines between high PTH levels and cardiovascular events93.
Integrin gp130 AT1R NOX β-AR TGFβR Secondary hyperparathyroidism in CKD is generally
thought to be induced by phosphate accumulation.
However, the role of FGF23 in the regulation of PTH
levels is unclear. Increases in FGF23 levels can inhibit
1α-​hydroxylase, which results in a reduction in the lev-
Gαq Gαs els of vitamin D94. As vitamin D regulates the response
of the parathyroid gland to extracellular calcium con-
SMAD2 centrations, this mechanism might result in indirect
MAPKs JAK PLC ROS PKA and SMAD3 stimulation of PTH production. Conversely, treatment
of parathyroid cells with FGF23 has been shown to
reduce PTH mRNA levels and protein secretion95, thus
STAT InsP3 DAG opposing the indirect effect of FGF23.
In cardiomyocytes, PTH binding activates the
G protein-coupled receptor (GPCR) PTH type 1 recep-
Ca2+ PKC MAPKs Ca2+
tor (PTH1R), leading to activation of adenylyl cyclase
and subsequent calcium influx into cardiac cells96 (Fig. 2).
Calcineurin This calcium influx is thought to trigger activation of
the phospholipase C (PLC)–PKC pathway. The down-
NFAT stream effects of PKC on gene expression and cell prolif-
eration then result in myocardial hypertrophy96–98. PTH
might also indirectly cause cardiovascular disease via its
Cardiac hypertrophy Cardiac fibrosis
effects on blood vessels. Although the exact mechanism
Fig. 1 | Molecular mechanisms of haemodynamic overload in uraemic cardiomyopathy. is unclear, one hypothesis is that increased PTH levels
In response to kidney-​injury-induced haemodynamic overload, cardiac myocytes are cause dysfunction of the vascular endothelium, which
subjected to mechanical stress, which activates integrins and leads to the induction of in turn triggers the secretion of collagen and β1 integ-
downstream hypertrophic signalling. Haemodynamic overload also causes the release rin from smooth muscle cells and thus leads to vascular
of humoral factors such as angiotensin II (Ang II), transforming growth factor-​β (TGFβ) remodelling and fibrosis99.
and catecholamines that stimulate their specific cell membrane receptors. Activation of
these receptors triggers intracellular signalling cascades that lead to the development
of a hypertrophic and fibrotic cardiac phenotype. Crosstalk also occurs between
Hyperphosphataemia
these pathways. β-​AR , β-​adrenergic receptor ; AT1R , angiotensin II receptor type 1; DAG, Regulation of phosphorus excretion by the kidney is
diacylglycerol; Gαs and Gαq, Gs and Gq α-​subunits, respectively ; gp130, glyco­protein 130; critical for maintaining phosphorus homeostasis; loss of
InsP3, inositol trisphosphate; JAK , Janus-​associated kinase; MAPK , mitogen-activated this homeostasis due to excretion failure in CKD results
protein kinase; NFAT, nuclear target of activated T cells; NOX, NADPH oxidase; in hyperphosphataemia100. Many studies suggest that
PKA , protein kinase A ; PKC, protein kinase C; PLC, phospholipase C; ROS, reactive oxygen hyperphosphataemia is an important cardiovascular risk
species; STAT, signal transducer and activator of transcription; TGFβR , TGFβ receptor. factor in patients with CKD101. For example, a study that
included >14,000 patients on dialysis reported a posi-
downstream SMAD proteins87. However, these increases tive correlation between serum phosphate concentration
in collagen production were abrogated by TGFβ receptor and cardiovascular disease102. The mechanisms by which
antagonists. Taken together, upregulation of TGFβ in the serum phosphate could contribute to cardiovascular dis-
setting of either haemodynamic overload or renal failure ease are complex. One hypothesis is that hyperphospha-
seems to have an important role in the pathogenesis of taemia induces vascular calcification and cardiovascular
cardiac fibrotic and hypertrophic remodelling (that is, abnormalities through the type III sodium-​dependent
uraemic cardiomyopathy). phosphate cotransporter 1 (PiT1) in vascular smooth
muscle cells. Hyperphosphataemia leads to increased
Alterations in mineral metabolism uptake of phosphate by vascular smooth muscle cells
Disorders of mineral metabolism in patients with CKD via PiT1 and the resulting increase in intracellular phos-
have implications not only for renal osteodystrophy phate levels induces an osteochondrogenic change103–105.
but also for cardiovascular disease in this population88 Additionally, after entry via PiT1 and/or PiT2, phos-
(Fig. 2). Alterations in the levels of parathyroid hormone phate is able to induce apoptosis in vascular smooth
(PTH), serum phosphate, vitamin D, FGF23 and Klotho muscle cells and endothelial cells106,107. Indirect conse-
might all contribute to the pathogenesis of uraemic quences of elevated phosphate concentrations include
cardiomyopathy. stimulation of the PTH and FGF23 systems108 (Fig. 2).

Secondary Secondary hyperparathyroidism Vitamin D deficiency

hyperparathyroidism
Refers to excessive secretion of
parathyroid hormone by the
parathyroid gland in response
to low serum calcium level and
high phosphorus level in the
setting of renal failure.
In patients with CKD, persistently elevated concentra-
tions of PTH are associated with vascular calcification,
myocardial hypertrophy and cardiac dysfunction89–91.
Hyperparathyroidism is suspected to be an important
contributor to cardiovascular mortality in CKD, particu-
larly in the advanced stages of the disease92, and studies in
Patients with CKD have a high rate of severe vitamin D defi-
ciency owing to an inability to convert 25-hydroxy-​vitamin D
into the active form of the hormone, 1,25-dihydroxy-​
vitamin D109. Several epidemiological and clinical studies
have reported associations between vitamin D deficiency
and cardiovascular disease in these patients109,110.

www.nature.com/nrneph
 Reviews

↑ PTH ↑ Phosphate ↑ FGF23 ↓ Vitamin D ↓ Soluble Klotho

PTH1R–cAMP– PiT-induced FGFR4–PLC– VDR RAAS TRPC6 • RAAS

PKA signalling vascular calcineurin–NFAT signalling activation signalling activation
calcification signalling • SNS activation
• TGFβ
• ROS
• Insulin–IGF1
signalling

Cardiac hypertrophy and fibrosis

Fig. 2 | The role of mineral and bone disorder in uraemic cardiomyopathy. In patients with chronic kidney disease or
end-​stage renal disease, the levels of circulating phosphate and fibroblast growth factor 23 (FGF23) are elevated,
whereas serum levels of 1,25-dihydroxy-​vitamin D (vitamin D) and soluble Klotho are reduced. Alterations in the levels
of all four of these factors might independently contribute to cardiac hypertrophy by directly and/or indirectly
interfering with cardiac remodelling. Direct effects of phosphate are not well understood; however, uptake of
phosphate via the type III sodium–phosphate cotransporter (PiT) might lead to endothelial cell damage and thereby
indirectly induce vascular calcification. Elevated phosphate levels can also lead to hyperparathyroidism. Increased
levels of parathyroid hormone (PTH) cause cardiac hypertrophy via activation of the PTH type 1 receptor (PTH1R) on
cardiomyocytes. FGF23 can directly target the myocardium via binding to FGF receptor 4 (FGFR4) and thereby induce
hypertrophic growth of cardiomyocytes and potentially subsequent damage, including cardiac fibrosis. Soluble Klotho
can directly target the heart and prevent the development of left ventricular hypertrophy via blocking transient
receptor potential cation channel, subfamily C, member 6 (TRPC6) and/or an unknown receptor. Soluble Klotho can
also block the activation of the renin–angiotensin–aldosterone system (RAAS), the sympathetic nervous system (SNS),
transforming growth factor-​β (TGFβ) and the reactive oxygen species (ROS)–insulin–insulin-​like growth factor I (IGF1)
signalling pathway and thereby protect the myocardium from pathological stress-​induced cardiac hypertrophy and
fibrosis. Vitamin D can directly target the heart via the vitamin D receptor (VDR) and downregulate cardiomyocyte
proliferation and hypertrophy. In addition, vitamin D might indirectly protect the heart against RAAS-​induced cardiac
damage, at least in part through the suppression of renal renin expression. As phosphate, vitamin D, FGF23 and soluble
Klotho regulate each other’s expression, they might also be able to amplify each other’s cardiac actions. For example,
FGF23 expression is increased by phosphate and reduced by vitamin D, and the expression of soluble Klotho is
increased by vitamin D. NFAT, nuclear target of activated T cells; PKA , protein kinase A ; PLC, phospholipase C.

The interaction of vitamin D with its receptor
increases the efficiency of intestinal calcium and phos-
phorus absorption to ~40% and 80%, respectively111.
In addition to its role in mineral metabolism, ample
evidence suggests that vitamin D may have a role in car-
diovascular disease112. For example, vitamin D may act as
an antiproliferative factor in the heart113. Proposed anti-
hypertrophic mechanisms of vitamin D include direct
effects on cardiomyocytes as well as indirect effects
via the RAAS and insulin systems (Fig. 2). Activated
vitamin D has been shown to downregulate proliferation
and hypertrophy in cultured cardiomyocytes114. By con-
trast, vitamin D receptor-​knockout mice had increased
levels of renin mRNA and plasma Ang II and developed
hypertension and cardiac hypertrophy, which could be
attenuated using an angiotensin-​converting enzyme
(ACE) inhibitor115. Vitamin D infusion also inhibited
renin mRNA expression in these mice115. In rats sub-
jected to partial nephrectomy, the cardioprotective
effect of vitamin D was accompanied by a substantial
reduction in FGF23 production and its downstream
signalling116. The role of the FGF23 system in cardiac
hypertrophy is discussed in greater detail below.
Overproduction of FGF23
FGF23 is produced by osteocytes in response to elevated
levels of calcitriol (the active form of vitamin D3) and has
important roles in the regulation of vitamin D and phos-
phate metabolism117–119. FGF23 is normally present in its
full-​length, biologically active form, which can be proteo-
lytically cleaved into amino-​terminal and carboxy-​terminal
fragments120,121. Binding of FGF23 to the FGF receptor 1
(FGFR1)–Klotho co-​receptor complex leads to a decrease
in the renal tubular reabsorption of phosphate and hence
a net increase in phosphate excretion122. FGF23 inhibits
the secretion of PTH and the activation of 1,25-vitamin D3
via suppression of 1α-​hydroxylase in the kidney119,122–126.
In patients with CKD, disordered phosphate metab-
olism leads to overproduction of FGF23 (ref.127). Other
factors that are altered in CKD such as vitamin D128,
PTH129, calcium130 and leptin131 might also contribute to
FGF23 regulation. The serum level of FGF23 progres-
sively increases as kidney function declines, resulting in
levels in patients with ESRD that are 1,000-fold higher
than the normal range127,132–134. Although this enormous
elevation in serum FGF23 levels (together with increases
in PTH) can initially maintain phosphate homeostasis,
clinical studies in patients with CKD demonstrate a sig-
nificant association between the level of serum FGF23
and the prevalence of cardiovascular disease, especially
cardiac hypertrophy135–140. Moreover, FGF23 is signifi-
cantly upregulated in the cardiac tissue of patients with
CKD, suggesting that it functions as a paracrine factor
with a role in cardiac remodelling120,141.
Detailed analyses of FGF23-induced signalling cas-
cades in cultured cardiac cells and in animal models sug-
gest an important role of FGF23 in the pathophysiology
of uraemic cardiomyopathy (Fig. 2). For example, FGF23

Nature Reviews | Nephrology

Reviews
has been shown to induce hypertrophic growth of iso-
lated neonatal rat ventricular cardiomyocytes and to
activate a multitude of genes with roles in hypertrophy,
including α-​actinin, α-​MHC, β-​MHC, ANP and brain
natriuretic peptide (BNP)139,142. These effects of FGF23
seem to be mediated by FGFR-​dependent activation
of the PLCγ–calcineurin–nuclear target of activated
T cells (NFAT) signalling pathway139,142. Furthermore,
intramyocardial or intravenous injection of FGF23 in
mice induced a left ventricular hypertrophic gene profile
and LVH independent of changes in cardiac contractility
and blood pressure139.
In the 5/6 partial nephrectomy rat model of renal
failure, serum FGF23 levels are significantly increased
and administration of FGFR inhibitor has been shown
to attenuate increases in left ventricular mass, wall thick-
ness and cardiomyocyte size139,143. The FGF23-mediated
PLCγ–calcineurin–NFAT signalling cascade in rat cardio­
myocytes seems to be dependent on activation of FGFR4
(refs116,144,145). In mice fed a high-​phosphate diet (which
induces upregulation of FGF23), FGFR4 knockout pro-
tected against the development of LVH and fibrosis144.
Similarly, administration of specific anti-​FGFR4 antibod-
ies attenuated the development of cardiomyopathy in rats
subjected to 5/6 partial nephrectomy144. By contrast, trans-
genic mice that expressed constitutively activated FGFR4
developed increases in left ventricle wall thickness, cardio­
myocyte size and hypertrophic gene expression as well as
increased serum levels of FGF23 (ref.144).
Clinical studies also support the importance of
FGF23–FGFR4–calcineurin–NFAT signalling in the
development of uraemia141,146,147. A case-​c ontrolled
study in patients with childhood-​onset ESRD reported
that cardiac FGF23 and FGFR4 were highly expressed in
heart tissue samples and that this increased expression
was positively associated with the presence of LVH141.
FGF23 levels are also highly associated with cardio-
vascular diseases in genetic disorders such as X-​linked
hypophosphataemia148.
Despite the evidence discussed above, some findings
suggest that FGF23 is not an independent risk factor for
uraemic cardiomyopathy. Instead of a protective effect in
CKD, FGF23-null mice showed severe growth retarda-
tion and died by the age of 12 weeks126. Administration
of an FGF23-blocking antibody resulted in severe vas-
cular calcification in CKD rats on a high-​phosphate
diet149. A 2018 study reported that in the absence of
renal impairment, the presence of high levels of circu-
lating FGF23 was not sufficient to cause cardiovascular
disease150. Moreover, the non-​calcium-based phosphate
binder sevelamer carbonate significantly reduced serum
FGF23 levels but failed to improve LVH or cardiac func-
tion in patients with CKD151. Clearly, the molecular
mechanisms by which FGF23 affects cardiac structure
and function are not yet fully understood. It is likely that
in addition to its direct cardiac effects, systemic changes
induced by FGF23, such as inflammation and hypophos-
phataemia, contribute to cardiac injury, suggesting that
CKD-​associated high circulating FGF23 levels can have
adverse effects on the heart via several mechanisms that
might act synergistically. Whether a direct link exists
between FGF23 and cardiac ROS generation has not
been established. However, in human coronary artery
endothelial cells, both FGFR-​dependent ROS generation
via activation of NOX2 and ROS degradation via SOD2
are stimulated by FGF23 (ref.152).
Klotho deficiency
Klotho is a transmembrane protein that acts as a co-​
receptor for the binding of specific FGFs to their
receptors123,153. Three isoforms of Klotho have been
identified: αKlotho, βKlotho and γKlotho (which is also
known as Klotho/lactase-​phlorizin hydrolase-​related
protein)119,154. αKlotho (which we refer to as Klotho
in this Review) is expressed in the kidney and para-
thyroid glands; forms complexes with FGFR1, FGFR3
and FGFR4; and is a co-​receptor for FGF23 (ref.153).
βKlotho is expressed in liver and fat, forms complexes
with FGFR1 and FGFR4 and is a co-​receptor for FGF19
and FGF21 (ref.155). γKlotho is expressed in the eye,
fat and kidney; forms complexes with FGFR1, FGFR2
and FGFR4; and is a co-​receptor for FGF19 (ref.156).
A reduction in Klotho expression has been reported
in patients with CKD157. This reduction may be due to
either defective renal production of Klotho, vitamin D
and erythropoietin158–160 or overproduction of other fac-
tors such as inflammatory cytokines161, ROS162, Ang II163
and phosphate164.
Mice with Klotho deficiency spontaneously develop
premature ageing, vascular calcification, LVH and car-
diac fibrosis164. Klotho-​deficient animals also show a
tenfold increase in the level of FGF23, a fivefold increase
in vitamin D and cardiac overexpression of hyper-
trophic genes139,164,165. However, the mechanism by which
Klotho deficiency might contribute to the development
of uraemic cardiomyopathy remains unclear139,165,166.
One potential mechanism is via the loss of its antioxi-
dative effects, as mice that overexpress Klotho have an
extended lifespan167 and show a reduction in systemic
oxidative stress168,169. As membrane-​bound Klotho is not
directly expressed in the heart139,165, its cardioprotective
effects must either be indirectly related to its effects in
other target organs or be mediated by soluble Klotho.
Soluble Klotho arises from alternative splicing170,171
or proteolytic cleavage171 of full-​length Klotho. Although
soluble Klotho is mainly produced in the kidney, it
seems to target a variety of cell types, including vascular
smooth muscle cells, cardiomyocytes and endothelial
cells, and to protect against inflammation, fibrosis, apop-
tosis and oxidative stress169,172–174. In patients with CKD,
levels of soluble Klotho were reduced and correlated
positively with estimated glomerular filtration rate175.
Several experimental studies suggest that soluble
Klotho could directly protect against LVH and cardiac
fibrosis (Fig. 2). Soluble Klotho blunted hypertrophic
effects induced by TGFβ and Ang II in rat cardiomyo-
cytes164,176 and attenuated Ang II and TGFβ-​mediated
activation of cardiac fibroblasts in vitro164. Moreover,
treatment of mice with soluble Klotho ameliorated
indoxyl-​sulfate-induced cardiomyocyte hypertrophy
by blocking ROS generation and inhibiting the p38 and
MAPK pathway176. In normal mice, a high-​phosphate diet
led to a reduction in the serum levels of soluble Klotho,
which were strongly associated with LVH and cardiac
www.nature.com/nrneph

fibrosis164. By contrast, intraperitoneal administration of
soluble Klotho protected against pathological changes in
cardiac function, morphology and biochemistry in mice
treated with isoprenaline177,178. Although the specific
receptor of soluble Klotho has not yet been identified,
soluble Klotho has been reported to inhibit transient
receptor potential cation channel, subfamily C, member 6
(TRPC6)179. In isolated cardiac myocytes that overex-
pressed TRPC6, soluble Klotho inhibited the cell surface
expression of TRPC6 and TRPC6 currents177. Mice with
cardiac-​specific TRPC6 overexpression spontaneously
developed cardiac hypertrophy and remodelling, which
could be prevented by overexpression of Klotho177.
Several studies suggest that the protective effects of
soluble Klotho are mediated through the attenuation
of oxidative stress. In a mouse model of CKD, treat-
ment with exogenous soluble Klotho reduced oxidative
stress in myocardial tissue through inhibition of NOX176.
Similarly, Klotho attenuated Ang-​II-mediated NOX2
expression, superoxide production, oxidative damage
and apoptosis in cultured aortic smooth muscle cells via
activation of the cAMP–protein kinase A pathway180.
Administration of Klotho also attenuated isoprenaline-​
induced cardiac remodelling and ROS generation in a
mouse model178. However, oxidative stress was shown
to inhibit Klotho production in this study.
Insulin resistance
Insulin resistance is one of the most common and earli-
est metabolic alterations that is identified in patients with
CKD181. This resistance becomes more pronounced as
renal function declines182. Moreover, ESRD (glomerular
filtration rate <15 ml/min/1.73 m2) is associated with
impaired insulin clearance, which further exacerbates
hyperinsulinaemia183.
The aetiology of insulin resistance in CKD is multi-
factorial and involves risk factors that are associated with
renal failure, including metabolic acidosis, inflamma-
tion, oxidative stress, microbial toxins, uraemic toxins,
anaemia and vitamin D deficiency184–190. Clinical stud-
ies have demonstrated that insulin resistance is highly
associated with cardiovascular disease in patients with
CKD and is an independent predictor of cardiovascular
mortality in patients with ESRD22,191,192.
Insulin resistance is associated with altered insulin–
PI3K–AKT signal transduction within the pathway that
regulates insulin-​mediated glucose metabolism, lipid
metabolism, protein synthesis and cell growth193,194.
Protein kinase B (AKT) is a key effector of insulin-​
mediated signal transduction. Three isoforms of AKT
have been identified in mammals: AKT1 and AKT2 are
predominately expressed in the heart195,196 and AKT3
is highly expressed in the central nervous system197.
Physiologically, stimulation of phosphoinositide 3-kinase
(PI3K) through insulin leads to the generation of phos-
phatidylinositol-3,4,5-trisphosphate (PtdIns(3,4,5)P3)
and the recruitment of AKT to the plasma mem-
brane197. AKT is then phosphorylated and activated by
phosphoinositide-​dependent kinase (PDK). The con-
sequence of AKT activation is dependent on the iso-
form as well as the route (physiological or pathological)
and duration of stimulation198.
Nature Reviews | Nephrology
Reviews
The role of the insulin–PI3K–AKT pathway in the
uraemic state is not fully understood (Fig. 3). However,
uraemia causes increases in AKT signalling that have
been implicated in the functional, metabolic and
morphological changes that are seen in uraemic cardio­
myopathy199–201. A study that involved modulation of
AKT expression in mice demonstrated that insulin-​
mediated cardiac hypertrophy predominantly occurs
via activation of AKT1 rather than AKT2 (refs202,203).
In the uraemic rat model, perturbations in the level
of both total and phosphorylated AKT were observed
when compared with normal controls204. A clinical study
reported that AKT was activated in the hearts of patients
with heart failure but not in those of patients with com-
pensated cardiac hypertrophy or healthy individuals;
however, whether there is a causal relationship between
AKT activity and heart failure is unclear205.
The importance of persistent AKT signalling in the
pathogenesis of cardiac hypertrophy was demonstrated
by a study in adult mice that showed a clear transi-
tion from physiological to pathological hypertrophy
with short-​term (2 weeks) versus long-​term (6 weeks)
induction of activated AKT1 (ref.206). Interestingly, this
Insulin ↑ Insulin
resistance
Insulin receptor
PtdInsP2 PtdInsP3
Ras IRS PDK
Raf PI3K
MAPK AKT
Cardiac hypertrophy and fibrosis
Fig. 3 | The role of insulin resistance in uraemic
cardiomyopathy. Insulin resistance and hyperinsulinaemia
are early metabolic alterations that occur in patients with
renal insufficiency. The aetiology of insulin resistance in
this population is multifactorial and risk factors include
inflammation, oxidative stress, uraemic toxins,
1,25-dihydroxy-​vitamin D (vitamin D) deficiency , metabolic
acidosis, anaemia, microbial toxins and reduced insulin
clearance. Upon binding to insulin, the insulin receptor
undergoes autophosphorylation, which increases its
tyrosine kinase activity. Tyrosine phosphorylation and
activation of the docking proteins insulin receptor
substrates 1 and 2 (IRS1 and IRS2, respectively) engage
regulatory subunits of phosphatidylinositol 3-kinase (PI3K)
that generate phosphatidylinositol-3,4,5-trisphosphate
(PtdIns(3,4,5)P3) from phosphatidylinositol-3,4-bisphos-
phate (PtdIns(3,4)P2). Protein kinase B (AKT) is then
recruited to the plasma membrane by PtdIns(3,4,5)P3,
enabling phosphorylation by phosphoinositide-​dependent
kinase (PDK). Activated AKT phosphorylates multiple
targets including vascular endothelial growth factor
(VEGF) and angiotensin II (Ang II), which ultimately leads
to the development of cardiac hypertrophy and fibrosis.
Insulin might also regulate cell growth via activation of
the Ras (small GTPase)–mitogen-​activated protein
kinase (MAPK) pathway. Raf, RAF proto-​oncogene
serine/threonine-​protein kinase.
Reviews
transition occurred in association with a decrease in capil-
lary density. Physiological cardiac hypertrophy is accom-
panied by increased coronary angiogenesis to maintain
capillary density207. However, in CKD models, coronary
angiogenesis fails to keep pace with cardiac hypertrophy,
resulting in reduced capillary density208,209. Coronary
angiogenesis is mediated by vascular endothelial growth
factor (VEGF) and Ang II, both of which are upregulated
by the insulin–PI3K–AKT pathway. Conversely, chronic
overexpression of AKT1 leads to pathological hypertro-
phy and reduced capillary density with downregulation
of VEGF and Ang II (ref.206). Additional studies suggest
that signalling through the PI3K–AKT–mechanistic tar-
get of rapamycin (mTOR) pathway is involved in a mouse
model of CKD210 and results in the chronic overexpres-
sion of AKT1, ultimately leading to the cardiac fibrosis
that is associated with LVH196,211.
Our understanding of the role that insulin resist-
ance plays in the development of oxidative stress is
incomplete. Numerous studies have shown that patients
with CKD and insulin resistance have higher levels of
oxidative stress than healthy individuals212,213. In three
large, cross-​sectional studies performed in patients on
dialysis, insulin resistance (measured using Homeostatic
Model Assessment (HOMA-​IR)) was positively associ-
ated with both inflammation and oxidative stress214–216.
However, the molecular pathophysiology is still unclear.
Elevated insulin concentrations (as seen in CKD) induce
a shift in the activities of PI3K. Under these conditions,
PI3K phosphorylates Rac rather than PtdInsP2, lead-
ing to an amplification of the activity of NOX4 and
increased oxidative stress217. Moreover, adipocytes are
now recognized as a major site for production of inflam-
matory cytokines and a source of oxidative stress. In the
general population, insulin resistance positively cor-
relates with body fat mass218. In cultured adipocytes,
insulin-​stimulated oxidative stress can be attenuated
by adenovirus-​mediated NOX4 deletion219. Conversely,
evidence suggests that oxidative stress activates a series
of signalling pathways that have negative effects on insu-
lin sensitivity220. As mentioned above, overexpression of
Klotho extends the lifespan of mice. This effect has been
attributed to inhibition of insulin–insulin-​like growth
factor I (IGF1) signalling as soluble Klotho suppressed
autophosphorylation of the insulin receptor and acti-
vation of the PI3K pathway in vitro167 as well as to the
antioxidative effects of Klotho164.
Uraemic toxins
Increasing evidence suggests that the uraemic state has
a critical role in the development and progression of
uraemic cardiomyopathy24,25. Numerous compounds
that are excreted or metabolized by the kidney in healthy
individuals accumulate in patients with renal insuf-
ficiency25,221–226. These putative uraemic toxins can be
characterized as small water-​soluble compounds with
molecular mass <500 Da that can be easily removed
by haemodialysis; molecules with molecular masses of
500–60,000 Da that can be removed only by haemo-
dialysis using membranes with large pore sizes; and
protein-​bound molecules that are difficult to remove
via haemodialysis (Supplementary Table 1). Some of
these toxins (for example, indoxyl sulfate and p-​cresyl
sulfate) are independent predictors of overall mor-
tality and cardiovascular outcomes in patients with
ESRD227. In addition, uraemic toxins, such as indoxyl
sulfate and p-​cresyl sulfate, have been shown to produce
pro-​hypertrophic and pro-​inflammatory effects and to
increase arrhythmias in cardiac tissues by increasing
oxidative stress228–230.
The accumulation of asymmetrical dimethylarginine
(ADMA) is a well-​defined risk factor for LVH in patients
with CKD231. ADMA is a small, water-​soluble uraemic
toxin that results from the degradation of methylated
proteins. As ADMA is an endogenous competitive inhib-
itor of nitric oxide synthase (NOS), it may cause LVH
and fibrosis through accentuation of oxidative stress in
cardiomyocytes231. A study that included 189 patients
on haemodialysis reported that the level of ADMA was
significantly associated with the degree of concentric
LVH232. In addition, endothelial dysfunction was shown
to be strongly and independently associated with ADMA
concentration in patients with atherosclerosis231–233.
The intestinal tract is an important source of poten-
tial uraemic toxins including indoxyl sulfate and p-​cresyl
sulfate25. Indoxyl sulfate is a protein-​bound uraemic
toxin that is produced by intestinal bacteria and is nor-
mally absorbed and metabolized in the liver but accu-
mulates in patients with CKD and is poorly removed by
dialysis24,234. A growing number of clinical studies sug-
gest that serum levels of indoxyl sulfate in these patients
are positively associated with heart failure, ischaemic
heart disease and diastolic dysfunction235–237.
Indoxyl sulfate seems to function as an inducer of
oxidative stress that directly targets cardiomyocytes. In
cultured neonatal rat cardiomyocytes, indoxyl sulfate
induced hypertrophy through inhibition of AMPK–
UCP2 signalling and amplification of oxidative stress238.
Similar effects of indoxyl sulfate have been observed in
cultured rat cardiomyocytes176. Moreover, in a rat model
of CKD, oral administration of a charcoal adsorbent
(AST-120) led to reductions in the levels of indoxyl sul-
fate, oxidative stress and TGFβ signalling and to atten-
uation of left ventricle fibrosis and LVH230,239. On the
other hand, research has suggested that indoxyl-​sulfate-
induced oxidative stress might be mediated by impaired
activation of nuclear factor erythroid 2-related factor 2
(NRF2) and impaired expression of major antioxi-
dant signalling pathways240. In cultured kidney cells,
indoxyl sulfate downregulates the expression of haem
oxygenase 1 (HO1) and NAD(P)H quinone dehydroge-
nase 1 (NQO1) with attendant accumulation of ROS241.
Conversely, in a rat model of CKD, a reduction in the
levels of indoxyl sulfate using AST-120 resulted in upreg-
ulation of NRF2, HO1 and NQO1 with decreases in
oxidant stress241.
As mentioned above, Klotho has been reported to
protect against indoxyl-​sulfate-induced myocardial
hypertrophy176. In a mouse model of uraemic cardio­
myopathy, renal Klotho expression was reduced,
whereas the serum indoxyl sulfate concentration was
increased compared with healthy controls176. In addition,
infusion of indoxyl sulfate resulted in a greater severity
of LVH in heterozygous Klotho-​deficient mice than in
www.nature.com/nrneph

Inflammasomes
A multiprotein intracellular
complex that detects
pathogenic microorganisms
and activates inflammatory
responses via the activation of
pro-​inflammatory cytokines
such as IL-1β and IL-18.
Nature Reviews | Nephrology
normal mice176. These findings suggest that an imbal-
ance between the levels of Klotho and indoxyl sulfate
might contribute to the development of LVH and fibrosis
in CKD.
Upregulation of inflammasomes has also been
reported in a mouse model of indoxyI-​sulfate-induced
uraemic cardiomyopathy242, and clinical studies have
demonstrated increased levels of circulating NOD-,
LRR- and pyrin domain-​containing 3 (NLRP3) in a
variety of kidney diseases243. In rat cardiomyocytes,
treatment with indoxyl sulfate resulted in activation of
the NLRP3 inflammasome–IL-1–IL-18 axis, which leads
to apoptosis through the activation of NF-​κB242,243.
Indoxyl sulfate might also target other cell types and
indirectly cause cardiac hypertrophy and remodelling.
For example, in vitro studies showed that indoxyl sulfate
reduces the viability of human vascular endothelial cells
via the activation of NOX228. By contrast, indoxyl sulfate
has been reported to promote the proliferation of vas-
cular smooth muscle cells by inducing oxidative stress
in a concentration-​dependent manner244. Similarly,
indoxyl sulfate was shown to stimulate the proliferation
of rat vascular smooth muscle cells via the activation of
MAPK245. Our laboratory has found that indoxyl sulfate
and other putative uraemic toxins induce adipocytes
to produce cytokines (for example, TNF and IL-6) that
could potentially cause adverse cardiac changes such
as LVH and cardiac fibrosis246–248. In addition, clinical
evidence suggests that increased adiposity may amplify
the oxidative stress and inflammation that accompanies
moderate to severe CKD249,250.
Similar to indoxyl sulfate, p-​cresyl sulfate is albumin-​
bound and its plasma concentration is determined
mainly by renal excretion251. In patients with CKD,
impaired renal function and reductions in albumin con-
centrations lead to high concentrations of free p-​cresyl
sulfate. An increasing body of clinical evidence demon-
strates that serum concentration of p-​cresyl sulfate is
a predictor of cardiovascular disease and mortality in
patients with CKD25,252. Mechanistically, the cardiac tox-
icity of p-​cresyl sulfate may be related to the induction
of ROS generation. In a mouse model of CKD, increase
in the levels of p-​cresyl sulfate promoted cardiac apopto-
sis and diastolic dysfunction, which were ameliorated by
the concomitant administration of a NOX inhibitor253.
Endogenous cardiotonic steroids
The concentrations of endogenous CTS are elevated in
various diseases such as CKD, ESRD, heart failure and
hypertension and are associated with clinical meas-
urements such as LVH and diastolic dysfunction254–258.
Several laboratories have reported significantly elevated
concentrations of endogenous ouabain, marinobufa-
genin and telocinobufagin in patients with CKD248
and ESRD256 and in animal models of uraemic cardio­
myopathy, suggesting an important role of these CTS in
the development of this phenotype26,258,259.
We found that experimental CKD induced by partial
nephrectomy resulted in increased levels of circulating
marinobufagenin and that active immunization against
marinobufagenin attenuated the development of exper-
imental uraemic cardiomyopathy87. Administration of
Reviews
marinobufagenin through a minipump to achieve sim-
ilar plasma levels to those in mice with partial nephrec-
tomy produced a similar cardiac phenotype to that seen
in the partially nephrectomized animals14,87. We also
found increases in oxidative stress and hypertrophic
gene expression in partial nephrectomy and marinob-
ufagenin infusion models260. Marinobufagenin derived
from cardiac tissues activated fibroblasts, and this effect
could be abrogated by administration of a nonspe-
cific tyrosine kinase inhibitor (herbimycin), a specific
tyrosine-​protein kinase Src inhibitor (PP2) or nonspe-
cific antioxidant (N-​acetylcysteine)87. This observation
suggests a pro-​fibrotic role of endogenous CTS in the
development of uraemic cardiomyopathy. Neutralization
of CTS by passive immunization and blockade of CTS
binding to the Na+/K+-ATPase using spironolactone
(which acts as a competitive inhibitor of CTS binding)
or rapamycin (which blocks mTOR) were effective in
blocking cardiac hypertrophy and fibrosis induced by
partial nephrectomy261–263.
Endogenous CTS have been reported to activate the
Na+/K+-ATPase-​mediated signalling cascade through
protein tyrosine phosphorylation and to ultimately
alter gene expression without affecting cellular Na+/K+-
ATPase pumping capacity264,265 (Fig. 4). This observation
suggests a receptor-​like function of Na+/K+-ATPase.
Similar to cytokine receptors and GPCRs, Na +/K+-
ATPase does not have intrinsic kinase activity; therefore,
binding to a non-​receptor tyrosine kinase is required to
enable tyrosine phosphorylation of the Na+/K+-ATPase
in response to the binding of CTS266. The receptor
function of α1 Na+/K+-ATPase requires Src-​mediated
transactivation of epidermal growth factor receptor
and subsequent recruitment and assembly of signalling
proteins266,267. Binding of ouabain to the Na+/K+-ATPase
releases the Src kinase domain from a binding site in
the α1 Na+/K+-ATPase amino domain and disinhibits
(or activates) this Src266. Activation of Src results in
transactivation of multiple downstream effectors such
as ERK1, ERK2, mTOR and MAPK268,269.
A study using transgenic mice that expressed either
ouabain-​s ensitive or ouabain-​resistant isoforms of
Na+/K+-ATPase reported that the ouabain-​sensitive mice
developed substantially more severe cardiac dysfunction
in response to left ventricle pressure overload than did
the ouabain-​resistant mice270. Moreover, knockdown of
α1 Na+/K+-ATPase resulted in significant increases in
cardiac cell death and in the abundance of cardiac pro-
genitor cells in mice following partial nephrectomy271.
These studies provide convincing support for a role
of endogenous CTS-​mediated Na+/K+-ATPase signal
transduction in uraemic cardiomyopathy.
The Na+/K+-ATPase–Src–ROS amplification loop
A link between Na+/K+-ATPase-​mediated signal trans-
duction and ROS generation was first identified in an
early study that showed that ROS generation was required
for ouabain-​induced hypertrophy of cardiomyocytes
in vitro and that this hypertrophy could be attenuated
by antioxidants such as N-​acetylcysteine or vitamin E272.
We subsequently showed that ouabain could stimulate
ROS generation in a Ras (small GTPase)-dependent
Reviews
↑ Endogenous
cardiotonic steroids
Na+/K+-ATPase EGFR
P P
P P
Src
FAK
SOS
Ras
↑ ROS
ERK1, ERK2
or MAPK
Cardiac hypertrophy and fibrosis
Fig. 4 | endogenous cardiotonic steroids and the
Na+/K+-ATpase–Src–roS amplification loop in uraemic
cardiomyopathy. Patients with chronic kidney disease or
end-​stage renal disease have increased levels of circulating
endogenous cardiotonic steroids (for example, ouabain,
marinobufagenin and telocinobufagin) and reactive oxygen
species (ROS). Upon binding to endogenous cardiotonic
steroids, the Na+/K+-ATPase changes its conformation and
activates proto-​oncogene tyrosine-​protein kinase Src (Src).
Src then transactivates epidermal growth factor receptor
(EGFR), which leads to a signal cascade involving focal
adhesion kinase (FAK), son-​of-sevenless 1 (SOS1) and Ras
(small GTPase). This cascade results in the generation of
ROS, which in turn activate additional Na+/K+-ATPase–Src
signalling complexes to form a positive feedback loop.
Elevated levels of ROS lead to downstream activation of
extracellular-​signal-regulated kinase 1 (ERK1), ERK2 and
mitogen-​activated protein kinase (MAPK), which induce
cardiac hypertrophy and fibrosis.
but intracellular Ca2+-independent manner in cultured
pig kidney cells273. Moreover, an increase in ROS stress
correlated with elevated levels of endogenous CTS in
partially nephrectomized rats87.
The finding that ROS could modulate the structure
and activity of the α1 Na+/K+-ATPase274 led to studies of
potential interactions between ouabain-​induced ROS gen-
eration and ROS-​induced Na+/K+-ATPase signalling. ROS
and ouabain were found to potentiate each other in the
stimulation of hypertrophic signalling in cultured cardio-
myocytes, leading to the hypothesis that ROS and ouabain
might form a feedforward amplification loop through the
Na+/K+-ATPase–Src signalling complex10,272,273,275 (Fig. 4).
In pig kidney cells, we observed that both ouabain and
increases in ROS levels (induced by glucose oxidase) can
induce carbonylation of α1 Na+/K+-ATPase at Pro222 and
Thr224 (refs274,276). Moreover, inhibition of this carbony­
lation using antioxidants or mutation of Pro222 attenu-
ated the activation of protein kinase cascades in response
to ouabain or glucose oxidase.
In view of the well-​characterized role of oxidative
stress in the progression of chronic disease, several
laboratories have investigated whether the Na+/K+-
ATPase–Src signalling complex is critical for ROS
amplification in disease models. A study using genet-
ically modified mice demonstrated that α1 Na+/K+-
ATPase is required for the formation of an oxidized LDL
(oxLDL)–CD36–Na+/K+-ATPase–Lyn kinase signalling
complex in macrophages that enables oxLDL to activate
downstream signalling277. The CD36–Na+/K+-ATPase
pro-​inflammatory signalling loop has also been reported
to be involved in the development of chronic inflam-
mation, oxidative stress and fibrosis in the kidney278.
Our animal studies utilizing pNaKtide (an antagonist
of Na+/K+-ATPase–Src signalling complex) support a
direct role of the Na+/K+-ATPase–Src–ROS amplifica-
tion loop in the development of uraemic cardiomyopa-
thy275. We found that in partially nephrectomized mice,
treatment with pNaKtide reduced systemic oxidative
stress and cardiac Na+/K+-ATPase–Src–ROS amplifica-
tion (as evidenced by a decrease in protein carbonylation
and HO1 expression), cardiac hypertrophy and fibro-
sis; improved left ventricular diastolic function; and,
somewhat surprisingly, ameliorated anaemia. pNaKtide
also reversed established uraemic cardiomyopathy in a
dose-​dependent manner275.
Crosstalk between signalling pathways
Although each of the aforementioned mechanisms can
produce some features that are consistent with uraemic
cardiomyopathy, it is clear that interactions and cross-
talk occur between the different signalling pathways. For
example, FGF23-mediated cellular hypertrophy is asso-
ciated with increased production and secretion of Ang II
by cardiomyocytes279. In human and rat models of kid-
ney injury, treatment with the Ang II receptor antagonist
valsartan is associated with an increase in the levels of
soluble Klotho280,281. Indoxyl sulfate increases Ang II sig-
nalling and the levels of this uraemic toxin are strongly
associated with the development of arteriosclerosis in
CKD282 and positively correlate with the levels of FGF23
in advanced CKD283. Moreover, TGFβ-​induced collagen
production in cardiac fibroblasts and the accumulation
of α-​actinin protein in cardiomyocytes are attenuated by
soluble Klotho164. Determining the relative contribution
of each pathway to the development of the uraemic car-
diomyopathy phenotype remains challenging. However,
as detailed above, oxidative stress has a key role in each
of the major mechanisms that induce LVH and cardiac
fibrosis in CKD (Fig. 5).
Accumulating data indicate that the major signal-
ling pathways that are operant in uraemic cardiomyo-
pathy involve derangements of cellular redox10,26,41,275,284.
For example, Ang II and α-​adrenoceptor agonists all cause
increased generation of NOX-​derived ROS through its
unique GPCR, which modulates specific signalling path-
ways during the development of cardiac hypertrophy285.
Excessive oxidative stress is a major cause of endothelial
dysfunction in CKD286 and results in oxidation of LDL
cholesterol, which triggers inflammation and progression
of atherosclerotic vascular disease286.
Therapeutic approaches
As LVH is the most commonly diagnosed cardiovascu-
lar abnormality and an extremely strong, independent
predictor of cardiovascular mortality in patients with
CKD11–13, targeting the mechanisms that are involved in
the development of uraemic cardiomyopathy is a logi­
cal approach to potentially improve outcomes in this
www.nature.com/nrneph
 Reviews

population. Conventional haemodialysis is the most
common treatment option for patients with ESRD.
However, uraemic cardiomyopathy tends to persist and
even worsen once haemodialysis is initiated.
Renin–angiotensin system
Targeting the RAAS is an effective antihypertensive
strategy287, and treatment with either an ACE inhibi-
tor or an angiotensin receptor blocker (ARB) reduces
the risk of heart failure in patients with proteinuria and
diabetic nephropathy288. Several clinical studies have
attempted to delineate the potential cardiovascular ben-
efits of targeting the RAAS in patients with CKD. The
PROGRESS study reported that treatment with the ACE
inhibitor perindopril reduced the risk of major cardio-
vascular events by 30% in patients with CKD (n = 1,757)
during 4 years of follow-​up289. Similarly, the HOPE ran-
domized trial, which enrolled 980 patients with CKD,
reported that treatment with the ACE inhibitor rami-
pril reduced the incidence of cardiovascular death and

Haemodynamic Hyperphosphataemia Retention ↑ Endogenous Insulin

overload and vitamin D deficiency of uraemic cardiotonic resistance
toxins steroids
Mechanical
stress
↓ Soluble
↑ FGF23 Klotho
FGFR4 Ca2+ ↑ Insulin
↑ TGFβ ↑ Ang II ↑ Catecholamines ↑ PTH ↑ IS
Cytokines
Integrin gp130 TGFβR AT1R β-AR PTH1R NOX Na+/K+-ATPase Insulin
receptor

TRPC6
FAK Src Src IRS1
JAK SMAD2 Gαq Gαs Gαs PLCγ
Ras and IS SOS PI3K
STAT PLC
Raf SMAD3 Ras PtdInsP3
InsP3 and
MEK DAG PKA Raf PDK
ERK1, PKC Glutathione MEK AKT
ERK2, JUN
and MAPK ERK1 and MAPK CaM ERK1
ERK2 and
Calcineurin ERK2
NFAT

ROS

Uraemic
Expression of hypertrophy and fibrosis genes
cardiomyopathy
Nucleus

Fig. 5 | Crosstalk between signalling pathways involved in uraemic
cardiomyopathy. All of the major mechanisms that are involved in the
pathogenesis of uraemic cardiomyopathy — haemodynamic overload,
mineral metabolic disorder, insulin resistance and increased levels of
uraemic toxins and endogenous cardiotonic steroids (CTS) — result in the
generation of reactive oxygen species (ROS). Mechanical stress stimulates
ROS production through integrin-​mediated Rac–mitogen-​activated
protein kinase (MAPK) signalling, whereas activation of G protein-​coupled
receptors, such as angiotensin II (Ang II) receptor type 1 (AT1R) and the
β-​adrenergic receptor (β-​AR), leads to ROS production via the phospholipase
C (PLC)–MAPK and protein kinase A (PKA)–Ca2+ signalling pathways,
respectively. Transforming growth factor-​β (TGFβ) stimulates mitochondrial
oxidative phosphorylation and further generation of ROS. The involvement
of ROS in hyperphosphataemia, hyperparathyroidism and elevated
fibroblast growth factor 23 (FGF23)-induced cardiac hypertrophy is not
clear. However, all of these mechanisms may produce ROS through
activation of Ca2+-mediated oxidative stress. Soluble Klotho, on the other
hand, not only directly blocks NADPH oxidase (NOX)-mediated ROS
generation but also inhibits transient receptor potential cation channel,
subfamily C, member 6 (TRPC6) and indoxyl sulfate (IS)-mediated ROS
generation. Insulin induces ROS generation through the insulin receptor
substrate 1 (IRS1)–Ras (small GTPase)–Raf (RAF proto-​oncogene serine/
threonine-​protein kinase) pathway. However, ROS can themselves inhibit
the insulin–phosphoinositide 3-kinase (PI3K)–protein kinase B (AKT)
pathway and thereby exacerbate insulin resistance. Accumulation of
endogenous CTS signalling through Na +/K +-ATPase results in the
generation of ROS, which in turn are capable of initiating further Na+/K+-
ATPase–tyrosine-​p rotein kinase Src signalling, forming an oxidant
amplification loop10,272,275,314,315. In addition to their role in regulating some
of the mediators of the signalling pathways that are involved in these
mechanisms, ROS induce the expression of genes that cause cardiac
hypertrophy and fibrosis. CaM, calmodulin; DAG, diacylglycerol; ERK ,
extracellular-​signal-regulated kinase; FAK , focal adhesion kinase; FGFR4,
fibroblast growth factor receptor 4; Gαs and Gαq, Gs and Gq α-subunits,
respectively ; gp130, glycoprotein 130; InsP3, inositol trisphosphate; JAK ,
Janus-​associated kinase; MEK , mitogen-activated protein kinase kinase;
NFAT, nuclear target of activated T cells; PDK , phosphoinositide-​dependent
kinase 1; PtdIns(3,4,5)P3, phosphatidylinositol-3,4,5-trisphosphate; PKC,
protein kinase C; PTH, parathyroid hormone; SOS, son-​of-sevenless; STAT,
signal transducer and activator of transcription; TGFβR , TGFβ receptor.

Nature Reviews | Nephrology

Reviews
myocardial infarction during 3.5–5.5 years of follow-​up290.
However, no significant cardiovascular benefit of
treatment with another ACE inhibitor, fosinopril, was
observed in patients with ESRD (n = 397) in another
well-​conducted study291.
Targeting the RAAS using the mineralocorticoid
receptor blocker spironolactone in addition to an ACE
inhibitor or an ARB in patients with CKD is associated
with increased risk of hyperkalaemia292. This risk is not
limited to patients with ESRD as indicated by the finding
that hyperkalaemia-​associated mortality in Canadian
patients with congestive heart failure increased fol-
lowing publication of the RALES study, which led to
widespread use of spironolactone in addition to other
RAAS therapy293.
The adrenergic system
β-Blockers are the most commonly prescribed cardio­
vascular medications among patients on dialysis294.
However, data on their utility in improving cardiovascular
outcomes in this population are conflicting.
A small randomized trial with 2 years of follow-​up
reported that carvedilol attenuated pathological cardiac
remodelling and reduced morbidity and mortality
in patients with dilated cardiomyopathy on dialysis
(n = 114)295. In the SENIORS trial, nebivolol therapy
reduced cardiovascular hospital admission among
elderly patients (n = 2,112) with heart failure and mild
or moderate renal impairment during a follow-​up
period of ~21 months296. In addition, a meta-​analysis
that included data from eight trials with a total of 6,949
participants identified cardiac benefits of β-​blockers in
patients with CKD and chronic heart failure297. A rand-
omized controlled trial in patients with LVH on haemo-
dialysis (n = 200) reported that treatment with atenolol
seemed to be superior to ACE inhibitor therapy using
lisinopril in terms of cardiovascular morbidity; how-
ever, changes in left ventricular mass index were simi-
lar in the study groups298. By contrast, an observational
study from Canada reported no beneficial effects of
β-blockers on cardiovascular outcomes among patients
on dialysis aged >66 years299. Similar to RAAS inhibi-
tors, use of β-​blockers is associated with increased risk
of hyperkalaemia in patients with CKD. Further studies of
β-​blockers in the setting of different stages of CKD are
certainly indicated.
FGF23 and Klotho
Although the molecular mechanisms by which FGF23
and Klotho affect cardiac function in patients with CKD
remain unclear, the available evidence strongly suggests
that these factors are involved in the development of
uraemic cardiomyopathy and might therefore serve as
potential therapeutic targets.
In a small open-​label single-​arm trial (n = 55), treat-
ment with the calcimimetic cinacalcet lowered serum
FGF23 levels in patients with secondary hyperparath-
yroidism on dialysis300. Unfortunately, cardiovascular
outcomes were not assessed in this study. The EVOLVE
trial, which included 2,602 patients with secondary
hyperparathyroidism on haemodialysis, reported that
treatment with cinacalcet significantly reduced the
serum level of FGF23 and seemed to have beneficial
effects on cardiovascular end points in older patients146.
A meta-​analysis that included data from 24 randomized
controlled trials reported that treatment with cinacalcet
lowered the serum levels of PTH, calcium, phosphate
and FGF23 in patients on dialysis, but this analysis did
not identify a beneficial effect on cardiovascular out-
comes (such as cardiac hypertrophy, ischaemic heart
diseases or cardiac function) or show that cinacalcet
significantly improved all-​cause mortality301. Inhibitors
of FGF23 synthesis, FGFR4 blockers and soluble Klotho
mimetics might be potential novel therapeutic agents for
uraemic cardiomyopathy.
Insulin resistance
The effectiveness of treatment for insulin resistance in
patients with CKD is still under debate. In a cohort of
5,290 patients on dialysis with diabetes, thiazolidinedi-
one treatment was associated with significantly lower
cardiovascular mortality among insulin-​independent
but not insulin-​dependent patients302. However, con-
cern exists that rosiglitazone might increase the risk of
adverse outcomes in patients with diabetes who are on
dialysis. Among 2,393 patients on long-​term haemo-
dialysis who were monitored for a median of 1.1 years
in the DOPPS trial, rosiglitazone use was significantly
associated with higher cardiovascular disease and
all-​cause mortality303.
Uraemic toxins
An orally administered carbon adsorbent, AST-120,
that can adsorb various uraemic toxins has been
approved in Japan, Korea and the Philippines for use
in delaying the initiation of dialysis and ameliorating
the symptoms of uraemia in patients with progressive
CKD. Although a small clinical trial in Japan confirmed
that AST-120 was effective in slowing the progression
of renal disease304, two randomized placebo-​controlled
trials involving 2,035 patients with moderate to severe
CKD did not show a beneficial effect of adding AST-120
to standard therapy305.
Oxidative stress
Increased levels of oxidative stress and inflammation are
prevalent in patients undergoing haemodialysis and are
associated with increased cardiovascular mortality. A study
conducted in patients with diabetes (n = 1,161) with ESRD
undergoing haemodialysis showed that carbonylated albu-
min was strongly associated with 1-year adjusted risk of
cardiovascular mortality and 4-year risk of congestive
heart failure306. A study that included 65 children with
CKD showed a positive correlation between serum levels
of oxLDL and LVH307. However, the results of studies of
antioxidative approaches have been disappointing. In a
prospective, placebo-​controlled, double-​blind clinical trial
that involved 353 patients on haemodialysis, administra-
tion of antioxidant therapy (mixed tocopherols (666 inter-
national units (IU) per day) and α-​lipoic acid (600 mg per
day)) did not have a significant effect on biomarkers of
inflammation or oxidative stress at 6-month follow-​up308.
Moreover, a meta-​analysis of 14 studies that investigated
the effectiveness of antioxidant agents in patients with
www.nature.com/nrneph
 Reviews

diabetic kidney disease found that antioxidant treatment Conclusions

significantly decreased albuminuria but had no beneficial
effect on cardiovascular outcomes309.
To date, most clinical antioxidant strategies employ
the use of antioxidant or free radical scavengers that
neutralize oxidants but do not affect the factors
that result in oxidative stress (for example, increased
production or impaired detoxification). We propose
that the results of targeting the amplification of ROS
generation might be more promising as we have shown
in experimental animals275. The Na+/K+-ATPase–Src–
ROS signalling amplification loop might be a prom-
ising therapeutic target (pNaKtide) for the prevention
and treatment of uraemic cardiomyopathy and other
comorbidities that are derived from ROS in CKD.
However, it must be stressed that this approach is still
at proof-​of-concept stage, and other strategies that also
once seemed promising have previously failed in the
clinical arena.
The pathophysiology of uraemic cardiomyopathy
involves multiple interacting mechanisms and current
clinical treatment is inadequate. The available evidence
strongly suggests that oxidative stress has an important
pathophysiological role and is involved in a variety
of molecular pathways that lead to the development of
uraemic cardiomyopathy. To date, the beneficial effects
of antioxidant therapy in patients with CKD in general
and in those with uraemic cardiomyopathy have not
been demonstrated. However, we believe that controlling
pathological ROS amplification by targeting the Na+/K+-
ATPase–Src signalling complex or other pathways that
generate ROS might be promising therapeutic targets
to address uraemic cardiomyopathy and other com-
plications that result from increased oxidative stress in
patients with CKD
Published online xx xx xxxx

1. Collins, A. J., Foley, R. N., Gilbertson, D. T. & Chen, S. C.
United States Renal Data System public health
surveillance of chronic kidney disease and
end-​stage renal disease. Kidney Int. Suppl. 5, 2–7
(2015).
2. Silverberg, D., Wexler, D., Blum, M., Schwartz, D. &
Iaina, A. The association between congestive heart
failure and chronic renal disease. Curr. Opin. Nephrol.
Hypertens. 13, 163–170 (2004).
3. London, G. M., Pannier, B., Marchais, S. J.
& Guerin, A. P. Calcification of the aortic valve in the
dialyzed patient. J. Am. Soc. Nephrol. 11, 778–783
(2000).
4. Dad, T. & Weiner, D. E. Stroke and chronic kidney
disease: epidemiology, pathogenesis, and management
across kidney disease stages. Semin. Nephrol. 35,
311–322 (2015).
5. Kulkarni, N., Gukathasan, N., Sartori, S. & Baber, U.
Chronic kidney disease and atrial fibrillation:
a contemporary overview. J. Atr. Fibrillation 5, 448
(2012).
6. Whitman, I. R., Feldman, H. I. & Deo, R. CKD and
sudden cardiac death: epidemiology, mechanisms,
and therapeutic approaches. J. Am. Soc. Nephrol. 23,
1929–1939 (2012).
7. Dennis, V. W. Coronary heart disease in patients with
chronic kidney disease. J. Am. Soc. Nephrol. 16
(Suppl. 2), 103–106 (2005).
8. Moe, S. M. & Chen, N. X. Mechanisms of vascular
calcification in chronic kidney disease. J. Am.
Soc. Nephrol. 19, 213–216 (2008).
9. Khan, N. A. et al. Kidney function and mortality among
patients with left ventricular systolic dysfunction.
J. Am. Soc. Nephrol. 17, 244–253 (2006).
10. Wang, X., Liu, J., Drummond, C. A. & Shapiro, J. I.
Sodium potassium adenosine triphosphatase
(Na/K-ATPase) as a therapeutic target for uremic
cardiomyopathy. Expert Opin. Ther. Targets 21,
531–541 (2017).
11. London, G. M. et al. Alterations of left ventricular
hypertrophy in and survival of patients receiving
hemodialysis: follow-​up of an interventional study.
J. Am. Soc. Nephrol. 12, 2759–2767 (2001).
12. Middleton, R. J., Parfrey, P. S. & Foley, R. N. Left
ventricular hypertrophy in the renal patient.
J. Am. Soc. Nephrol. 12, 1079–1084 (2001).
13. Zoccali, C. et al. Prognostic value of echocardiographic
indicators of left ventricular systolic function in
asymptomatic dialysis patients. J. Am. Soc. Nephrol.
15, 1029–1037 (2004).
14. Kennedy, D. et al. Effect of chronic renal failure on
cardiac contractile function, calcium cycling, and gene
expression of proteins important for calcium
homeostasis in the rat. J. Am. Soc. Nephrol. 14,
90–97 (2003).
15. Nagueh, S. F. et al. Recommendations for the
evaluation of left ventricular diastolic function by
echocardiography: an update from the American
Society of Echocardiography and the European
Association of Cardiovascular Imaging. Eur. Heart J.
Cardiovasc. Imaging 17, 1321–1360 (2016).
16. Otsuka, T., Suzuki, M., Yoshikawa, H. & Sugi, K. Left
ventricular diastolic dysfunction in the early stage of
chronic kidney disease. J. Cardiol. 54, 199–204
(2009).
17. de Almeida, E. A. et al. Diastolic function in several
stages of chronic kidney disease in patients with
autosomal dominant polycystic kidney disease:
a tissue Doppler imaging study. Kidney Blood
Press. Res. 30, 234–239 (2007).
18. Diez, J. Mechanisms of cardiac fibrosis in hypertension.
J. Clin. Hypertens. 9, 546–550 (2007).
19. Lopez, B., Gonzalez, A., Hermida, N., Laviades, C. &
Diez, J. Myocardial fibrosis in chronic kidney disease:
potential benefits of torasemide. Kidney Int.
74 (Suppl. 111), S19–S23 (2008).
20. Hung, S. C., Lai, Y. S., Kuo, K. L. & Tarng, D. C. Volume
overload and adverse outcomes in chronic kidney
disease: clinical observational and animal studies.
J. Am. Heart Assoc. 4, e001918 (2015).
21. Grabner, A. & Faul, C. The role of fibroblast growth
factor 23 and Klotho in uremic cardiomyopathy.
Curr. Opin. Nephrol. Hypertens. 25, 314–324
(2016).
22. Shinohara, K. et al. Insulin resistance as an
independent predictor of cardiovascular mortality in
patients with end-​stage renal disease. J. Am. Soc.
Nephrol. 13, 1894–1900 (2002).
23. Spoto, B., Pisano, A. & Zoccali, C. Insulin resistance
in chronic kidney disease: a systematic review.
Am. J. Physiol. Renal Physiol. 311, F1087–F1108
(2016).
24. Hung, S. C., Kuo, K. L., Wu, C. C. & Tarng, D. C.
Indoxyl sulfate: a novel cardiovascular risk factor in
chronic kidney disease. J. Am. Heart Assoc. 6,
e005022 (2017).
25. Vanholder, R., Schepers, E., Pletinck, A., Nagler, E. V.
& Glorieux, G. The uremic toxicity of indoxyl sulfate
and p-​cresyl sulfate: a systematic review. J. Am. Soc.
Nephrol. 25, 1897–1907 (2014).
26. Kennedy, D. J., Malhotra, D. & Shapiro, J. I. Molecular
insights into uremic cardiomyopathy: cardiotonic
steroids and Na/K ATPase signaling. Cell. Mol. Biol.
52, 3–14 (2006).
27. Alhaj, E. et al. Uremic cardiomyopathy:
an underdiagnosed disease. Congest. Heart Fail.
19, E40–E45 (2013).
28. Zoccali, C. et al. Chronic fluid overload and mortality in
ESRD. J. Am. Soc. Nephrol. 28, 2491–2497 (2017).
29. Ruwhof, C. & van der Laarse, A. Mechanical stress-​
induced cardiac hypertrophy: mechanisms and signal
transduction pathways. Cardiovasc. Res. 47, 23–37
(2000).
30. Sadoshima, J., Jahn, L., Takahashi, T., Kulik, T. J. &
Izumo, S. Molecular characterization of the
stretch-induced adaptation of cultured cardiac cells.
An in vitro model of load-​induced cardiac hypertrophy.
J. Biol. Chem. 267, 10551–10560 (1992).
31. Kira, Y. et al. Effect of long-​term cyclic mechanical load
on protein synthesis and morphological changes in
cultured myocardial cells from neonatal rat.
Cardiovasc. Drugs Ther. 8, 251–262 (1994).
32. Komuro, I. et al. Stretching cardiac myocytes stimulates
protooncogene expression. J. Biol. Chem. 265,
3595–3598 (1990).
33. Cooper, G. t., Kent, R. L., Uboh, C. E., Thompson, E. W.
& Marino, T. A. Hemodynamic versus adrenergic
control of cat right ventricular hypertrophy.
J. Clin. Invest. 75, 1403–1414 (1985).
34. Komuro, I., Kurabayashi, M., Takaku, F. & Yazaki, Y.
Expression of cellular oncogenes in the myocardium
during the developmental stage and pressure-​
overloaded hypertrophy of the rat heart. Circ. Res. 62,
1075–1079 (1988).
35. Sadoshima, J., Xu, Y., Slayter, H. S. & Izumo, S.
Autocrine release of angiotensin II mediates stretch-​
induced hypertrophy of cardiac myocytes in vitro.
Cell 75, 977–984 (1993).
36. Tamura, K. et al. Activation of angiotensinogen gene in
cardiac myocytes by angiotensin II and mechanical
stretch. Am. J. Physiol. 275, R1–R9 (1998).
37. Malhotra, R., Sadoshima, J. & Brosius, F. C. 3rd &
Izumo, S. Mechanical stretch and angiotensin II
differentially upregulate the renin-​angiotensin system
in cardiac myocytes in vitro. Circ. Res. 85, 137–146
(1999).
38. Rockman, H. A. et al. Segregation of atrial-​specific and
inducible expression of an atrial natriuretic factor
transgene in an in vivo murine model of cardiac
hypertrophy. Proc. Natl Acad. Sci. USA 88,
8277–8281 (1991).
39. Fiorillo, C. et al. Cardiac volume overload rapidly
induces oxidative stress-​mediated myocyte apoptosis
and hypertrophy. Biochim. Biophys. Acta 1741,
173–182 (2005).
40. Kennedy, D. J. et al. Partial nephrectomy as a
model for uremic cardiomyopathy in the mouse.
Am. J. Physiol. Renal Physiol. 294, F450–F454 (2008).
41. Kennedy, D. J. et al. Central role for the cardiotonic
steroid marinobufagenin in the pathogenesis of
experimental uremic cardiomyopathy. Hypertension
47, 488–495 (2006).
42. Tsujimoto, I. et al. The antioxidant edaravone
attenuates pressure overload-​induced left ventricular
hypertrophy. Hypertension 45, 921–926 (2005).
43. Hotamisligil, G. S. & Davis, R. J. Cell signaling and
stress responses. Cold Spring Harb. Perspect. Biol. 8,
a006072 (2016).
44. Cohen, P. The search for physiological substrates
of MAP and SAP kinases in mammalian cells.
Trends Cell Biol. 7, 353–361 (1997).
45. Dingar, D. et al. Effect of pressure overload-​induced
hypertrophy on the expression and localization of p38
MAP kinase isoforms in the mouse heart. Cell. Signal.
22, 1634–1644 (2010).
46. Ihle, J. N. Cytokine receptor signalling. Nature 377,
591–594 (1995).
47. Schindler, C. & Darnell, J. E. Jr. Transcriptional
responses to polypeptide ligands: the JAK-​STAT
pathway. Annu. Rev. Biochem. 64, 621–651 (1995).
48. Pan, J. et al. Role of angiotensin II in activation of the
JAK/STAT pathway induced by acute pressure overload
in the rat heart. Circ. Res. 81, 611–617 (1997).

Nature Reviews | Nephrology

Reviews
49. Lambers Heerspink, H. J., de Borst, M. H.,
Bakker, S. J. & Navis, G. J. Improving the efficacy of
RAAS blockade in patients with chronic kidney
disease. Nat. Rev. Nephrol. 9, 112–121 (2013).
50. Franssen, C. F. & Navis, G. Chronic kidney disease:
RAAS blockade and diastolic heart failure in chronic
kidney disease. Nat. Rev. Nephrol. 9, 190–192 (2013).
51. Hudlicka, O., Brown, M. & Egginton, S. Angiogenesis
in skeletal and cardiac muscle. Physiol. Rev. 72,
369–417 (1992).
52. Kurdi, M. & Booz, G. W. New take on the role of
angiotensin II in cardiac hypertrophy and fibrosis.
Hypertension 57, 1034–1038 (2011).
53. Mehta, P. K. & Griendling, K. K. Angiotensin II cell
signaling: physiological and pathological effects in the
cardiovascular system. Am. J. Physiol. Cell Physiol.
292, C82–C97 (2007).
54. Fernandez-​Ruiz, I. Pharmacotherapy: angiotensin II —
a new tool in vasodilatory shock. Nat. Rev. Cardiol.
14, 384 (2017).
55. Taniyama, Y. et al. Role of p38 MAPK and MAPKAPK-2
in angiotensin II-​induced Akt activation in vascular
smooth muscle cells. Am. J. Physiol. Cell Physiol. 287,
C494–C499 (2004).
56. Pellieux, C. et al. Dilated cardiomyopathy and impaired
cardiac hypertrophic response to angiotensin II in mice
lacking FGF-2. J. Clin. Invest. 108, 1843–1851 (2001).
57. Zablocki, D. & Sadoshima, J. Angiotensin II and
oxidative stress in the failing heart. Antioxid. Redox
Signal. 19, 1095–1109 (2013).
58. Kawada, N., Imai, E., Karber, A., Welch, W. J. &
Wilcox, C. S. A mouse model of angiotensin II slow
pressor response: role of oxidative stress. J. Am.
Soc. Nephrol. 13, 2860–2868 (2002).
59. Polizio, A. H. et al. Angiotensin II regulates cardiac
hypertrophy via oxidative stress but not antioxidant
enzyme activities in experimental renovascular
hypertension. Hypertens. Res. 31, 325–334 (2008).
60. Zhao, Q. D. et al. NADPH oxidase 4 induces cardiac
fibrosis and hypertrophy through activating Akt/mTOR
and NFkappaB signaling pathways. Circulation 131,
643–655 (2015).
61. Ferrario, C. M., Chappell, M. C., Dean, R. H. & Iyer, S. N.
Novel angiotensin peptides regulate blood pressure,
endothelial function, and natriuresis. J. Am. Soc.
Nephrol. 9, 1716–1722 (1998).
62. Balakumar, P. & Jagadeesh, G. A century old renin-​
angiotensin system still grows with endless possibilities:
AT1 receptor signaling cascades in cardiovascular
physiopathology. Cell. Signal. 26, 2147–2160 (2014).
63. Jankowski, V. et al. Angioprotectin: an angiotensin
II-​like peptide causing vasodilatory effects. FASEB J.
25, 2987–2995 (2011).
64. Lautner, R. Q. et al. Discovery and characterization
of alamandine: a novel component of the renin-​
angiotensin system. Circ. Res. 112, 1104–1111
(2013).
65. Liu, C. et al. Alamandine attenuates hypertension and
cardiac hypertrophy in hypertensive rats. Amino Acids
50, 1071–1081 (2018).
66. Schlaich, M. P. et al. Sympathetic activation in chronic
renal failure. J. Am. Soc. Nephrol. 20, 933–939
(2009).
67. Park, J. Cardiovascular risk in chronic kidney disease:
role of the sympathetic nervous system. Cardiol. Res.
Pract. 2012, 319432 (2012).
68. Fisher, J. P., Young, C. N. & Fadel, P. J. Central
sympathetic overactivity: maladies and mechanisms.
Auton. Neurosci. 148, 5–15 (2009).
69. Zoccali, C. et al. Plasma norepinephrine predicts
survival and incident cardiovascular events in patients
with end-​stage renal disease. Circulation 105,
1354–1359 (2002).
70. Grassi, G., Seravalle, G., Dell’Oro, R. & Mancia, G.
Sympathetic mechanisms, organ damage, and
antihypertensive treatment. Curr. Hypertens. Rep. 13,
303–308 (2011).
71. Chalothorn, D. et al. Differential cardiovascular
regulatory activities of the alpha 1B- and alpha 1D-​
adrenoceptor subtypes. J. Pharmacol. Exp. Ther. 305,
1045–1053 (2003).
72. Xu, Q. et al. Myocardial oxidative stress contributes to
transgenic beta(2)-adrenoceptor activation-​induced
cardiomyopathy and heart failure. Br. J. Pharmacol.
162, 1012–1028 (2011).
73. Cohn, J. N. et al. Plasma norepinephrine as a guide
to prognosis in patients with chronic congestive heart
failure. N. Engl. J. Med. 311, 819–823 (1984).
74. Elias, A. N., Vaziri, N. D. & Maksy, M. Plasma
norepinephrine, epinephrine, and dopamine levels
in end-​stage renal disease. Effect of hemodialysis.
Arch. Intern. Med. 145, 1013–1015 (1985).
75. Patel, M. B. et al. Altered function and structure
of the heart in dogs with chronic elevation in plasma
norepinephrine. Circulation 84, 2091–2100 (1991).
76. Barki-​Harrington, L., Perrino, C. & Rockman, H. A.
Network integration of the adrenergic system in
cardiac hypertrophy. Cardiovasc. Res. 63, 391–402
(2004).
77. Vidal, M., Wieland, T., Lohse, M. J. & Lorenz, K.
beta-Adrenergic receptor stimulation causes cardiac
hypertrophy via a Gbetagamma/Erk-​dependent
pathway. Cardiovasc. Res. 96, 255–264 (2012).
78. Moniri, N. H. & Daaka, Y. Agonist-​stimulated reactive
oxygen species formation regulates beta2-adrenergic
receptor signal transduction. Biochem. Pharmacol.
74, 64–73 (2007).
79. Bovo, E., Lipsius, S. L. & Zima, A. V. Reactive oxygen
species contribute to the development of
arrhythmogenic Ca(2)(+) waves during beta-​adrenergic
receptor stimulation in rabbit cardiomyocytes.
J. Physiol. 590, 3291–3304 (2012).
80. Villarreal, F. J. & Dillmann, W. H. Cardiac
hypertrophy-induced changes in mRNA levels for
TGF-beta 1, fibronectin, and collagen. Am. J. Physiol.
262, H1861–H1866 (1992).
81. Lee, A. A., Dillmann, W. H., McCulloch, A. D. &
Villarreal, F. J. Angiotensin II stimulates the autocrine
production of transforming growth factor-​beta 1 in
adult rat cardiac fibroblasts. J. Mol. Cell. Cardiol. 27,
2347–2357 (1995).
82. Murakami, K., Takemura, T., Hino, S. & Yoshioka, K.
Urinary transforming growth factor-​beta in patients
with glomerular diseases. Pediatr. Nephrol. 11,
334–336 (1997).
83. Bottinger, E. P. & Bitzer, M. TGF-​beta signaling in
renal disease. J. Am. Soc. Nephrol. 13, 2600–2610
(2002).
84. Dobaczewski, M., Chen, W. & Frangogiannis, N. G.
Transforming growth factor (TGF)-beta signaling in
cardiac remodeling. J. Mol. Cell. Cardiol. 51,
600–606 (2011).
85. Kuwahara, F. et al. Transforming growth factor-​beta
function blocking prevents myocardial fibrosis and
diastolic dysfunction in pressure-​overloaded rats.
Circulation 106, 130–135 (2002).
86. Saito, K. et al. Iron chelation and a free radical
scavenger suppress angiotensin II-​induced
upregulation of TGF-​beta1 in the heart. Am. J. Physiol.
Heart Circ. Physiol. 288, H1836–H1843 (2005).
87. Elkareh, J. et al. Marinobufagenin stimulates
fibroblast collagen production and causes fibrosis in
experimental uremic cardiomyopathy. Hypertension
49, 215–224 (2007).
88. de Albuquerque Suassuna, P. G., Sanders-​Pinheiro, H.
& de Paula, R. B. Uremic cardiomyopathy: a new piece
in the chronic kidney disease-​mineral and bone
disorder puzzle. Front. Med. 5, 206 (2018).
89. London, G. M. et al. Uremic cardiomyopathy:
an inadequate left ventricular hypertrophy. Kidney Int.
31, 973–980 (1987).
90. Goodman, W. G. The consequences of uncontrolled
secondary hyperparathyroidism and its treatment in
chronic kidney disease. Semin. Dial. 17, 209–216
(2004).
91. Andersson, P., Rydberg, E. & Willenheimer, R. Primary
hyperparathyroidism and heart disease—a review.
Eur. Heart J. 25, 1776–1787 (2004).
92. Rostand, S. G. & Drueke, T. B. Parathyroid hormone,
vitamin D, and cardiovascular disease in chronic renal
failure. Kidney Int. 56, 383–392 (1999).
93. Lishmanov, A., Dorairajan, S., Pak, Y., Chaudhary, K. &
Chockalingam, A. Elevated serum parathyroid
hormone is a cardiovascular risk factor in moderate
chronic kidney disease. Int. Urol. Nephrol. 44,
541–547 (2012).
94. Silver, J. & Naveh-​Many, T. FGF-23 and secondary
hyperparathyroidism in chronic kidney disease.
Nat. Rev. Nephrol. 9, 641–649 (2013).
95. Krajisnik, T. et al. Fibroblast growth factor-23
regulates parathyroid hormone and 1alpha-​
hydroxylase expression in cultured bovine parathyroid
cells. J. Endocrinol. 195, 125–131 (2007).
96. Schluter, K. D. & Piper, H. M. Cardiovascular actions
of parathyroid hormone and parathyroid hormone-​
related peptide. Cardiovasc. Res. 37, 34–41 (1998).
97. Urena, P. et al. Parathyroid hormone (PTH)/PTH-​
related peptide receptor messenger ribonucleic acids
are widely distributed in rat tissues. Endocrinology
133, 617–623 (1993).
98. Smogorzewski, M., Zayed, M., Zhang, Y. B., Roe, J. &
Massry, S. G. Parathyroid hormone increases cytosolic
calcium concentration in adult rat cardiac myocytes.
Am. J. Physiol. 264, H1998–H2006 (1993).
99. Yao, L. et al. Parathyroid hormone and the risk of
incident hypertension: the Atherosclerosis Risk in
Communities study. J. Hypertens. 34, 196–203
(2016).
100. Craver, L. et al. Mineral metabolism parameters
throughout chronic kidney disease stages 1-5—
achievement of K/DOQI target ranges. Nephrol. Dial.
Transplant. 22, 1171–1176 (2007).
101. Hruska, K. A., Mathew, S., Lund, R., Qiu, P.
& Pratt, R. Hyperphosphatemia of chronic kidney
disease. Kidney Int. 74, 148–157 (2008).
102. Slinin, Y., Foley, R. N. & Collins, A. J. Calcium,
phosphorus, parathyroid hormone, and cardiovascular
disease in hemodialysis patients: the USRDS waves 1,
3, and 4 study. J. Am. Soc. Nephrol. 16, 1788–1793
(2005).
103. Shaman, A. M. & Kowalski, S. R. Hyperphosphatemia
management in patients with chronic kidney disease.
Saudi Pharm. J. 24, 494–505 (2016).
104. Vervloet, M. G. et al. The role of phosphate in kidney
disease. Nat. Rev. Nephrol. 13, 27–38 (2017).
105. Yamazaki-​Nakazawa, A. et al. Correction of
hyperphosphatemia suppresses cardiac remodeling in
uremic rats. Clin. Exp. Nephrol. 18, 56–64 (2014).
106. Rahabi-​Layachi, H., Ourouda, R., Boullier, A.,
Massy, Z. A. & Amant, C. Distinct effects of inorganic
phosphate on cell cycle and apoptosis in human
vascular smooth muscle cells. J. Cell. Physiol. 230,
347–355 (2015).
107. Di Marco, G. S. et al. Increased inorganic phosphate
induces human endothelial cell apoptosis in vitro.
Am. J. Physiol. Renal Physiol. 294, F1381–F1387
(2008).
108. Gupta, D., Brietzke, S., Hayden, M. R.,
Kurukulasuriya, L. R. & Sowers, J. R. Phosphate
metabolism in cardiorenal metabolic disease.
Cardiorenal Med. 1, 261–270 (2011).
109. Mehrotra, R. et al. Chronic kidney disease,
hypovitaminosis D, and mortality in the United States.
Kidney Int. 76, 977–983 (2009).
110. Gluba-​Brzozka, A., Franczyk, B., Cialkowska-​Rysz, A.,
Olszewski, R. & Rysz, J. Impact of vitamin D on the
cardiovascular system in advanced chronic kidney
disease (CKD) and dialysis patients. Nutrients 10, 709
(2018).
111. Holick, M. F. Vitamin D deficiency. N. Engl. J. Med.
357, 266–281 (2007).
112. Jones, G. Expanding role for vitamin D in chronic
kidney disease: importance of blood 25-OH-​D levels
and extra-​renal 1alpha-​hydroxylase in the classical and
nonclassical actions of 1alpha, 25-dihydroxyvitamin
D(3). Semin. Dial. 20, 316–324 (2007).
113. Nitsa, A. et al. Vitamin D in cardiovascular disease.
In Vivo 32, 977–981 (2018).
114. Wu, J., Garami, M., Cheng, T. & Gardner, D. G.
1,25(OH)2 vitamin D3, and retinoic acid antagonize
endothelin-​stimulated hypertrophy of neonatal rat
cardiac myocytes. J. Clin. Invest. 97, 1577–1588
(1996).
115. Li, Y. C. et al. 1,25-Dihydroxyvitamin D(3) is a negative
endocrine regulator of the renin-​angiotensin system.
J. Clin. Invest. 110, 229–238 (2002).
116. Leifheit-​Nestler, M. et al. Vitamin D treatment
attenuates cardiac FGF23/FGFR4 signaling and
hypertrophy in uremic rats. Nephrol. Dial. Transplant.
32, 1493–1503 (2017).
117. Benet-​Pages, A. et al. FGF23 is processed by proprotein
convertases but not by PHEX. Bone 35, 455–462
(2004).
118. Quarles, L. D. Endocrine functions of bone in mineral
metabolism regulation. J. Clin. Invest. 118,
3820–3828 (2008).
119. Hu, M. C., Shiizaki, K., Kuro-​o, M. & Moe, O. W.
Fibroblast growth factor 23 and Klotho: physiology and
pathophysiology of an endocrine network of mineral
metabolism. Annu. Rev. Physiol. 75, 503–533 (2013).
120. Leifheit-​Nestler, M. & Haffner, D. Paracrine effects of
FGF23 on the heart. Front. Endocrinol. 9, 278
(2018).
121. Tagliabracci, V. S. et al. Dynamic regulation of FGF23
by Fam20C phosphorylation, GalNAc-​T3 glycosylation,
and furin proteolysis. Proc. Natl Acad. Sci. USA 111,
5520–5525 (2014).
122. Shimada, T. et al. FGF-23 is a potent regulator of
vitamin D metabolism and phosphate homeostasis.
J. Bone Miner. Res. 19, 429–435 (2004).
123. Urakawa, I. et al. Klotho converts canonical FGF
receptor into a specific receptor for FGF23. Nature
444, 770–774 (2006).
124. Saito, H. et al. Circulating FGF-23 is regulated by
1alpha, 25-dihydroxyvitamin D3 and phosphorus
in vivo. J. Biol. Chem. 280, 2543–2549 (2005).
www.nature.com/nrneph

125. Ben-​Dov, I. Z. et al. The parathyroid is a target organ
for FGF23 in rats. J. Clin. Invest. 117, 4003–4008
(2007).
126. Shimada, T. et al. Targeted ablation of Fgf23
demonstrates an essential physiological role of
FGF23 in phosphate and vitamin D metabolism.
J. Clin. Invest. 113, 561–568 (2004).
127. Hasegawa, H. et al. Direct evidence for a causative
role of FGF23 in the abnormal renal phosphate
handling and vitamin D metabolism in rats with
early-stage chronic kidney disease. Kidney Int. 78,
975–980 (2010).
128. Liu, S. et al. Fibroblast growth factor 23 is a
counter-regulatory phosphaturic hormone for vitamin D.
J. Am. Soc. Nephrol. 17, 1305–1315 (2006).
129. Lopez, I. et al. Direct and indirect effects of parathyroid
hormone on circulating levels of fibroblast growth
factor 23 in vivo. Kidney Int. 80, 475–482 (2011).
130. Rodriguez-​Ortiz, M. E. et al. Calcium deficiency reduces
circulating levels of FGF23. J. Am. Soc. Nephrol. 23,
1190–1197 (2012).
131. Tsuji, K., Maeda, T., Kawane, T., Matsunuma, A. &
Horiuchi, N. Leptin stimulates fibroblast growth
factor 23 expression in bone and suppresses renal
1alpha, 25-dihydroxyvitamin D3 synthesis in leptin-​
deficient mice. J. Bone Miner. Res. 25, 1711–1723
(2010).
132. Gutierrez, O. et al. Fibroblast growth factor-23
mitigates hyperphosphatemia but accentuates
calcitriol deficiency in chronic kidney disease. J. Am.
Soc. Nephrol. 16, 2205–2215 (2005).
133. Isakova, T. et al. Fibroblast growth factor 23 is
elevated before parathyroid hormone and phosphate
in chronic kidney disease. Kidney Int. 79, 1370–1378
(2011).
134. Isakova, T. et al. Postprandial mineral metabolism and
secondary hyperparathyroidism in early CKD. J. Am.
Soc. Nephrol. 19, 615–623 (2008).
135. Gutierrez, O. M. et al. Fibroblast growth factor 23 and
left ventricular hypertrophy in chronic kidney disease.
Circulation 119, 2545–2552 (2009).
136. Hsu, H. J. & Wu, M. S. Fibroblast growth factor 23:
a possible cause of left ventricular hypertrophy in
hemodialysis patients. Am. J. Med. Sci. 337, 116–122
(2009).
137. Isakova, T. et al. Fibroblast growth factor 23 and risks
of mortality and end-​stage renal disease in patients
with chronic kidney disease. JAMA 305, 2432–2439
(2011).
138. Gutierrez, O. M. et al. Fibroblast growth factor 23 and
mortality among patients undergoing hemodialysis.
N. Engl. J. Med. 359, 584–592 (2008).
139. Faul, C. et al. FGF23 induces left ventricular
hypertrophy. J. Clin. Invest. 121, 4393–4408 (2011).
140. Seeherunvong, W. et al. Fibroblast growth factor 23
and left ventricular hypertrophy in children on dialysis.
Pediatr. Nephrol. 27, 2129–2136 (2012).
141. Leifheit-​Nestler, M. et al. Induction of cardiac FGF23/
FGFR4 expression is associated with left ventricular
hypertrophy in patients with chronic kidney disease.
Nephrol. Dial. Transplant. 31, 1088–1099 (2016).
142. Touchberry, C. D. et al. FGF23 is a novel regulator
of intracellular calcium and cardiac contractility in
addition to cardiac hypertrophy. Am. J. Physiol.
Endocrinol. Metab. 304, E863–E873 (2013).
143. Faul, C. Fibroblast growth factor 23 and the heart.
Curr. Opin. Nephrol. Hypertens. 21, 369–375 (2012).
144. Grabner, A. et al. Activation of cardiac fibroblast
growth factor receptor 4 causes left ventricular
hypertrophy. Cell Metab. 22, 1020–1032 (2015).
145. Grabner, A. et al. FGF23/FGFR4-mediated left
ventricular hypertrophy is reversible. Sci. Rep. 7,
1993 (2017).
146. Moe, S. M. et al. Cinacalcet, fibroblast growth
factor-23, and cardiovascular disease in hemodialysis:
the evaluation of cinacalcet HCl therapy to lower
cardiovascular events (EVOLVE) trial. Circulation 132,
27–39 (2015).
147. Isakova, T. et al. Associations between fibroblast
growth factor 23 and cardiac characteristics in
pediatric heart failure. Pediatr. Nephrol. 28,
2035–2042 (2013).
148. Nehgme, R., Fahey, J. T., Smith, C. & Carpenter, T. O.
Cardiovascular abnormalities in patients with X-​linked
hypophosphatemia. J. Clin. Endocrinol. Metab. 82,
2450–2454 (1997).
149. Shalhoub, V. et al. FGF23 neutralization improves
chronic kidney disease-​associated hyperparathyroidism
yet increases mortality. J. Clin. Invest. 122, 2543–2553
(2012).
150. Pastor-​Arroyo, E. M. et al. The elevation of circulating
fibroblast growth factor 23 without kidney disease
Nature Reviews | Nephrology
does not increase cardiovascular disease risk.
Kidney Int. 94, 49–59 (2018).
151. Chue, C. D. et al. Cardiovascular effects of sevelamer
in stage 3 CKD. J. Am. Soc. Nephrol. 24, 842–852
(2013).
152. Richter, B., Haller, J., Haffner, D. & Leifheit-​Nestler, M.
Klotho modulates FGF23-mediated NO synthesis and
oxidative stress in human coronary artery endothelial
cells. Pflugers Arch. 468, 1621–1635 (2016).
153. Kurosu, H. et al. Regulation of fibroblast growth
factor-23 signaling by klotho. J. Biol. Chem. 281,
6120–6123 (2006).
154. Ito, S., Fujimori, T., Hayashizaki, Y. & Nabeshima, Y.
Identification of a novel mouse membrane-​bound
family 1 glycosidase-​like protein, which carries an
atypical active site structure. Biochim. Biophys. Acta
1576, 341–345 (2002).
155. Ogawa, Y. et al. BetaKlotho is required for metabolic
activity of fibroblast growth factor 21. Proc. Natl Acad.
Sci. USA 104, 7432–7437 (2007).
156. Fon Tacer, K. et al. Research resource: comprehensive
expression atlas of the fibroblast growth factor system
in adult mouse. Mol. Endocrinol. 24, 2050–2064
(2010).
157. Barker, S. L. et al. The demonstration of alphaKlotho
deficiency in human chronic kidney disease with a
novel synthetic antibody. Nephrol. Dial. Transplant.
30, 223–233 (2015).
158. Leone, F. et al. Soluble Klotho levels in adult renal
transplant recipients are modulated by recombinant
human erythropoietin. J. Nephrol. 27, 577–585
(2014).
159. Ritter, C. S., Zhang, S., Delmez, J., Finch, J. L. &
Slatopolsky, E. Differential expression and regulation
of Klotho by paricalcitol in the kidney, parathyroid,
and aorta of uremic rats. Kidney Int. 87, 1141–1152
(2015).
160. Lau, W. L. et al. Vitamin D receptor agonists increase
klotho and osteopontin while decreasing aortic
calcification in mice with chronic kidney disease fed a
high phosphate diet. Kidney Int. 82, 1261–1270
(2012).
161. Moreno, J. A. et al. The inflammatory cytokines
TWEAK and TNFalpha reduce renal klotho expression
through NFkappaB. J. Am. Soc. Nephrol. 22,
1315–1325 (2011).
162. Zhu, H., Gao, Y., Zhu, S., Cui, Q. & Du, J. Klotho
improves cardiac function by suppressing reactive
oxygen species (ROS) mediated apoptosis by
modulating MAPKs/Nrf2 signaling in doxorubicin-​
induced cardiotoxicity. Med. Sci. Monit. 23,
5283–5293 (2017).
163. Mitani, H. et al. In vivo klotho gene transfer
ameliorates angiotensin II-​induced renal damage.
Hypertension 39, 838–843 (2002).
164. Hu, M. C. et al. Klotho and phosphate are modulators
of pathologic uremic cardiac remodeling. J. Am.
Soc. Nephrol. 26, 1290–1302 (2015).
165. Kuro-​o, M. et al. Mutation of the mouse klotho gene
leads to a syndrome resembling ageing. Nature 390,
45–51 (1997).
166. Corsetti, G. et al. Decreased expression of Klotho in
cardiac atria biopsy samples from patients at higher
risk of atherosclerotic cardiovascular disease.
J. Geriatr. Cardiol. 13, 701–711 (2016).
167. Kurosu, H. et al. Suppression of aging in mice by the
hormone Klotho. Science 309, 1829–1833 (2005).
168. Couzin, J. Boosting gene extends mouse life span.
Science 309, 1310–1311 (2005).
169. Yamamoto, M. et al. Regulation of oxidative stress by
the anti-​aging hormone klotho. J. Biol. Chem. 280,
38029–38034 (2005).
170. Shiraki-​Iida, T. et al. Structure of the mouse klotho
gene and its two transcripts encoding membrane and
secreted protein. FEBS Lett. 424, 6–10 (1998).
171. Matsumura, Y. et al. Identification of the human klotho
gene and its two transcripts encoding membrane
and secreted klotho protein. Biochem. Biophys.
Res. Commun. 242, 626–630 (1998).
172. Lindberg, K. et al. The kidney is the principal organ
mediating klotho effects. J. Am. Soc. Nephrol. 25,
2169–2175 (2014).
173. Maekawa, Y. et al. Klotho protein diminishes
endothelial apoptosis and senescence via a mitogen-​
activated kinase pathway. Geriatr. Gerontol. Int. 11,
510–516 (2011).
174. Hui, H. et al. Klotho suppresses the inflammatory
responses and ameliorates cardiac dysfunction in
aging endotoxemic mice. Oncotarget 8,
15663–15676 (2017).
175. Shimamura, Y. et al. Serum levels of soluble secreted
alpha-​Klotho are decreased in the early stages of
Reviews
chronic kidney disease, making it a probable novel
biomarker for early diagnosis. Clin. Exp. Nephrol. 16,
722–729 (2012).
176. Yang, K. et al. Klotho protects against indoxyl
sulphate-​induced myocardial hypertrophy. J. Am.
Soc. Nephrol. 26, 2434–2446 (2015).
177. Xie, J. et al. Cardioprotection by Klotho through
downregulation of TRPC6 channels in the mouse
heart. Nat. Commun. 3, 1238 (2012).
178. Song, S. & Si, L. Y. Klotho ameliorated isoproterenol-​
induced pathological changes in cardiomyocytes via
the regulation of oxidative stress. Life Sci. 135,
118–123 (2015).
179. Kuwahara, K. et al. TRPC6 fulfills a calcineurin
signaling circuit during pathologic cardiac remodeling.
J. Clin. Invest. 116, 3114–3126 (2006).
180. Wang, Y., Kuro-​o, M. & Sun, Z. Klotho gene delivery
suppresses Nox2 expression and attenuates oxidative
stress in rat aortic smooth muscle cells via the
cAMP-PKA pathway. Aging Cell 11, 410–417 (2012).
181. Fliser, D. et al. Insulin resistance and hyperinsulinemia
are already present in patients with incipient renal
disease. Kidney Int. 53, 1343–1347 (1998).
182. DeFronzo, R. A. et al. Insulin resistance in uremia.
J. Clin. Invest. 67, 563–568 (1981).
183. Feneberg, R., Schaefer, F. & Veldhuis, J. D.
Neuroendocrine adaptations in renal disease.
Pediatr. Nephrol. 18, 492–497 (2003).
184. Walker, B. G., Phear, D. N., Martin, F. I. & Baird, C. W.
Inhibition of insulin by acidosis. Lancet 2, 964–965
(1963).
185. Hotamisligil, G. S. et al. IRS-1-mediated inhibition of
insulin receptor tyrosine kinase activity in TNF-​alpha-
and obesity-​induced insulin resistance. Science 271,
665–668 (1996).
186. Khedr, E. et al. Effect of recombinant human
erythropoietin on insulin resistance in hemodialysis
patients. Hemodial. Int. 13, 340–346 (2009).
187. Vaziri, N. D. et al. Chronic kidney disease alters
intestinal microbial flora. Kidney Int. 83, 308–315
(2013).
188. Levin, A. et al. Prevalence of abnormal serum vitamin D,
PTH, calcium, and phosphorus in patients with chronic
kidney disease: results of the study to evaluate early
kidney disease. Kidney Int. 71, 31–38 (2007).
189. Koppe, L. et al. Urea impairs beta cell glycolysis and
insulin secretion in chronic kidney disease. J. Clin.
Invest. 126, 3598–3612 (2016).
190. Koppe, L. et al. p-​Cresyl sulfate promotes insulin
resistance associated with CKD. J. Am. Soc. Nephrol.
24, 88–99 (2013).
191. Xu, H. et al. Clinical correlates of insulin sensitivity and
its association with mortality among men with CKD
stages 3 and 4. Clin. J. Am. Soc. Nephrol. 9, 690–697
(2014).
192. Li, Y., Zhang, L., Gu, Y., Hao, C. & Zhu, T. Insulin
resistance as a predictor of cardiovascular disease
in patients on peritoneal dialysis. Perit. Dial. Int. 33,
411–418 (2013).
193. Cusi, K. et al. Insulin resistance differentially affects
the PI 3-kinase- and MAP kinase-​mediated signaling in
human muscle. J. Clin. Invest. 105, 311–320 (2000).
194. Aroor, A. R., Mandavia, C. H. & Sowers, J. R. Insulin
resistance and heart failure: molecular mechanisms.
Heart Fail. Clin. 8, 609–617 (2012).
195. Boucher, J., Kleinridders, A. & Kahn, C. R. Insulin
receptor signaling in normal and insulin-​resistant
states. Cold Spring Harb. Perspect. Biol. 6, a009191
(2014).
196. Matsui, T. & Rosenzweig, A. Convergent signal
transduction pathways controlling cardiomyocyte
survival and function: the role of PI 3-kinase and Akt.
J. Mol. Cell. Cardiol. 38, 63–71 (2005).
197. Manning, B. D. & Toker, A. AKT/PKB signaling:
navigating the network. Cell 169, 381–405 (2017).
198. Alessi, D. R. et al. Mechanism of activation of protein
kinase B by insulin and IGF-1. EMBO J. 15,
6541–6551 (1996).
199. Semple, D., Smith, K., Bhandari, S. & Seymour, A. M.
Uremic cardiomyopathy and insulin resistance:
a critical role for Akt? J. Am. Soc. Nephrol. 22,
207–215 (2011).
200. McMullen, J. R. et al. Phosphoinositide
3-kinase(p110alpha) plays a critical role for the
induction of physiological, but not pathological,
cardiac hypertrophy. Proc. Natl Acad. Sci. USA 100,
12355–12360 (2003).
201. Samuelsson, A. M. et al. Hyperinsulinemia: effect
on cardiac mass/function, angiotensin II receptor
expression, and insulin signaling pathways.
Am. J. Physiol. Heart Circ. Physiol. 291, H787–H796
(2006).
Reviews
202. Cho, H., Thorvaldsen, J. L., Chu, Q., Feng, F. &
Birnbaum, M. J. Akt1/PKBalpha is required for normal
growth but dispensable for maintenance of glucose
homeostasis in mice. J. Biol. Chem. 276, 38349–38352
(2001).
203. DeBosch, B. et al. Akt1 is required for physiological
cardiac growth. Circulation 113, 2097–2104 (2006).
204. Li, Y. et al. Molecular signaling mediated by
angiotensin II type 1A receptor blockade leading to
attenuation of renal dysfunction-​associated heart
failure. J. Card Fail. 13, 155–162 (2007).
205. Haq, S. et al. Differential activation of signal
transduction pathways in human hearts with
hypertrophy versus advanced heart failure. Circulation
103, 670–677 (2001).
206. Shiojima, I. et al. Disruption of coordinated cardiac
hypertrophy and angiogenesis contributes to the
transition to heart failure. J. Clin. Invest. 115,
2108–2118 (2005).
207. Maillet, M., van Berlo, J. H. & Molkentin, J. D.
Molecular basis of physiological heart growth:
fundamental concepts and new players. Nat. Rev.
Mol. Cell Biol. 14, 38–48 (2013).
208. Amann, K. et al. Reduced capillary density in the
myocardium of uremic rats—a stereological study.
Kidney Int. 42, 1079–1085 (1992).
209. Amann, K., Breitbach, M., Ritz, E. & Mall, G.
Myocyte/capillary mismatch in the heart of uremic
patients. J. Am. Soc. Nephrol. 9, 1018–1022 (1998).
210. Siedlecki, A. M., Jin, X. & Muslin, A. J. Uremic cardiac
hypertrophy is reversed by rapamycin but not by
lowering of blood pressure. Kidney Int. 75, 800–808
(2009).
211. Matsui, T. et al. Phenotypic spectrum caused by
transgenic overexpression of activated Akt in the
heart. J. Biol. Chem. 277, 22896–22901 (2002).
212. Kataria, A., Trasande, L. & Trachtman, H. The effects
of environmental chemicals on renal function. Nat Rev.
Nephrol. 11, 610–625 (2015).
213. Thomas, S. S., Zhang, L. & Mitch, W. E. Molecular
mechanisms of insulin resistance in chronic kidney
disease. Kidney Int. 88, 1233–1239 (2015).
214. Borazan, A. & Binici, D. N. Relationship between
insulin resistance and inflamation markers in
hemodialysis patients. Ren. Fail. 32, 198–202 (2010).
215. Kursat, S. et al. Relationship of insulin resistance in
chronic haemodialysis patients with inflammatory
indicators, malnutrition, echocardiographic
parameters and 24 hour ambulatory blood pressure
monitoring. Scand. J. Urol. Nephrol. 44, 257–264
(2010).
216. Martins, C. et al. Insulin resistance is associated with
circulating fibrinogen levels in nondiabetic patients
receiving peritoneal dialysis. J. Ren. Nutr. 17,
132–137 (2007).
217. Campa, C. C., Ciraolo, E., Ghigo, A., Germena, G.
& Hirsch, E. Crossroads of PI3K and Rac pathways.
Small GTPases 6, 71–80 (2015).
218. Trirogoff, M. L., Shintani, A., Himmelfarb, J.
& Ikizler, T. A. Body mass index and fat mass are the
primary correlates of insulin resistance in nondiabetic
stage 3–4 chronic kidney disease patients. Am. J.
Clin. Nutr. 86, 1642–1648 (2007).
219. Mahadev, K. et al. The NAD(P)H oxidase homolog
Nox4 modulates insulin-​stimulated generation of
H2O2 and plays an integral role in insulin signal
transduction. Mol. Cell. Biol. 24, 1844–1854 (2004).
220. Morino, K., Petersen, K. F. & Shulman, G. I. Molecular
mechanisms of insulin resistance in humans and their
potential links with mitochondrial dysfunction.
Diabetes 55 (Suppl. 2), 9–15 (2006).
221. Fujii, H., Goto, S. & Fukagawa, M. Role of uremic
toxins for kidney, cardiovascular, and bone dysfunction.
Toxins 10, 202 (2018).
222. Dobre, M., Meyer, T. W. & Hostetter, T. H. Searching
for uremic toxins. Clin. J. Am. Soc. Nephrol. 8,
322–327 (2013).
223. Neirynck, N. et al. An update on uremic toxins.
Int. Urol. Nephrol. 45, 139–150 (2013).
224. Koppe, L. & Fouque, D. Microbiota and prebiotics
modulation of uremic toxin generation.
Panminerva Med. 59, 173–187 (2017).
225. Vanholder, R. et al. Review on uremic toxins:
classification, concentration, and interindividual
variability. Kidney Int. 63, 1934–1943 (2003).
226. Duranton, F. et al. Normal and pathologic
concentrations of uremic toxins. J. Am. Soc. Nephrol.
23, 1258–1270 (2012).
227. Zoccali, C. et al. Plasma concentration of asymmetrical
dimethylarginine and mortality in patients with end-​
stage renal disease: a prospective study. Lancet 358,
2113–2117 (2001).
228. Tumur, Z. & Niwa, T. Indoxyl sulfate inhibits nitric
oxide production and cell viability by inducing
oxidative stress in vascular endothelial cells.
Am. J. Nephrol. 29, 551–557 (2009).
229. Huang, C. Y. et al. Effects of pamidronate and calcitriol
on the set point of the parathyroid gland in
postmenopausal hemodialysis patients with secondary
hyperparathyroidism. Nephron Clin. Pract. 122,
93–101 (2012).
230. Fujii, H. et al. Oral charcoal adsorbent (AST-120)
prevents progression of cardiac damage in chronic
kidney disease through suppression of oxidative
stress. Nephrol. Dial. Transplant. 24, 2089–2095
(2009).
231. Sibal, L., Agarwal, S. C., Home, P. D. & Boger, R. H.
The role of asymmetric dimethylarginine (ADMA) in
endothelial dysfunction and cardiovascular disease.
Curr. Cardiol. Rev. 6, 82–90 (2010).
232. Zoccali, C. et al. Left ventricular hypertrophy, cardiac
remodeling and asymmetric dimethylarginine (ADMA)
in hemodialysis patients. Kidney Int. 62, 339–345
(2002).
233. Elesber, A. A. et al. Coronary endothelial dysfunction
is associated with erectile dysfunction and elevated
asymmetric dimethylarginine in patients with early
atherosclerosis. Eur. Heart J. 27, 824–831 (2006).
234. Wu, I. W. et al. p-​Cresyl sulphate and indoxyl sulphate
predict progression of chronic kidney disease.
Nephrol. Dial. Transplant. 26, 938–947 (2011).
235. Barreto, F. C. et al. Serum indoxyl sulfate is associated
with vascular disease and mortality in chronic kidney
disease patients. Clin. J. Am. Soc. Nephrol. 4,
1551–1558 (2009).
236. Cao, X. S. et al. Association of indoxyl sulfate with
heart failure among patients on hemodialysis. Clin. J.
Am. Soc. Nephrol. 10, 111–119 (2015).
237. Wu, C. C. et al. Serum indoxyl sulfate associates with
postangioplasty thrombosis of dialysis grafts. J. Am.
Soc. Nephrol. 27, 1254–1264 (2016).
238. Yang, K. et al. Indoxyl sulfate induces oxidative stress
and hypertrophy in cardiomyocytes by inhibiting the
AMPK/UCP2 signaling pathway. Toxicol. Lett. 234,
110–119 (2015).
239. Lekawanvijit, S. et al. Chronic kidney disease-​induced
cardiac fibrosis is ameliorated by reducing circulating
levels of a non-​dialysable uremic toxin, indoxyl sulfate.
PLOS ONE 7, e41281 (2012).
240. Stockler-​Pinto, M. B., Fouque, D., Soulage, C. O.,
Croze, M. & Mafra, D. Indoxyl sulfate and p-​cresyl
sulfate in chronic kidney disease. Could these toxins
modulate the antioxidant Nrf2-Keap1 pathway?
J. Ren. Nutr. 24, 286–291 (2014).
241. Bolati, D., Shimizu, H., Yisireyili, M., Nishijima, F. &
Niwa, T. Indoxyl sulfate, a uremic toxin, downregulates
renal expression of Nrf2 through activation of
NF-kappaB. BMC Nephrol. 14, 56 (2013).
242. Chin, L. H. et al. The regulation of NLRP3
inflammasome expression during the development
of cardiac contractile dysfunction in chronic kidney
disease. Oncotarget 8, 113303–113317 (2017).
243. Vilaysane, A. et al. The NLRP3 inflammasome
promotes renal inflammation and contributes to CKD.
J. Am. Soc. Nephrol. 21, 1732–1744 (2010).
244. Muteliefu, G., Enomoto, A. & Niwa, T. Indoxyl sulfate
promotes proliferation of human aortic smooth muscle
cells by inducing oxidative stress. J. Ren. Nutr. 19,
29–32 (2009).
245. Yamamoto, H. et al. Indoxyl sulfate stimulates
proliferation of rat vascular smooth muscle cells.
Kidney Int. 69, 1780–1785 (2006).
246. Bartlett, D. E. et al. Uremic toxins activates
Na/K-ATPase oxidant amplification loop causing
phenotypic changes in adipocytes in in vitro models.
Int. J. Mol. Sci. 19, E2685 (2018).
247. Zhao, L. et al. Deletion of interleukin-6 attenuates
pressure overload-​induced left ventricular
hypertrophy and dysfunction. Circ. Res. 118,
1918–1929 (2016).
248. Sriramula, S. & Francis, J. Tumor necrosis factor-​alpha
is essential for angiotensin II-​induced ventricular
remodeling: role for oxidative stress. PLOS ONE 10,
e0138372 (2015).
249. Furukawa, S. et al. Increased oxidative stress in
obesity and its impact on metabolic syndrome.
J. Clin. Invest. 114, 1752–1761 (2004).
250. Ramos, L. F., Shintani, A., Ikizler, T. A. & Himmelfarb, J.
Oxidative stress and inflammation are associated
with adiposity in moderate to severe CKD. J. Am.
Soc. Nephrol. 19, 593–599 (2008).
251. Viaene, L. et al. Albumin is the main plasma binding
protein for indoxyl sulfate and p-​cresyl sulfate.
Biopharm. Drug Dispos. 34, 165–175 (2013).
252. Meijers, B. K. et al. Free p-​cresol is associated with
cardiovascular disease in hemodialysis patients.
Kidney Int. 73, 1174–1180 (2008).
253. Han, H. et al. p-​Cresyl sulfate aggravates cardiac
dysfunction associated with chronic kidney disease
by enhancing apoptosis of cardiomyocytes. J. Am.
Heart Assoc. 4, e001852 (2015).
254. Manunta, P. et al. Left ventricular mass, stroke
volume, and ouabain-​like factor in essential
hypertension. Hypertension 34, 450–456 (1999).
255. Kennedy, D. J. et al. Elevated plasma
marinobufagenin, an endogenous cardiotonic steroid,
is associated with right ventricular dysfunction and
nitrative stress in heart failure. Circ. Heart Fail. 8,
1068–1076 (2015).
256. Komiyama, Y. et al. A novel endogenous digitalis,
telocinobufagin, exhibits elevated plasma levels in
patients with terminal renal failure. Clin. Biochem. 38,
36–45 (2005).
257. Bagrov, A. Y. et al. Characterization of a urinary
bufodienolide Na+,K+-ATPase inhibitor in patients
after acute myocardial infarction. Hypertension 31,
1097–1103 (1998).
258. Kolmakova, E. V. et al. Endogenous cardiotonic
steroids in chronic renal failure. Nephrol. Dial.
Transplant. 26, 2912–2919 (2011).
259. Hamlyn, J. M. & Manunta, P. Endogenous cardiotonic
steroids in kidney failure: a review and an hypothesis.
Adv. Chron. Kidney Dis. 22, 232–244 (2015).
260. Haller, S. T. et al. Monoclonal antibody against
marinobufagenin reverses cardiac fibrosis in rats with
chronic renal failure. Am. J. Hypertens. 25, 690–696
(2012).
261. Tian, J. et al. Spironolactone attenuates experimental
uremic cardiomyopathy by antagonizing
marinobufagenin. Hypertension 54, 1313–1320
(2009).
262. Haller, S. T. et al. Rapamycin attenuates cardiac
fibrosis in experimental uremic cardiomyopathy by
reducing marinobufagenin levels and inhibiting
downstream pro-​fibrotic signaling. J. Am. Heart Assoc.
5, e004106 (2016).
263. Haller, S. T. et al. Passive immunization against
marinobufagenin attenuates renal fibrosis and
improves renal function in experimental renal disease.
Am. J. Hypertens. 27, 603–609 (2014).
264. Arnon, A., Hamlyn, J. M. & Blaustein, M. P. Ouabain
augments Ca(2+) transients in arterial smooth muscle
without raising cytosolic Na(+). Am. J. Physiol. Heart
Circ. Physiol. 279, H679–H691 (2000).
265. Skou, J. C. The identification of the sodium pump.
Biosci. Rep. 24, 436–451 (2004).
266. Tian, J. et al. Binding of Src to Na+/K+-ATPase forms
a functional signaling complex. Mol. Biol. Cell 17,
317–326 (2006).
267. Haas, M., Wang, H., Tian, J. & Xie, Z. Src-​mediated
inter-​receptor cross-​talk between the Na+/K+-ATPase
and the epidermal growth factor receptor relays
the signal from ouabain to mitogen-​activated
protein kinases. J. Biol. Chem. 277, 18694–18702
(2002).
268. Liu, J. et al. Ouabain induces endocytosis of
plasmalemmal Na/K-​ATPase in LLC-​PK1 cells by a
clathrin-​dependent mechanism. Kidney Int. 66,
227–241 (2004).
269. Tian, J., Gong, X. & Xie, Z. Signal-​transducing function
of Na+-K+-ATPase is essential for ouabain’s effect on
[Ca2+]i in rat cardiac myocytes. Am. J. Physiol. Heart
Circ. Physiol. 281, H1899–H1907 (2001).
270. Wansapura, A. N., Lasko, V. M., Lingrel, J. B. &
Lorenz, J. N. Mice expressing ouabain-​sensitive alpha1-
Na, K-​ATPase have increased susceptibility to pressure
overload-​induced cardiac hypertrophy. Am. J. Physiol.
Heart Circ. Physiol. 300, H347–H355 (2011).
271. Drummond, C. A. et al. Reduction of Na/K-​ATPase
affects cardiac remodeling and increases c-​kit cell
abundance in partial nephrectomized mice. Am. J.
Physiol. Heart Circ. Physiol. 306, H1631–H1643
(2014).
272. Xie, Z. et al. Intracellular reactive oxygen species
mediate the linkage of Na+/K+-ATPase to hypertrophy
and its marker genes in cardiac myocytes.
J. Biol. Chem. 274, 19323–19328 (1999).
273. Liu, J. et al. Ouabain interaction with cardiac Na+/K+-
ATPase initiates signal cascades independent of
changes in intracellular Na+ and Ca2+ concentrations.
J. Biol. Chem. 275, 27838–27844 (2000).
274. Yan, Y. et al. Protein carbonylation of an amino acid
residue of the Na/K-​ATPase alpha1 subunit determines
Na/K-​ATPase signaling and sodium transport in renal
proximal tubular cells. J. Am. Heart Assoc. 5,
e003675 (2016).
www.nature.com/nrneph

275. Liu, J. et al. Attenuation of Na/K-​ATPase mediated
oxidant amplification with pNaKtide ameliorates
experimental uremic cardiomyopathy. Sci. Rep. 6,
34592 (2016).
276. Yan, Y. et al. Involvement of reactive oxygen species in
a feed-​forward mechanism of Na/K-​ATPase-mediated
signaling transduction. J. Biol. Chem. 288,
34249–34258 (2013).
277. Chen, Y. et al. Oxidized LDL-​bound CD36 recruits an
Na+/K+-ATPase-​Lyn complex in macrophages that
promotes atherosclerosis. Sci. Signal. 8, ra91 (2015).
278. Kennedy, D. J. et al. CD36 and Na/K-​ATPase-alpha1
form a proinflammatory signaling loop in kidney.
Hypertension 61, 216–224 (2013).
279. Mhatre, K. N. et al. Crosstalk between FGF23- and
angiotensin II-​mediated Ca(2+) signaling in
pathological cardiac hypertrophy. Cell. Mol. Life Sci.
75, 4403–4416 (2018).
280. Raeisi, S. et al. Effects of angiotensin II receptor
blockade on soluble Klotho and oxidative stress in
calcineurin inhibitor nephrotoxicity in rats. Iran. J.
Kidney Dis. 10, 358–363 (2016).
281. Karalliedde, J., Maltese, G., Hill, B., Viberti, G. &
Gnudi, L. Effect of renin-​angiotensin system blockade
on soluble Klotho in patients with type 2 diabetes,
systolic hypertension, and albuminuria. Clin. J. Am.
Soc. Nephrol. 8, 1899–1905 (2013).
282. Shimizu, H. et al. Indoxyl sulfate enhances angiotensin
II signaling through upregulation of epidermal growth
factor receptor expression in vascular smooth muscle
cells. Life Sci. 91, 172–177 (2012).
283. Lin, C. J. et al. Association of indoxyl sulfate with
fibroblast growth factor 23 in patients with advanced
chronic kidney disease. Am. J. Med. Sci. 347,
370–376 (2014).
284. Taylor, D., Bhandari, S. & Seymour, A. M. Mitochondrial
dysfunction in uremic cardiomyopathy. Am. J. Physiol.
Renal Physiol. 308, F579–F587 (2015).
285. Burgoyne, J. R., Mongue-​Din, H., Eaton, P. &
Shah, A. M. Redox signaling in cardiac physiology
and pathology. Circ. Res. 111, 1091–1106
(2012).
286. Annuk, M., Zilmer, M., Lind, L., Linde, T. & Fellstrom, B.
Oxidative stress and endothelial function in chronic
renal failure. J. Am. Soc. Nephrol. 12, 2747–2752
(2001).
287. Ruggenenti, P., Cravedi, P. & Remuzzi, G. Mechanisms
and treatment of CKD. J. Am. Soc. Nephrol. 23,
1917–1928 (2012).
288. Balamuthusamy, S. et al. Renin angiotensin system
blockade and cardiovascular outcomes in patients with
chronic kidney disease and proteinuria: a meta-​
analysis. Am. Heart J. 155, 791–805 (2008).
289. Perkovic, V. et al. Chronic kidney disease,
cardiovascular events, and the effects of perindopril-​
based blood pressure lowering: data from the
PROGRESS study. J. Am. Soc. Nephrol. 18,
2766–2772 (2007).
290. Mann, J. F., Gerstein, H. C., Pogue, J., Bosch, J. &
Yusuf, S. Renal insufficiency as a predictor of
cardiovascular outcomes and the impact of ramipril:
the HOPE randomized trial. Ann. Intern. Med. 134,
629–636 (2001).
291. Zannad, F. et al. Prevention of cardiovascular events in
end-​stage renal disease: results of a randomized trial
Nature Reviews | Nephrology
of fosinopril and implications for future studies.
Kidney Int. 70, 1318–1324 (2006).
292. Marquez, D. F., Ruiz-​Hurtado, G., Ruilope, L. M. &
Segura, J. An update of the blockade of the renin
angiotensin aldosterone system in clinical
practice. Expert Opin. Pharmacother. 16,
2283–2292 (2015).
293. Juurlink, D. N. et al. Rates of hyperkalemia after
publication of the Randomized Aldactone Evaluation
Study. N. Engl. J. Med. 351, 543–551 (2004).
294. Frankenfield, D. L. et al. Utilization and costs of
cardiovascular disease medications in dialysis patients
in Medicare Part D. Am. J. Kidney Dis. 59, 670–681
(2012).
295. Cice, G. et al. Carvedilol increases two-​year survivalin
dialysis patients with dilated cardiomyopathy:
a prospective, placebo-​controlled trial. J. Am. Coll.
Cardiol. 41, 1438–1444 (2003).
296. Cohen-​Solal, A. et al. Efficacy and safety of nebivolol in
elderly heart failure patients with impaired renal
function: insights from the SENIORS trial. Eur. J.
Heart Fail. 11, 872–880 (2009).
297. Badve, S. V. et al. Effects of beta-​adrenergic
antagonists in patients with chronic kidney disease:
a systematic review and meta-​analysis. J. Am. Coll.
Cardiol. 58, 1152–1161 (2011).
298. Agarwal, R., Sinha, A. D., Pappas, M. K., Abraham, T. N.
& Tegegne, G. G. Hypertension in hemodialysis patients
treated with atenolol or lisinopril: a randomized
controlled trial. Nephrol. Dial. Transplant. 29,
672–681 (2014).
299. Kitchlu, A. et al. Beta-​blockers and cardiovascular
outcomes in dialysis patients: a cohort study in
Ontario, Canada. Nephrol. Dial. Transplant. 27,
1591–1598 (2012).
300. Koizumi, M., Komaba, H., Nakanishi, S., Fujimori, A. &
Fukagawa, M. Cinacalcet treatment and serum FGF23
levels in haemodialysis patients with secondary
hyperparathyroidism. Nephrol. Dial. Transplant. 27,
784–790 (2012).
301. Greeviroj, P. et al. Cinacalcet for treatment of chronic
kidney disease-​mineral and bone disorder: a meta-​
analysis of randomized controlled trials. Nephron 139,
197–210 (2018).
302. Brunelli, S. M., Thadhani, R., Ikizler, T. A. &
Feldman, H. I. Thiazolidinedione use is associated
with better survival in hemodialysis patients with
non-insulin dependent diabetes. Kidney Int. 75,
961–968 (2009).
303. Ramirez, S. P. et al. Rosiglitazone is associated with
mortality in chronic hemodialysis patients. J. Am.
Soc. Nephrol. 20, 1094–1101 (2009).
304. Hatakeyama, S. et al. Effect of an oral adsorbent,
AST-120, on dialysis initiation and survival in patients
with chronic kidney disease. Int. J. Nephrol. 2012,
376128 (2012).
305. Schulman, G. et al. Randomized placebo-​controlled
EPPIC trials of AST-120 in CKD. J. Am. Soc. Nephrol.
26, 1732–1746 (2015).
306. Drechsler, C. et al. Protein carbamylation is associated
with heart failure and mortality in diabetic patients
with end-​stage renal disease. Kidney Int. 87,
1201–1208 (2015).
307. Drozdz, D. et al. Oxidative stress biomarkers and left
ventricular hypertrophy in children with chronic kidney
Reviews
disease. Oxid. Med. Cell. Longev. 2016, 7520231
(2016).
308. Himmelfarb, J. et al. Provision of antioxidant
therapy in hemodialysis (PATH): a randomized
clinical trial. J. Am. Soc. Nephrol. 25, 623–633
(2014).
309. Bolignano, D. et al. Antioxidant agents for delaying
diabetic kidney disease progression: a systematic
review and meta-​analysis. PLOS ONE 12, e0178699
(2017).
310. Cheitlin, M. D. et al. ACC/AHA/ASE 2003
guideline update for the clinical application of
echocardiography: summary article. J. Am. Soc.
Echocardiogr. 16, 1091–1110 (2003).
311. Marwick, T. H. et al. Recommendations on the use of
echocardiography in adult hypertension: a report from
the European Association of Cardiovascular Imaging
(EACVI) and the American Society of Echocardiography
(ASE). J. Am. Soc. Echocardiogr. 28, 727–754
(2015).
312. Lang, R. M. et al. Recommendations for cardiac
chamber quantification by echocardiography in
adults: an update from the American Society of
Echocardiography and the European Association
of Cardiovascular Imaging. J. Am. Soc. Echocardiogr.
28, 1–39 (2015).
313. Khouri, S. J., Maly, G. T., Suh, D. D. & Walsh, T. E.
A practical approach to the echocardiographic
evaluation of diastolic function. J. Am. Soc.
Echocardiogr. 17, 290–297 (2004).
314. Sodhi, K. et al. pNaKtide attenuates
steatohepatitis and atherosclerosis by blocking
Na/K-ATPase/ROS amplification in C57Bl6 and
ApoE knockout mice fed a Western diet. Sci. Rep. 7,
193 (2017).
315. Sodhi, K. et al. pNaKtide inhibits Na/K-​ATPase
reactive oxygen species amplification and
attenuates adipogenesis. Sci. Adv. 1, e1500781 (2015).
Acknowledgements
The authors’ work was supported by US National Institutes
of Health grants HL109015, HL071556 and HL105649;
by the Brickstreet Foundation; and by the Huntington
Foundation, Inc.
Author contributions
Both authors researched the data discussed in this article,
discussed the content, wrote the article and reviewed or
edited the text before submission.
Competing interests
The authors declare no competing interests.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Reviewer information
Nature Reviews Nephrology thanks C. Faul, J. Jankowski and
the other anonymous reviewer(s), for their contribution to the
peer review of this work.
Supplementary information
Supplementary information is available for this paper at
https://doi.org/10.1038/s41581-018-0101-8.