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Review
Received 7 March 2005; received in revised form 21 April 2005; accepted 3 May 2005
Available online 9 June 2005
Time for primary review 20 days
Abstract
Renal ischemia – reperfusion (I/R) is an important etiopathological mechanism of acute renal failure (ARF). Despite improvements in the
treatment of ARF, it is associated with significant morbidity and mortality. I/R injury also occurs during renal transplantation and leads to
reduced allograft survival. Sex differences have been found in I/R injury in many different organs including the kidney. Women have half the
mortality of men in ARF. In animal models also, females are protected against renal I/R injury. The mechanisms by which sex affects the
outcome to renal I/R injury are being actively investigated. This review will examine the evidence for gender differences in renal I/R injury
and discuss the probable mechanisms by which sex affects the renal response to I/R injury.
D 2005 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
cholesterol the gender differences were no longer signifi- 8% males compared with 75% females survived seven days
cant. In contrast, studies looking at outcomes in ARF after ischemia. In another study, Fekete et al. [24] showed
patients have shown that men have twice the mortality of that females have lower blood urea nitrogen, serum
women and have found that gender is an independent creatinine and less severe tubular necrosis after renal I/R
predictor of mortality in ARF [19 –21]. compared to males. These studies show that sex differences
Consistent with the clinical studies in ARF, animal in renal I/R injury exist.
studies have also shown females to be protected against This review will provide a brief overview of the
renal I/R injury. A study by Park et al. [22] showed that pathophysiology of renal I/R injury followed by a dis-
males had deterioration of kidney function after bilateral cussion of the possible mechanisms of sex differences in
Epithelium
Actin Cytoskeleton
Leukocyte Endothelium
Basement
Membrane
Loss of polarity
B Apical Na+ /K+- ATPase
Epithelium
Disrupted actin
cytoskeleton
Epithelial
inflammatory cytokine
Leukocyte
inflammatory cytokine
Endothelial
Leukocyte adhesion molecule
Basement
Membrane
Fig. 1. Schematic illustration of the renal inflammatory response after ischemia – reperfusion. (A) Pre-ischemic kidney with sodium – potassium ATPase (Na+/
K+ ATPase) localized to the basolateral membrane. (B) Post ischemia/reperfusion kidney with disruption of actin cytoskeleton and loss of polarity in epithelial
cells causing apical localization of Na+/K+ ATPase. The injured epithelial and endothelial cells also secrete inflammatory cytokines which upregulate adhesion
molecules. Leukocytes are recruited and activated by the adhesion molecules and inflammatory mediators present. The activated leukocytes also generate
inflammatory cytokines thus further increasing the injury.
596 A. Kher et al. / Cardiovascular Research 67 (2005) 594 – 603
2. Renal ischemia reperfusion injury production and TNF mediated apoptosis [3,5,6,8,9]. Two
pathways of apoptosis have been clearly delineated each of
Renal I/R injury occurs through a complex interaction which leads to activation of the downstream effector
between renal hemodynamics, inflammatory mediators, caspase-3. One is receptor dependent and initiated by
endothelial and tubular injury. The kidney receives 25% activation through death domains (TNF receptor associated
of the cardiac output but the majority goes to the cortex and and Fas associated), which activate caspase-8 followed by
hence even slight changes in perfusion may lead to ischemia caspase-3. The other pathway is through mitochondrial
of the medulla. The S3 segment of the proximal tubule in release of cytochrome c, which activates caspase-9 and then
the outer strip of the outer medulla is the most susceptible to caspase-3. The cells have many molecules that regulate
Table 1
Effects of estrogen and testosterone on mechanisms involved in I/R injury
Mechanism Estrogen Testosterone
Mitogen activated protein kinases (MAPK) [14,22] Increases ERK activation, decreases JNK activation Increases JNK and p38 activation
Endothelial nitric oxide synthase (eNOS) [22] Increases eNOS activity Decreases eNOS activity
Endothelin [89] Decreases production
ATP sensitive potassium channels (KATP) [98,102] Activates KATP channels Activates KATP channels
Akt [22,114] Increases the sustained activation of Akt Decreases the sustained activation of Akt
ERK indicates extracellular regulated kinase, JNK is c-Jun N-terminal kinase and p38 is p38 mitogen activated protein kinase.
598 A. Kher et al. / Cardiovascular Research 67 (2005) 594 – 603
Similarly, Angele et al. [52] have shown that testosterone is by sodium – calcium exchanger (NCX) and hence Ca2+
responsible for the increased p38 MAPK activation in male overload (Fig. 2E). Sex differences in renal NKA have been
macrophages after trauma-hemorrhage. As p38 MAPK shown by Fekete et al. [24]. They found that the mRNA
mediates I/R induced TNF production and TNF induced expression of NKA a1 subunit was higher in females and
apoptosis, therefore, sex differences in p38 MAPK may be this difference was further increased after I/R. I/R lead to a
responsible for the gender differences noted in renal I/R. decrease in mRNA expression of NKA a1 subunit in both
These studies show that there are sex differences in genders but it was more severe in males. However, protein
MAPK activation after I/R and they may mediate the gender levels of NKA a1 and NKA activity were similar between
differences in renal I/R injury. However, more studies are genders in the control groups but after I/R males had a
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