Serum Lactate Dehydrogenase is Elevated in Ischemic Acute Tubular Necrosis but Not in Acute Rejection in Kidney Transplant Patients.

BACKGROUND: Serum lactate dehydrogenase (LDH) levels may help to distinguish ischemic acute tubular necrosis (ATN) from acute rejection after kidney transplantation. METHODS: All kidney biopsies performed in the years 2010 to 2012 were reviewed. Serum LDH, creatinine level, clinical variables, and presence of donor-specific antibodies were recorded before the biopsy. RESULTS: Overall 150 biopsies were included. Ischemic ATN was diagnosed in 45 biopsies and acute cellular-mediated rejection and/or antibody-mediated rejection in 59 biopsies, 38 of which were accompanied by ATN. Serum LDH was elevated in 23 (51%) of 45 cases with ischemic ATN versus 15 (14%) of 105 cases with other diagnoses ( P < .0001). Median serum LDH was 478 U/L (range 277-2018) for ischemic ATN and 372 U/L (range 191-748) for all other diagnoses ( P < .001). When delayed graft function or primary nonfunctioning grafts were caused by ischemic ATN, serum LDH was elevated in 58% of cases, but when caused by acute rejection, LDH was normal in 88% of cases ( P = .02). CONCLUSIONS: There is a strong association between elevated serum LDH 1 to 3 days before performing kidney biopsy and the diagnosis of ischemic ATN after kidney transplantation, especially at the immediate posttransplantation period. Normal serum LDH at this period should raise a suspicion of acute rejection.

Sub-nephrotoxic cisplatin sensitizes rats to acute renal failure and increases urinary excretion of fumarylacetoacetase.

Nephrotoxicity limits the therapeutic efficacy of the antineoplastic drug cisplatin. Due to dosage adjustment and appropriate monitoring, most therapeutic courses with cisplatin produce no or minimal kidney damage. However, we studied whether even sub-nephrotoxic dosage of cisplatin poses a potential risk for the kidneys by predisposing to acute kidney injury (AKI), specifically by lowering the toxicity threshold for a second nephrotoxin. With this purpose rats were treated with a single sub-nephrotoxic dosage of cisplatin (3mg/kg, i.p.) and after two days, with a sub-nephrotoxic regime of gentamicin (50mg/kg/day, during 6 days, i.p.). Control groups received only one of the drugs or the vehicle. Renal function and renal histology were monitored throughout the experiment. Cisplatin treatment did not cause any relevant functional or histological alterations in the kidneys. Rats treated with cisplatin and gentamicin, but not those under single treatments, developed an overt renal failure characterized by both renal dysfunction and massive tubular necrosis. In addition, the urinary excretion of fumarylacetoacetase was increased in cisplatin-treated animals at subtoxic doses, which might be exploited as a cisplatin-induced predisposition marker. In fact, the urinary level of fumarylacetoacetase prior to the second nephrotoxin correlated with the level of AKI triggered by gentamicin in predisposed animals.

Irreversible immunoexpression of matrix metalloproteinase-9 in proximal tubular epithelium of renal allografts with acute rejection.

BACKGROUND: Matrix metalloproteinase-9 (MMP-9) is the most important member of the MMP family responsible for the development and progression of various renal diseases. Our study aims to investigate the localization of MMP-9 in human renal allografts and to assess whether MMP-9 immunostaining is contributory to detect pathological change in renal biopsy. METHODS: We examined 150 renal allograft biopsies (48 baseline and 102 follow-up) from 49 transplants and analyzed the associations of clinical and histopathological data with the MMP-9 staining intensity using a semi-quantitative scoring. RESULTS: MMP-9 immunostaining in proximal tubule epithelium was negative before transplantation, but positive in biopsies with episodes, particularly with acute cellular rejection (ACR) and acute calcineurin inhibitor (CNI) toxicity. Tubulitis was the most significant association factor (p < 0.0001) with increased MMP-9 staining intensity. The expression in proximal tubules remained augmented in allografts recovered from ACR episodes, while it was disappeared or diminished in those recovered from acute CNI toxicity or ischemia/reperfusion effects. CONCLUSION: These findings suggest the necessary participation of MMP-9 in the pathogenesis of tubulitis and the subsequent stage of pathogenesis in ACR. Up-regulation of MMP-9 expression in the proximal tubule could be a new indicator of tubular injury and a predictive factor for the prognosis of renal allograft.

Effects of metalloproteinase inhibition in a murine model of renal ischemia-reperfusion injury.

Ischemia-reperfusion injury (IRI) is a leading cause of acute tubular necrosis (ATN) and delayed graft function in transplanted organs. Up-regulation of matrix metalloproteinases (MMPs) propagates the microinflammatory response that drives IRI. This study sought to determine the specific effects of Marimastat (Vernalis, BB-2516), a broad spectrum MMP and TNF-alpha-converting enzyme inhibitor, on IRI-induced ATN. Mice were pretreated with Marimastat or methylcellulose vehicle for 4 d before surgery. Renal pedicles were bilaterally occluded for 30 min and allowed to reperfuse for 24 h. Baseline creatinine levels were consistent between experimental groups; however, post-IRI creatinine levels were 4-fold higher in control mice (p < 0.0001). The mean difference between the post-IRI histology grades of Marimastat-treated and control kidneys was 1.57 (p = 0.003), demonstrating more severe damage to control kidneys. Post-IRI mean (+/-SEM) MMP-2 activity rose from baseline levels in control mice (3.62 +/- 0.99); however, pretreated mice presented only a slight increase in mean MMP-2 activity (1.57 +/- 0.72) (p < 0.001). In conclusion, these data demonstrate that MMP inhibition is associated with a reduction of IRI in a murine model.

Caspase-4 may play a role in loss of proximal tubules and renal injury in nephropathic cystinosis.

Nephropathic cystinosis is characterized clinically by generalized proximal renal tubular dysfunction, renal Fanconi Syndrome and progressive renal failure. Glomerular-proximal tubule disconnection has been noted in renal biopsies from patients with nephropathic cystinosis. In vitro studies performed in cystinotic fibroblasts and renal proximal tubular cells support a role for apoptosis of the glomerulotubular junction, and we have further extended these studies to human native cystinotic kidney specimens. We performed semi-quantitative analysis of tubular density in kidney biopsies from patients with nephropathic cystinosis and demonstrated a significant reduction (p=0.0003) in the number of proximal tubules in the kidney tissue of patients with cystinosis compared to normal kidneys and kidneys with other causes of renal injury; this reduction appears to be associated with the over-expression of caspase-4. This study provides the first quantitative evidence of a loss of proximal tubules in nephropathic cystinosis and suggests a possible role of caspase-4 in the apoptotic loss of proximal tubular cells. Further work is needed to elucidate if this injury mechanism may be causative for the progression of renal functional decline in nephropathic cystinosis.

Increased expression of p38 mitogen- activated protein kinase is related to the acute renal lesions induced by gentamicin

Mitogen-activated protein kinases (MAPK) may be involved in the pathogenesis of acute renal failure. This study investigated the expression of p-p38 MAPK and nuclear factor kappa B (NF-kappaB) in the renal cortex of rats treated with gentamicin. Twenty rats were injected with gentamicin, 40 mg/kg, im, twice a day for 9 days, 20 with gentamicin + pyrrolidine dithiocarbamate (PDTC, an NF-kappaB inhibitor), 14 with 0.15 M NaCl, im, twice a day for 9 days, and 14 with 0.15 M NaCl , im, twice a day for 9 days and PDTC, 50 mg kg-1 day-1, ip, twice a day for 15 days. The animals were killed 5 and 30 days after the last of the injections and the kidneys were removed for histological, immunohistochemical and Western blot analysis and for nitrate determination. The results of the immunohistochemical study were evaluated by counting the p-p38 MAPK-positive cells per area of renal cortex measuring 0.05 mm². Creatinine was measured by the Jaffé method in blood samples collected 5 and 30 days after the end of the treatments. Gentamicin-treated rats presented a transitory increase in plasma creatinine levels. In addition, animals killed 5 days after the end of gentamicin treatment presented acute tubular necrosis and increased nitrate levels in the renal cortex. Increased expression of p-p38 MAPK and NF-kappaB was also observed in the kidneys from these animals. The animals killed 30 days after gentamicin treatment showed residual areas of interstitial fibrosis in the renal cortex, although the expression of p-p38 MAPK in their kidneys did not differ from control. Treatment with PDTC reduced the functional and structural changes induced by gentamicin as well as the expression of p-p38 MAPK and NF-kappaB. The increased expression of p-p38 MAPK and NF-kappaB observed in these rats suggests that these signaling molecules may be involved in the pathogenesis of tubulointerstitial nephritis induced by gentamicin.

Study of serum and tissues angiotensin converting enzyme (ACE) activity in rat with gentamicin induced renal toxicity.

PURPOSE: In this research ACE activity (as a marker of epithelial injury) was studied in rats with gentamicin induced renal toxicity. METHODS: Male Sprague-Dawley rats were sacrificed 1, 3, 5, and 7 days after gentamicin injection, 100 mg/kg/day for 1, 3, 5, and 7 consecutive days. ACE activity was measured in serum, kidney and lung. These data were compared with normal saline-treated rats. Histological scoring of renal cortical pathology was performed on days 1, 3, 5, and 7. RESULTS: Treatment of rats with gentamicin resulted in renal damage evidenced by proteinuria, polyuria, and decreased creatinine clearance. The damage to the kidney proximal tubule was evident by (a) the histological analysis at light microscopy and (b) the augmentation in the urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG). Kidney ACE activity decreased while lung and serum ACE activity didn't change until day 7. Lung ACE activity increased significantly on day 7. Kidney and serum ACE activity increased too. Blood pressure increased significantly on day 7. This corresponded well with the lung ACE activity increment. CONCLUSION: These data suggest that kidney ACE activity decreased significantly just one day after gentamicin administration and prior to kidney NAG decrease.

Molecular mechanisms of renal tissue repair in survival from acute renal tubule necrosis: role of ERK1/2 pathway.

Our earlier studies with S-(1,2-dichlorovinyl)-L-cysteine (DCVC) showed that prior administration of a low priming dose of 15 mg/kg, i.p. to mice, given 72 hours before administration of a normally lethal dose of DCVC (75 mg/kg, i.p.) led to renal tubule necrosis, however sustained renal tubule regeneration was observed and these mice recovered from renal failure and survived. The objective of the present study was to investigate the role of extracellular signal-regulated kinase (ERK) pathway in this autoprotection model. Following the priming dose of DCVC, IL-6 protein and mRNA increased markedly as early as 1 hour after dosing, peaking at 3 hours with a 1.5-fold increase in plasma. Immunocytochemistry on kidney sections using specific antibodies against TGF-alpha, HB-EGF, EGFr, IGF-1Rbeta, Grb-2, and phospho-p44/42 MAP kinase (ERK1/2) revealed a significantly higher staining of these molecules 3 to 72 hours after dosing, indicating up regulation of the ERK pathway. Following a lethal dose of DCVC (75 mg/kg) the early increase in these signaling molecules was not sustained, being markedly reduced 24 and 36 hours after dosing, leading to inhibition of S-phase DNA synthesis, cell division and renal tubule repair. In contrast, prior treatment with a low dose of DCVC, followed by a high dose led to a sustained stimulation of the renal ERK pathway, renal tubule regeneration and recovery from acute renal failure. These results suggest that a sustained activation of the ERK1/2 pathway may be a key factor in enabling a continued renal tubule repair and hence protection from the progressive phase of DCVC-induced acute renal tubular necrosis in the mouse.

Toxic acute tubular necrosis following treatment with zoledronate (Zometa).

BACKGROUND: Renal failure and toxic acute tubular necrosis (ATN) may be seen following exposure to a variety of therapeutic agents. Zoledronate (Zometa) is a new, highly potent bisphosphonate used in the treatment of hypercalcemia of malignancy. We report the first clinical-pathologic study of nephrotoxicity associated with this agent. METHODS: A cohort of six patients (four males and two females) with a mean age of 69.2 years received bisphosphonate therapy for multiple myeloma (five patients) or Paget's disease (one patient). In all patients, zoledronate was administered at a dose of 4 mg intravenously monthly, infused over at least 15 minutes, and the duration of therapy was mean 4.7 months (range, 3 to 9 months). RESULTS: All patients developed renal failure with a rise in serum creatinine from a mean baseline level of 1.4 mg/dL to 3.4 mg/dL. Renal biopsy revealed toxic ATN, characterized by tubular cell degeneration, loss of brush border, and apoptosis. Immunohistochemical staining revealed a marked increase in cell cycle-engaged cells (Ki-67 positive) and derangement in tubular Na+,K+-ATPase expression. Importantly, although all patients had been treated with pamidronate prior to zoledronate, no biopsy exhibited the characteristic pattern of collapsing focal segmental glomerulosclerosis observed in pamidronate nephrotoxicity. Following renal biopsy, treatment with zoledronate was discontinued and all six patients had a subsequent improvement in renal function (mean final serum creatinine, 2.3 mg/dL at 1 to 4 months of follow-up). CONCLUSION: The close temporal relationship between zoledronate administration and the onset of renal failure and the partial recovery of renal function following drug withdrawal strongly implicate this important and widely used agent in the development of toxic ATN.

Gamma-glutamyl transpeptidase accelerates tumor growth and increases the resistance of tumors to cisplatin in vivo.

We have shown previously that gamma-glutamyl transpeptidase (GGT) activity is essential for the nephrotoxicity of cisplatin. In this study we asked whether GGT activity was necessary for the antitumor activity of cisplatin. GGT was transfected into PC3 cells, a human prostate tumor cell line. Two independent GGT-positive cell lines were isolated and characterized. GGT cleaves extracellular glutathione providing the cells with access to additional cysteine. Expression of GGT had no effect on the growth rate of the cells in vitro where the culture medium contains high levels of cysteine. However, when the cells were injected into nude mice the GGT-positive tumors grew at more than twice the rate of the GGT-negative tumors. Weekly treatment with cisplatin was toxic to both GGT-positive and -negative tumors. The GGT-positive tumors were significantly more resistant to the toxicity of cisplatin than the GGT-negative tumors. Therefore, expression of GGT is required for the nephrotoxicity of cisplatin, but diminishes the tumor toxicity of the drug. These results indicate that the nephrotoxicity and the tumor toxicity of cisplatin are via two distinct pathways.

Serum levels of IgG antibodies against Tamm-Horsfall protein and urinary excretion of NAG and alpha-1-microglobulin as possible markers for tubular damage in patients with a continent ileal reservoir for urinary diversion.

Serum IgG antibodies against Tamm-Horsfall protein and urinary excretion of NAG and alpha-1-microglobulin were measured in 26 patients with a Kock reservoir for continent urinary diversion or orthotopic bladder reconstruction in order to detect any signs of tubular damage. None of these markers for tubular damage was correlated to the postoperative observation time ranging between 2 and 16 years. No correlation was found between these markers and signs of renal scarring or upper urinary tract dilatation as judged from urographies. A positive correlation was demonstrated between NAG excretion and antibodies against Tamm-Horsfall protein. The annual reduction in GFR was increased in patients with elevated alpha-1-microglobulin excretion but not in patients with elevated titres of antibodies against Tamm-Horsfall protein or increased NAG excretion. Patients with previous or present reflux nipple problems had elevated excretion of alpha-1-microglobulin. Regular determinations of alpha-1-microglobulin excretion appear to be of value in the follow-up of these patients.

Roles of cysteine conjugate beta-lyase and S-oxidase in nephrotoxicity: studies with S-(1,2-dichlorovinyl)-L-cysteine and S-(1,2-dichlorovinyl)-L-cysteine sulfoxide.

Effects of S-(1,2-dichlorovinyl)-L-cysteine (DCVC) and its putative metabolite DCVC sulfoxide (DCVCO) on renal function in vivo and in vitro were investigated to assess the role of sulfoxidation in the mechanism of toxicity of cysteine S-conjugates. Both conjugates were potent nephrotoxicants in rats in vivo, but at equimolar doses, DCVCO produced greater renal injury (i.e., increases in blood urea nitrogen levels and anuria and more severe and widespread proximal tubular necrosis) than DCVC. Pretreatment of rats with aminooxyacetic acid (AOAA), a selective cysteine conjugate beta-lyase (beta-lyase) inhibitor, did not protect against DCVCO nephrotoxicity, whereas rats given DCVC and AOAA exhibited partial protection. These results suggest that in addition to cleavage by the beta-lyase, sulfoxidation by the cysteine conjugate S-oxidase (S-oxidase) may play a role in DCVC nephrotoxicity. In isolated rat kidney proximal tubular (PT) and distal tubular (DT) cells, both DCVC and DCVCO produced time- and concentration-dependent increases in the release of lactate dehydrogenase. Because DCVC was generally more toxic in PT cells and DCVCO was more toxic in DT cells, an attempt was made to correlate in vitro cytotoxicity with the cellular distribution of the beta-lyase and S-oxidase. The finding that beta-lyase activity exhibited a 2-fold higher Vmax/Km ratio in PT cells than in DT cells, the greater inhibition of both beta-lyase activity and DCVC toxicity by AOAA in PT cells than in DT cells and the lower (40%) S-oxidase activity in PT cells than in DT cells provide evidence for the importance of the beta-lyase in DCVC toxicity in PT cells. The finding that DCVCO was more toxic in DT cells than in PT cells and the inability of AOAA to protect DT cells from DCVC-induced cytotoxicity, however, provide further evidence for DCVC bioactivation by S-oxidase.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced Na-K-ATPase in distal nephron in glycerol-induced acute tubular necrosis.

To further characterize changes in tubular Na-K-ATPase in acute tubular necrosis (ATN), segmental analysis was performed in rat nephrons. Na-K-ATPase was assayed in the following segments: proximal convolution (PC), proximal straight (PS), outer medullary thick ascending limb (MTAL), cortical thick ascending limb (CTAL), distal convolution (DC) and cortical collecting duct (CCD) in three groups of rats: 1.) intact; 2.) moderate non-oliguric ATN; and 3.) severe oliguric ATN. GFR and CNa/GFR X 100 were in group 1 0.80 +/- 0.05 ml/min and 0.68 +/- 0.06, in group 2 0.14 +/- 0.02 and 1.46 +/- 0.35, and in group 3 0.04 +/- 0.01 and 0.46 +/- 0.15, respectively. Na-K-ATPase in PC and PS were similar in all three groups. Na-K-ATPase levels were in MTAL: in group 1 37 +/- 2 X 10(-11) mol/mm/min, in group 2 20 +/- 1 X 10(-11), P less than 0.001 versus group 1, and in group 3 24 +/- 2 X 10(-11), P less than 0.001 versus group 1. In CTAL Na-K-ATPase levels were: in group 1 40 +/- 2 X 10(-11), in group 2 33 +/- 1 X 10(-11), P less than 0.001 versus group 1, and in group 3 27 +/- 2 X 10(-11), P less than 0.001 versus groups 1 and 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Cisplatin nephrotoxicity in lead-pretreated rats: enzymatic and morphological studies.

Treatment of rats with cisplatin or with cisplatin after chronic pre-exposure to lead induced a decrease in cytochrome P-450, reduced glutathione (GSH), GSH-S-transferase, reductase and peroxidase activities, and an increase in N-glucuronyl transferase, lipid peroxidation and oxidized glutathione (GSSG). On histological examination, rats treated by lead or cisplatin and by lead + cisplatin revealed significant proximal tubular lesions which varied from minimal changes to severe necrosis. Lead toxicity was characterized by irregularity and thickening of glomerular basement membranes, and by tubular mitochondrial alterations associated with the presence of intranuclear inclusions. Cisplatin injury showed more extensive lesions with cellular disorganization. Except for an increase in N-glucuronyl transferase activity, lead did not exert any significant effect on these biochemical and histological parameters and did not significantly modify the deleterious effects of further therapy by cisplatin.

Role of gamma-glutamyltranspeptidase and beta-lyase in the nephrotoxicity of hexachloro-1,3-butadiene and methyl mercury in mice.

Male Swiss OF1 mice received a single oral dose of either 80 mg/kg hexachloro-1,3-butadiene (HCBD) or 80 mg/kg methyl mercury (MeHg). Examination of cryostat kidney sections stained for alkaline phosphatase (APP) revealed damage to about 50% of the proximal tubules after 8 h. Pretreatment with the gamma-glutamyltranspeptidase (gamma-GT) inactivator AT-125 (Acivin, 50 mg/kg i.p., plus 50 mg/kg p.o., reduced the number of damaged tubules by 59 and 58% in mice treated with HCBD and MeHg, respectively. Pretreatment with the two beta-lyase inhibitors, amino-oxyacetic acid (AOAA, 3 x 100 mg/kg p.o.) and DL-propargylglycine (PPG, 300 mg/kg i.p. plus 300 mg/kg p.o.), reduced HCBD nephrotoxicity by 46 and 59%, respectively, but did not protect against MeHg nephrotoxicity. The results support a role for gamma-GT and beta-lyase in the mouse renal toxicity of HCBD and implicate gamma-GT but not beta-lyase in MeHg-induced nephrotoxicity in mice.

[Evaluation of the liberation of urinary necrosis enzymes (NAG-AAP) after administration of plasma expanders: study of dextran 40, hydroxyethyl starch and polymerized gelatin]. / Valutazione della liberazione degli enzimi urinari di necrosi (NAG-AAP) dopo somministrazione di plasmaexpanders: studio su destrano 40, amido-idrossietilico e gelatina polimerizzata.

We studied the 24-hour urinary elimination of enzymatic markers of renal tubular necrosis (NAG-AAP) in 21 patients (mean age 34.6 years old) who were treated with plasma expanders before peridural anesthesia. The patients were divided into three groups of seven subjects each: - 14 ml/Kg -1 of dextran 40 was administered to group 1 - 14 ml/Kg -1 of gelatin was administered to group 2 - 14 ml/Kg -1 of hydroxyethyl starch was administered to group 3. Urinary elimination of N-acetylglucosaminidase and of alanine aminopeptidase was determined in the 24-hour urine the day before surgery (controls), the day of surgery (G1) and the day after surgery (G2). The values of the samples, taken after plasma expander administration, did differ significantly from the control values (G1, G2). Therefore the administration of 14 ml/Kg -1 of dextran, gelatin or hydroxyethyl starch does not affect the renal tubular epithelium.

Renal function and Na-K-ATPase in rats after suprarenal ligation of inferior vena cava.

To assess the effects of altered renal function on Na-K-ATPase, the following groups of rats were studied: 1. rats with suprarenal vena cava ligation (SVCL), la. DOCA-treated rats with SVCL, 2. rats with infrarenal vena cava ligation (IVCL), 3. rats with glycerol-induced acute renal failure, 4. rats with bilateral ureteric ligation, and 5. K-exalate-treated rats with SVCL. In group 1, acute renal failure with hyperkalemia developed and medullary Na-K-ATPase increased from 95 +/- 5 in control to 155 +/- 7 mumol Pi/mg prot/h, P less than 0.001, DOCA did not prevent the increase of Na-K-ATPase. In group 2, medullary Na-K-ATPase decreased from 130 +/- 10 in control to 88 +/- 7, P less than 0.01, in rats with IVCL. In group 3, cortical Na-K-ATPase decreased from 55 +/- 5 to 27 +/- 6, P less than 0.02. In group 4, Na-K-ATPase was unchanged. In group 5, maintenance of normokalemia prevented the rise in Na-K-ATPase. These experiments demonstrated a K-dependent activation of medullary Na-K-ATPase after SVCL but not in other forms of renal failure. Because SVCL diminishes drastically GFR per nephron, the present findings imply that increased loads of Na and K per nephron are not a prerequisite for an increase in medullary Na-K-ATPase. Hyperkalemia in presence of increased renal venous pressure seems to be causally related to the rise in medullary Na-K-ATPase activity.

The value of lactic dehydrogenase as a predictor of early allograft survival.

Levels of serum lactic dehydrogenase (LDH) were determined in renal transplant recipients to assess their value as consistent predictors of acute allograft rejection. Although serum LDH levels of more than 250 U/l were in most cases associated with irreversible graft rejection, they were unreliable as a predictor or as an early indication of allograft rejection. Their chief value appears to be as an aid in determining when to discontinue high dose immunosuppression in an attempt to save an allograft that is most probably doomed to ultimate failure.

Molecular basis for several drug-induced nephropathies.

A recent clinical advance has been the discovery that many drug-induced hepatic diseases result from the metabolic activation of chemically stable drugs to potent alkylating agents by the liver. In addition to the liver, however, the kidney also contains active enzyme systems capable of metabolically activating drugs and other chemicals. For this reason a systematic investigation of the possible role of metabolic activation in the pathogenesis of several drug-induced renal diseases has been undertaken. These laboratory results are reviewed in the light of the clinical spectrum of the renal injuries, and possible therapeutic implications of these new findings are briefly discussed. The potential use of these models of nephrotoxicity to probe a variety of physiologic and pathophysiologic mechanisms of renal function are noted.