CHAPTER 92
Oxidants in Progressive Kidney Disease
Sudhir V. Shah
University of Arkansas School for Medical Sciences, Little Rock, Arkansas, USA
Chronic kidney disease (CKD) is a worldwide public
health problem with a rising incidence and prevalence
affecting approximately 10% of the U.S. adult population
(Table 1) (96). Chronic renal insufciency, once estab-
lished, tends to progress to end-stage renal disease (ESRD).
The number of patients receiving treatment for ESRD in
the United States has doubled in the past decade with
431,128 patients receiving ESRD therapy, a number ex-
pected to increase to 2 million by year 2030 (132). The
total estimated cost for Medicare patients with ESRD is
currently $15.48 billion, consuming 6.4% of the Medicare
budget (132), and is forecasted to increase to $28.3 billion
by 2010 (146). In addition, there is a high prevalence
of cardiovascular disease in subjects with CKD. The
American Heart Associations Councils on Kidney in
Cardiovascular Disease, High Blood Pressure Research,
Clinical Cardiology, and Epidemiology and Prevention, in
a statement entitled, Kidney Disease as a Risk Factor for
Development of Cardiovascular Disease, concluded that the
presence of CKD, whether it is manifested by proteinuria
(albuminuria) or reduced GFR [glomerular ltration
rate], appears to be an independent risk factor for CVD
[cardiovascular disease] outcomes, particularly in higher-
risk populations (118). Progression of renal failure occurs
even when the primary disease process has been treated or
is apparently inactive, indicating that the alterations and
adaptations in nephrons that remain after the initial insult
ultimately cause scarring and further nephron loss, which
result in the end-stage kidney. The overall impact of CKD
is summarized in Table 2.
Although various mechanisms have been suggested to
promote progressive renal injury (31), in this chapter I will
focus on partially reduced oxygen metabolites, which have
been shown to be important mediators of ischemic, toxic,
and immune-mediated tissue injury (9, 23, 33, 34, 81, 143).
Numerous studies have examined the role of reactive oxygen
metabolites in leukocyte-dependent and -independent mod-
els, with proteinuria as a major endpoint. To the extent that
proteinuria is an important determinant of progression, re-
duction of proteinuria would result in retardation of pro-
gression. In addition, evidence suggests a role of oxidants
and iron in diabetic nephropathy, a major cause of ESRD.
Seldin and Giebischs The Kidney
There are also studies that have examined the role of oxi-
dants and iron in models of progressive renal disease. In this
review I dene the term reactive oxygen metabolites, or oxi-
dants, briey recount the sequence of events that led to the
consideration of these metabolites as important mediators of
tissue injury, and present the available evidence in support of
the role of oxidants in both diabetic and nondiabetic glo-
merular disease and their role in tubular interstitial damage
which accompanies progression.
Oxygen normally accepts four electrons and is converted
directly to water. However, partial reduction of oxygen can
and does occur in biological systems, which leads to the
generation of partially reduced and potentially toxic reactive
oxygen intermediates (35, 82). Thus sequential reduction of
oxygen along the univalent pathway leads to the generation
of superoxide anion, hydrogen peroxide, hydroxyl radical,
and water (35, 82).
Oxygen superoxide hydrogen peroxide hydroxyl radical water
(free radical) (free radical)
(Eq. 1)
Superoxide and hydrogen peroxide appear to be the pri-
mary species generated; they may play a role in the genera-
tion of additional and more reactive oxidants, including the
highly reactive hydroxyl radical (or a related highly oxidizing
species) in which iron salts act as a catalyst in a reaction
commonly referred to as the metal-catalyzed Haber-Weiss
reaction (49).
Fe 3 O 2 Fe 2 O 2
Fe 2 H 2 O 2 Fe 3 OH OH
O 2 H 2 O 2 O 2 OH OH
(Eq. 2)
Iron, a transitional metal, can serve as a carrier for oxygen
and electrons and a catalyst for oxygenation, hydroxylation,
and other critical metabolic processes, in part because of its
ability to reversibly and readily cycle between the ferrous
and ferric oxidation states. The ease with which iron is
Copyright 2008, Elsevier Inc.
2601 All rights reserved.
2602 SECTION IV Progression of Renal Disease
TABLE 1 Stages of Chronic Kidney Disease and Prevalence in the Adult U.S.
Population
Stage Description
1 Kidney damage with normal or GFR
2 Kidney damage with mild GFR
3 Moderate GFR
4 Severe GFR
5 Kidney failure
GFR, glomerular ltration rate.
Source: National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evalu-
ation, classication, and stratication. Part IV: denition and classication of stages of chronic kidney disease.
Am J Kid Dis. 2002;39(2 Suppl 1):S46S75.
reversibly oxidized and reduced is essential for its metabolic
functions. However, this property makes iron potentially
hazardous by enabling it to participate in the generation of
such powerful oxidant species as hydroxyl radical and/or
reactive ironoxygen complexes such as ferryl or perferryl
ion (49).
Iron also has a major role in the initiation and propaga-
tion of lipid peroxidation by catalyzing the conversion of
primary oxygen radicals to hydroxyl radicals or forming a
perferryl ion. In addition, iron can directly catalyze lipid
peroxidation, the oxidative reaction of polyunsaturated
lipids, by removing hydrogen atoms from the polyunsatu-
rated fatty acids in the lipid bilayers of organelle mem-
branes. An important feature of lipid peroxidation is that
the process can amplify the production of free radicals and
thus increase the number of chain reactions. Other reac-
tions in which the effect of iron catalysts is to convert
poor reactive species into more reactive species are well
described in the excellent review by Halliwell and Gut-
teridge (49).
Because iron can participate in the formation of reac-
tive oxygen species, organisms take great care in the han-
dling of iron, using such transport proteins as transferrin
and such storage proteins as ferritin and minimizing the
size of the intracellular iron pool. The availability of iron
to stimulate hydroxyl generation in vivo is very limited
under normal conditions; this iron sequestration may be
regarded as a contribution to antioxidant defenses. Al-
though there has been much debate about the availability
of catalytic metal ions in vivo, it is well established that
oxidant stress itself can provide the catalytic iron. For ex-
ample, superoxide can mobilize iron from ferritin and
TABLE 2 Impact of Chronic Kidney Disease
Affects about 10% of the population
Progressive, culminating in end-stage kidney disease
Enormous human and economic cost
Independent risk factor for cardiovascular disease
GFR (ml/min/1.73 m2) Population %
90 5.9 million 3.3
6089 5.3 million 3.0
3059 7.6 million 4.3
1529 400,000 0.2
15 (or dialysis) 300,000 0.2
19.2 million 11
hydrogen peroxide can release iron by degrading heme
proteins (49).
Additional reactive oxygen metabolites are formed as a
result of the metabolism of hydrogen peroxide by
neutrophil-derived myeloperoxidase (MPOthe enzyme
responsible for the green color of pus) to produce highly
reactive toxic products including hypochlorous acid. MPO
reacting with hydrogen peroxide forms an enzyme sub-
strate complex that can oxidize various halides to produce
highly reactive toxic products. Because of the wide distri-
bution of chloride ion in biologic systems, the formation
of hypochlorous acid (HOClthe active ingredient in
Clorox bleach) is probably te most signicant product (33,
69, 74, 144).
H 2 O 2  Cl MPO
HOCl  H 2 O
The reader is referred to an excellent review that details
the various products including tyrosyl radical adduction
products, resulting from the MPO-hydrogen peroxide-
chloride system, as well as the potential role in kidney
disease (78). These oxygen metabolites, including the free
radical species superoxide and hydroxyl radical and other
metabolites such as hydrogen peroxide and hypohalous
acids, are often referred to collectively as reactive oxygen
metabolites or reactive oxygen species, or simply as
oxidants.
It is now well established that oxidants generated by
leukocytes have bactericidal activity, which indicates at
least one functional role for oxidants (5). The notion that
oxidants are important in inammation was rst suggested
by McCord. He reasoned that, because phagocytizing neu-
trophils, the effector cells of the acute inammatory re-
sponse, release large amounts of superoxide extracellularly
and because superoxide dismutase, an enzyme that scav-
enges superoxide, possesses anti-inammatory activity, su-
peroxide anion and other oxygen metabolites could be
important chemical mediators of the inammatory process
(80). This hypothesis has received considerable support
from numerous studies in which the effect of oxidants,
produced either by an enzymatic-generating system or by
 CHAPTER 92 Oxidants in Progressive Kidney Disease 2603

activated leukocytes, has been examined in a variety of bio-
logical systems as well as in vivo studies, where scavengers
of oxidants are protective.
ROLE OF OXIDANTS IN NONDIABETIC
GLOMERULAR DISEASE
The evidence implicating oxidants in glomerular injury may
be addressed by three broad questions. What are the sources
of oxidants that may participate in glomerular injury? What
are the biological effects of oxidants relevant to glomerular
pathophysiology? How well has the role of oxidants been
demonstrated in animal models of glomerular disease?
Sources of Oxidants
Neutrophils and monocytes/macrophages exhibit a burst of
oxidative metabolism (respiratory burst), with a marked in-
crease in oxygen uptake and a generation of oxidants in re-
sponse to plasma membrane perturbation by a variety of
soluble and particulate stimuli (33). Phagocytosis per se is
not essential to trigger the oxidative burst; perturbation of
the plasma membrane appears to be the critical event. In in
vitro studies, a variety of soluble and particulate stimuli,
many of them relevant to glomerular injury, enhance the
generation of oxidants by neutrophils and monocytes. Of
particular interest is the demonstration that several immune
reactants such as serum-treated zymosan (a C3b receptor
stimulus), heat-aggregated IgG (Fc receptor stimulus), im-
mune complexes, and complement components have been
shown to trigger the oxidative burst (33). Antineutrophil
cytoplasmic autoantibodies (ANCAs) present in the circula-
tion of patients with pauci-immune necrotizing vasculitis
and pauci-immune crescentic glomerulonephritis have been
shown to signicantly increase the generation of superoxide
by neutrophils (32). Thus stimulated neutrophils or mono-
cytes are potential sources of oxidants in leukocyte-
dependent glomerular injury. More direct evidence support-
ing this concept has been given by Poelstra et al., who used
cytochemical techniques to demonstrate the presence of
superoxide anion and hydrogen peroxide-generating leuko-
cytes in antiThy-1 and anti-glomerular basement mem-
brane (GBM)-induced glomerulonephritis (105). Similarly,
enhanced generation of oxidants by macrophages isolated
from glomeruli of rabbits with anti-GBM antibody disease
and by macrophages isolated from nephritic glomeruli in the
antithymocyte serum model has been demonstrated (17,
99). Thus stimulated neutrophils or monocytes may serve as
sources of oxidants in proliferative and exudative glomerulo-
nephritides (Table 3).
Ample evidence supports the concept that resident
glomerular cells serve as sources of oxidants in noninam-
matory forms of glomerular disease (Table 3). Because
phagocyte-like cells are present in the glomerulus
(particularly mesangial cells), it was postulated that glo-
merular cells, like other phagocytic cells, would also gen-
erate oxidants in response to plasma membrane perturba-
tion. In response to phorbol myristate acetate, a plasma
membrane-perturbing agent, rat glomeruli showed a

TABLE 3 Leukocytes as a Source of Oxidants for Glomerular

Injury
In vitro studies
o A wide variety of soluble and particulate stimuli, including immune complexes,
complement components, (30) and ANCA (21)
In vivo studies
o Cytochemical detection of the presence of superoxide- and hydrogen peroxide-
generating leukocytes in anti-Thy-1 and anti-GBM-induced GN (22)
o Enhanced superoxide and hydroxyl radical are generated by macrophages isolated
from glomeruli of rabbits with anti-GBM antibody disease (23)
o Enhanced superoxide generation by macrophages isolated from nephritic glomeruli
(antithymocyte serum) (24)

Resident glomerular cells as a source of oxidants for glomerular injury

In vitro studies (150)
o Isolated glomeruli Phorbol myristate acetate, zymosan, trypsin,
ehymotrypsin, adriamycin
o Mesangial cells PAF, immune complexes, MAC, TNF,
interleukin-1
o Glomerular epithelial cells Puromycin aminonucleoside
In vivo studies
o Production of hydrogen peroxide by normal rat kidney glomeruli (151)
o Increased generation of hydrogen peroxide in passive Heymann nephritis (152)

ANCA, antineutrophil cytoplasmic autoantibody; GBM, glomerular basement mem-

brane; GN, glomerulonephritis.
2604 SECTION IV Progression of Renal Disease
marked chemiluminescence response, a sensitive measure
of oxidants generated by phagocytic cells. In a subsequent
study, chymotrypsin or trypsin markedly increased light
emission from the glomeruli. Neutral proteases from inl-
trating leukocytes and/or renal tissue are released in glo-
merular diseases, which suggest a potential mechanism for
the production of oxidants in glomerular diseases. In vivo
generation of hydrogen peroxide by normal glomeruli has
been demonstrated using aminotriazole-induced inactiva-
tion of catalase as a measure of intracellular generation of
hydrogen peroxide (40). Adriamycin, an agent that in-
duces nephrotic syndrome, has been shown to enhance the
intracellular generation of oxidants by freshly isolated
glomeruli in vitro (140).
These studies with isolated glomeruli are supported by
studies using cultured glomerular cells. Mesangial cells have
enhanced generation of superoxide and hydrogen peroxide
in response to a variety of stimuli, including opsonized
zymosan, immune complexes, membrane attack complex,
and platelet-activating factor (11, 108, 125). Radeke et al.
showed that human glomerular mesangial cells express
low potential cytochrome b558  and  subunits, a 45- or
66-kD avoprotein, and a 47-kD phosphoprotein, the three
essential components of a plasma membrane-associated
NADPH (nicotinamide adenine dinucleotide phosphate)
oxidase system, in a manner similar to that described in
neutrophils (107). Finally, glomerular epithelial cells appear
to be the target of injury in many of the noninammatory
forms of glomerular disease, including nephrotic syndrome
induced by the injection of puromycin aminonucleoside.
In response to puromycin aminonucleoside, cultured glo-
merular epithelial cells enhance the generation of hydrogen
peroxide (67). The ability of glomerular cells to generate
oxidants appears to be well established (Table 3). Therefore,
either leukocytes in inammatory glomerular diseases or
resident glomerular cells in noninammatory diseases serve
as sources for oxidants.
Effects of Oxidants Relevant to Glomerular Disease
The major manifestations of glomerular disease are protein-
uria, altered glomerular ltration rate (GFR), and depend-
ing on the type of glomerular disease, morphological changes
(Fig. 1). The biological effects of oxidants have been divided
into three general areas: those that are most relevant to the
occurrence of proteinuria, those that are most relevant to
altered GFR, and those that are most relevant to morpho-
logical changes.
FIGURE 1 The role of random oxygen metabolites (ROM) in glo-
merular disease. The major manifestations of glomerular disease.
EFFECTS OF OXIDANTS RELEVANT TO PROTEINURIA
It is generally accepted that leukocytes cause proteinuria
(a hallmark of glomerular diseases) by damaging the GBM,
which serves as the major ultraltration barrier to restrict the
entry of proteins into the urinary space. The degradation of
the GBM by stimulated neutrophils is caused by the activa-
tion of a latent metalloenzyme (most likely gelatinase)
by hypochlorous acid or a similar oxidant generated by the
myleoperoxidase-hydrogen peroxide-halide system (Table 4)
(126). Other studies have shown that oxidants could contrib-
ute to GBM damage by increasing its susceptibility to pro-
teolytic damage (142) and by inactivating the 1-proteinase
inhibitor (the primary regulator of neutrophil elastase) (145),
thus allowing the released elastase to more readily inict
damage to the extracellular matrix. Lipid peroxide enhances
the production of gelatinase by mesangial cells, and thus
enhanced generation of matrix-degrading proteinase may
contribute to proteinuria (64). Prevention of proteinuria by
catalase in neutrophil-dependent glomerulonephritides (vide
infra) suggests that the oxidative mechanism for GBM deg-
radation described above may be relevant to leukocyte-
dependent glomerular injury.
In contrast to the increased degradation suggested by
these studies, Kanwar et al. suggest that synthesis of glo-
merular heparan sulfate proteoglycans (HSPGs) is highly
susceptible to oxidant injury (66). A drastic dose-dependent
decrease in the de novo synthesis of proteoglycans in re-
sponse to xanthine-xanthine oxidase (a system that gener-
ates oxidants) was demonstrated using an isolated perfused
kidney model. Morphological studies revealed a marked
decrease in the synthesis of the proteoglycan. Thus the na-
scent core peptide appears to be highly susceptible to selec-
tive direct damage from oxidants during de novo synthesis
of HSPGs necessary to maintain integrity of the GBM and
normal glomerular ultraltration.
Direct in vivo effects of oxidants on glomerular function
have been examined in several studies (Table 4). Infusion of
phorbol myristate acetate (a potent activator of leukocytes)
or of cobra venom factor in the renal artery caused signi-
cant proteinuria that was prevented by catalase (which
destroys hydrogen peroxide) and neutrophil depletion (111,
113, 148). It was shown that hydrogen peroxide infused
directly into the renal artery caused massive transient pro-
teinuria with no effect on GFR and renal plasma ow (149).
Fraction clearances of graded-size neutral dextrans of larger
molecular radii, an index of glomerular size selectivity, were
signicantly and substantially elevated after hydrogen per-
oxide infusion.
These studies indicate that hydrogen peroxide and/or
its metabolites generated by neutrophils can cause protein-
uria. Johnson et al. reasoned that hydrogen peroxide-
mediated injury involves the myeloperoxidase-hydrogen
peroxide-halide system. The postulate is particularly
attractive in view of the high cationic nature of myeloper-
oxidase with an isoelectric point above 10. Johnson et al.
demonstrated that infusion of myeloperoxidase followed
 CHAPTER 92 Oxidants in Progressive Kidney Disease 2605

TABLE 4 Effects of Oxidants Relevant to Occurrence of Proteinuria

in Glomerular Injury
Oxidants participate in glomerular basement membrane degradation (33, 34).
Lipid peroxide induces enhanced generation of gelatinase by mesangial cells (36).
Oxidants decrease de novo synthesis of glomerular proteoglycans (37).
Oxidants increase albumin permeability in freshly isolated glomeruli in vitro (153).
Direct in vivo effects of oxidants on urinary protein
Infusion of phorbol myristate acetate, an activator of neutrophils, results in proteinuria (38) and
a fall in glomerular ltration rate (40). These effects are prevented by a catalase.
Hydrogen peroxide infused directly into the renal artery causes massive transient proteinuria by
inducing a molecular size selectivity defect (41). These effects are prevented by an iron chelator.
Infusion of myeloperoxidase-hydrogen peroxide induces proteinuria (42).

by hydrogen peroxide in a chloride-containing solution
into the renal artery in rats results in signicant proteinuria
(62) and, 4 to 10 days later, development of a marked
proliferative glomerular lesion (Table 4) (63). In addition,
halogenation of glomeruli was demonstrated in an in situ
model of neutrophil-mediated immune complex glomeru-
lonephritis (62). These studies indicate that the myeloper-
oxidase-hydrogen peroxide-halide system is activated in
a model of neutrophil-mediated immune complex glo-
merulonephritis and that the myeloperoxidase-hydrogen
peroxide-halide system is capable of inducing glomerular
injury that results in proteinuria.
EFFECTS OF OXIDANTS RELEVANT TO ALTERED GFR
Increased production of prostaglandins and thrombox-
ane has been demonstrated in various human and experi-
mental glomerulopathies and these agents have been impli-
cated as important mediators that cause proteinuria and/or
a fall in GFR in experimental models of glomerular disease,
including anti-GBM antibody disease, adriamycin-induced
nephrotic syndrome in rats, and complement-mediated
glomerular injury (24, 76, 115). Because the most dramatic
effect of these autocoids is on glomerular hemodynamics,
they are further discussed under the effects of oxidants that
are relevant to altered GFR. It has been demonstrated that
oxidants generated either enzymatically or by stimulated
neutrophils increase the synthesis of prostaglandin E2,
PGF2, 6ketoPGF1, the stable metabolite of prostacyclin,
and thromboxane B2 (Table 2) (1, 12, 122). Thus some of
the observed effects of oxidants may be mediated through
their effect on prostaglandin and thromboxane synthesis.
Roberts et al. identied a series of prostaglandin F2-like
compounds that are produced in vivo in humans by a non-
cyclooxygenase mechanism involving free radical-catalyzed
peroxidation of arachidonic acid (87). Intrarenal arterial in-
fusion of small amounts (0.5 g/kg/min) of 8-epi-PGF2
resulted in a dose-dependent reduction in GFR and renal
plasma ow (133). The changes were completely reversed by
thromboxane A2 receptor antagonist, which indicates that
8-epi-PGF2 is a potent preglomerular vasoconstrictor act-
ing principally through thromboxane A2 receptor activation.
This nding suggests that in those glomerular injuries
where free radical mechanisms, including lipid peroxidation,
have been implicated, the formation of novel prostanoids
plays an important role in the fall in the GFR and the al-
terations in renal plasma ow (RPF) (Table 5). Infusion of
dibutryl cAMP (cyclic adenosine 3 ,5 -cyclic phosphate)
and several hormones that increase cAMP content in glom-
eruli cause a fall in the glomerular ultraltration coefcient
(30). In addition, the cAMP content in glomeruli is altered
most strikingly by several local mediators of inammation
such as serotonin, histamine, and prostaglandins, which sug-
gests that, as in other systems, cyclic nucleotides modulate
inammatory and/or immune response in glomerular dis-
ease (26, 27). It has been shown that xanthine-xanthine
oxidase increases cAMP content in freshly isolated glomer-
uli, and the responsible metabolite appears to be hydrogen
peroxide (123). Similarly, cell-free supernatants from

TABLE 5 Effect of Oxidants Relevant to Altered GFR in Glomerular

Injury
Oxidants generated enzymatically or by stimulated neutrophils
o Increase glomerular cyclic AMP content (5556)
o Induce a reduction in glomerular and mesangial cell planar surface and myosin light chain
phosphorylation (57)
o Increase glomerular eicosanoid synthesis (4749)
Infusion of 8-epi-PGF2, a novel prostanoid produced by noncyclo-oxygenase mechanism
involving lipid peroxidation (50) results in a marked fall in GFR and RPF (51).

AMP, adenosine monophosphate; GFR, glomerular ltration rate; RPF, renal plasma ow.
2606 SECTION IV Progression of Renal Disease

stimulated neutrophils increase cAMP content in freshly
isolated glomeruli, and this effect appears to be mediated by
hydrogen peroxide and hypochlorous acid, the product of
the myleoperoxidase-hydrogen peroxide-halide system (8).
It was shown that the xanthine-xanthine oxidase system
induced a reduction in the glomerular and mesangial cell
planar surface and an increase in myosin light chain phos-
phorylation, a biochemical marker of contraction (28). In-
terestingly, these effects were completely blocked by a
platelet-activating factor antagonist, which suggests that the
effects of oxidants are mediated by platelet-activating factor.
Duque et al. suggest that oxidants, particularly hydrogen
peroxide, could modulate the surface area of mesangial cells,
modifying the ultraltration coefcient, and this change
could explain the decrease in the GFR in those pathological
conditions characterized by a fall in GFR.
EFFECTS OF OXIDANTS RELEVANT
TO MORPHOLOGICAL CHANGES
Several studies have implicated platelets in glomerular
injury. As mentioned previously, infusion of myleoperoxi-
B (119, 120, 136) and
dase and hydrogen peroxide causes a marked inux of plate-
lets, endothelial cell swelling, and epithelial cell foot process
effacement followed by a marked proliferative glomerular
lesion (63). In addition, low doses of hydrogen peroxide
stimulate the proliferation of cultured rat mesangial cells
(29). These ndings indicate that oxidants are capable of
inducing morphological changes that are similar to those
seen in models of immune complex glomerulonephritis and
anti-GBM antibody disease.
It has been suggested that glomerular ADPase is of major
importance in preventing intraglomerular thrombus forma-
tion in experimental glomerulonephritis (105). Membrane-
associated enzymes are apparently highly susceptible to oxi-
dants (6). There is a marked decrease in the activity of these
enzymes in two models of glomerulonephritis (anti-GBM
and anti-Thy-1) that is characterized by an inux of poly-
morphonuclear neutrophils (105). Scavengers of oxygen
metabolites prevent the decrease in glomerular ADPase,
which suggests that oxidants act in the reduction of glo-
merular ADPase activity (Table 6) (105).
Necrotizing crescentic glomerulonephritis associated
with anti-MPO antibodies is part of ANCA-associated
glomerulonephritis and is characterized by segmental bri-
noid necrosis of the GBM and marked inltration of neu-
trophils and mononuclear cells. The close association of
pauci-immune necrotizing glomerulonephritis and anti-
MPO antibodies suggests a pathogenetic role for anti-
MPO-directed immune response. Rats immunized with
MPO and perfused with lysosomal enzyme extract and hy-
drogen peroxide developed glomerular intracapillary throm-
boses, followed by a proliferative glomerulonephritis charac-
terized by glomerular capillary wall necrosis, extracapillary
cell proliferation, inltration of neutrophils and monocytes,
and vasculitis (29). These studies indicate that oxidants are
capable of inducing many of the functional and morpho-
logical changes that are observed in glomerular diseases.
Oxidants have usually been regarded as toxic metabolites
with cytotoxic properties. However, at low concentrations
they seem to play a signicant regulatory role without in-
ducing cell death. The effects of oxidants in altering cAMP
levels have been described above. In addition, regulated
generation of low concentrations of oxidants may serve as
intracellular signals for gene activation involving specic
transcription factors such as NF-
may represent a second messenger system for generation of
cytokines involved in tissue injury and repair. A number of
monocyte-specic cytokines have been described that in-
clude the monocyte colony-stimulating factor (M-CSF) and
the monocyte chemoattractant protein-1 (MCP-1). MCP-1
has been identied as a product of a gene belonging to the
small, inducible cytokine family, known in the murine sys-
tem as the JE gene. CSF1 is a cytokine required for prolif-
eration, maturation, and activation. Expression of the
JE/MCP-1 and CSF1 genes can be rapidly induced by a
number of agents, including tumor necrosis factor. Satriano
et al. have shown that scavengers of free radicals attenuate
the increase in the mRNA level in response to TNF- and
aggregated IgG. Generation of superoxide anion by xan-
thine oxidase and hypoxanthine increases the mRNA levels
of these genes. They concluded that the generation of reac-
tive oxygen species, possibly by NADPH-dependent oxi-
dase, is involved in the induction of the JE/MCP-1 and
CSF-1 genes by TNF- and IgG complexes. Local genera-
tion of oxidants could represent a factor responsible for the
expression of JE/MCP-1 in immune-mediated increased
expression of monocyte chemoattractant protein in glom-
eruli from rats with anti-Thy-1 glomerulonephritis (130).

TABLE 6 Role of Oxidants in the Morphological Changes Relevant

to Glomerular Injury
Infusion of myeloperoxidasehydrogen peroxide causes marked inux of platelets, signi-
cant proteinuria, followed by a marked proliferative glomerular lesion (4243).
Scavengers of oxidants prevent the reduction in glomerular ADPase activity in anti-Th- 1
and anti-glomerular basement membrane antibody disease models (22).
Rats immunized with myeloperoxidase and perfused with lysosomal enzyme extract and
hydrogen peroxide develop a proliferative glomerulonephritis (58).
Oxidants induce JE/MCP-1 and CSF-1 genes by TNF- and IgG complexes in mesangial
cells (154).

Tumor necrosis factor is able to generate oxidants, super-
oxide anion, and hydrogen peroxide in glomerular mesan-
gial cells. There is also in vitro evidence of effects of
oxidants on the release of TNF- from lipopolysaccharide-
activated mesangial cells (10, 11). Although the role of
these cytokines has not been adequately dened in glo-
merular diseases, these results indicate important interac-
tions between other mediators and reactive oxygen species.
For additional examples of such interactions, the reader is
referred to a review (4).
Oxidants in Animal Models of Glomerular Disease
ANTI-GBM ANTIBODY DISEASE
One of the best-characterized models of complement-
and neutrophil-dependent glomerular injury is the heterolo-
gous phase of anti-GBM antibody disease. In this model,
treatment with catalase markedly reduced proteinuria,
whereas superoxide dismutase had no protective effect
(Table 7) (112). In another study, dimethylthiourea, a potent
hydroxyl radical scavenger, or deferoxamine, an iron chela-
tor, signicantly attenuated proteinuria in the complement-
and neutrophil-dependent heterologous phase of anti-GBM
antibody disease in rabbits (16). Although the role of iron is
not completely understood, the protective effect of iron
chelators has generally been taken as evidence for the par-
ticipation of hydroxyl radical in tissue injury because iron is
critical in the generation of hydroxyl radical (via the
Haber-Weiss reaction).
ANIMAL MODEL OF MINIMAL CHANGE DISEASE
The ability of glomerular cells to generate oxidants sug-
gests that they may be important mediators of glomerular
injury in glomerular diseases that lack inltrating leuko-
cytes (Table 8). A single intravenous injection of puromy-
cin aminonucleoside (PAN) results in marked proteinuria
and glomerular morphological changes that are similar to
minimal change disease in humans. Diamond et al. re-
ported that allopurinol (an inhibitor of xanthine oxidase)
and superoxide dismutase were protective in PAN-induced
nephrotic syndrome, which suggests a role for xanthine
oxidase-generated superoxide anion in this model of mini-
mal change disease (25). Beaman et al. conrmed the
TABLE 7 Evidence for the Role of Oxidants in Anti-
GBM Antibody Disease
In the complement and neutrophil-dependent heterologous phase of
anti-GBM antibody disease.
o Anti-GBM enhances generation of oxidants by neutrophils in vitro.
o Catalase markedly reduces the proteinuria, whereas superoxide
dismutase has no protective effect in the heterologous phase (66).
A hydroxyl radical scavenger and an iron chelator signicantly attenuate
antiGBM antibodyinduced proteinuria in the heterologous phase (67).
GBM, glomerular basement membrane.
CHAPTER 92 Oxidants in Progressive Kidney Disease 2607
TABLE 8 Evidence for the Role of Oxidants in an
Animal Model of Minimal Change Disease
In a puromycin aminonucleoside model of minimal change disease
Cultured glomerular epithelial cells exhibit an enhanced generation of
hydrogen peroxide (32).
Administration of scavengers of oxidants and antioxidants results in re-
duction in proteinuria (68, 69, 72, 155).
Glomerular catalytic iron increases (156).
Feeding a selenium-decient diet results in a marked diminution of glu-
tathione peroxidase accompanied by an increase in proteinuria (157).
protective effect of superoxide dismutase and in addition
reported that proteinuria was signicantly reduced in rats
receiving polyethylene glycol (PEG) catalase, which sug-
gested a role for hydrogen peroxide and superoxide anion
in this model of glomerular disease (13). Superoxide anion
and hydrogen peroxide may interact (with iron as a cata-
lyst) to generate hydroxyl radical. Several studies have in
fact shown that enhanced generation of hydrogen peroxide
and superoxide anion is accompanied by enhanced genera-
tion of a hydroxyl radical (or a similar highly oxidizing
species). Thakur et al. reported the protective effects of two
hydroxyl radical scavengers and an iron chelator, further
implicating hydroxyl radical in PAN-induced nephrotic
syndrome (136).
A single intravenous injection of adriamycin (an anthra-
cycline antibiotic used in cancer chemotherapy) causes
nephrotic syndrome in rats with morphological and func-
tional changes similar to those seen in minimal change
disease in humans (125). Adriamycin undergoes a one-
electron reduction to a free radical, a semiquinone species
catalyzed by microsomes, sarcosomes, mitochondria, nu-
clei, and cytoplasm (125). Thus adriamycin-induced ne-
phrotic syndrome appears to be a good model to demon-
strate the concept that oxidants generated intracellularly by
glomerular cells can cause glomerular injury resulting in
proteinuria. However, the evidence from scavenger studies
is somewhat controversial. One study showed the protec-
tive effect of superoxide dismutase (Table 8) (100), whereas
another study did not nd any protective effects of
scavengers of oxidants (14).
ANIMAL MODEL OF MEMBRANOUS NEPHROPATHY
Passive Heymann nephritis, induced by a single intrave-
nous injection of anti-Fx1A, is a complement-dependent and
neutrophil-independent model of glomerular disease that re-
sembles membranous nephropathy in humans. Shah reported
that superoxide dismutase or catalase (native or PEG-coupled)
did not affect anti-Fx1A-induced proteinuria. In contrast,
scavengers of hydroxyl radical and deferoxamine markedly re-
duced proteinuria (134). The protective effects of hydroxyl
radical scavengers and an iron chelator suggest that hydroxyl
radical plays a part in passive Heymann nephritis. Similarly,
Rahman et al. reported that two hydroxyl radical scavengers
2608 SECTION IV Progression of Renal Disease
signicantly reduced proteinuria in cationized -globulin-
induced immune complex glomerulonephritis, a complement-
and neutrophil-independent model of membranous nephrop-
athy (109). Taken together these studies suggest an important
role for hydroxyl radical in animal models of membranous
nephropathy (Table 9).
Although leukocytes have not been considered to be im-
portant pathogenetically in animal models of membranous
nephropathy, there is evidence for the potential participation
of an MPO-hydrogen-peroxide-chloride system in patients
with membranous nephropathy (78). Grone et al. demon-
strated staining for hypochlorous-modied epitopes in con-
junction with MPO in the GBM (38). Thus it appears that
leukocytes or resident glomerular cells serve as sources for
oxidants. In vitro and in vivo studies indicate that oxidants
have many effects that are relevant to functional and mor-
phological changes observed in glomerular injury, and data
on scavengers of oxidants document the importance of
oxidants in glomerular injury.
OXIDANT MECHANISMS IN DIABETES
There is a large body of evidence indicating that diabetes
is a state of increased oxidative stress (52, 79, 117, 128,
147). This chapter summarizes only the information perti-
nent to diabetic nephropathy. In a paper published in
Nature (94), Nishikawa et al. state that three seemingly
independent biochemical pathways are involved in the
pathogenesis of vascular disease: glucose-induced activa-
tion of protein kinase C isoforms (61, 71); increased for-
mation of glucose-derived advanced glycation end-
products (18); and increased glucose ux through the
aldose reductase pathway (75). The relevance of each of
these pathways is supported by animal studies in which
pathway-specic inhibitors prevent various hyperglycemia-
induced abnormalities (18, 60, 102, 129). Hyperglycemia
increases the production of reactive oxygen species inside
cultured bovine aortic endothelial cells (36). In their study,
Nishikawa et al. show that normalizing levels of reactive
oxygen species prevents glucose-induced activation of
protein kinase C, formation of advanced glycation end-
products, sorbitol accumulation and NF-
B activation glomeruli, which is prevented by hydroxyl radical scaven-
(94). In a review published in Kidney International in 2000
TABLE 9 Evidence for the Role of Oxidants in Passive
Heymann Nephritis
There is an increased generation of hydrogen peroxide in passive Hey-
mann nephritis (152).
In a passive Heymann nephritis model of membranous nephropathy,
hydroxyl radical scavengers and an iron chelator and probucol are signi-
cantly reduced proteinuria (158, 159).
Feeding an iron-decient diet results in a reduction in proteinuria (160).
Feeding a selenium-decient diet results in marked diminution of gluta-
thione peroxidase in anti-Fx1A-induced proteinuria (157).
(93), Nishikawa and Brownlee in an article entitled, The
Missing Link: A Single Unifying Mechanism for Diabetic
Complications, argue and provide convincing evidence
that reactive oxygen metabolites are the causative link
for all the major pathways that have been implicated in
diabetic complications.
Additional support for oxidants in vascular disease of
diabetes comes from an in vivo study published in the
Journal of Clinical Investigation in 2001 (104), where it was
reported that a hydroxyl radical-like species was responsible
for changes in arterial wall proteins in a model of diabetes in
monkeys (Table 10). Iron may play an important role in the
auto-oxidation reactions of glucose leading to the generation
of free radicals (86). In addition, it has been shown that
glycation of proteins leads to a substantial increase in the
afnity for translational metals such as iron and copper
(106). These glycochelates have the ability to participate in
free-radical reactions. Iron chelators have been shown to
improve coronary artery response to physiological stimuli
and blood ow in diabetes (95).
In addition to these effects on the vascular bed
(93, 104, 127), which are likely to be important in the
glomerular vascular bed, there is more direct evidence for
oxidants in diabetic nephropathy (19, 42, 56, 68, 110).
The in vitro evidence for the role of oxidants in diabetic
nephropathy can be summarized as follows: High glucose
increases production of reactive oxygen species in glo-
merular cells; reactive oxygen species directly have bio-
logical effects relevant to diabetic nephropathy; and anti-
oxidants reduce the high glucose-induced biological effects
(Table 11). High glucose increases the production of reac-
tive oxygen species directly via glucose metabolism and
auto-oxidation and indirectly through the formation of
advanced glycation end products (AGEs) and their recep-
tor binding (43). In in vitro studies it has been shown that
high glucose results in increased generation of reactive
oxygen species by mesangial cells (42, 44). AGEs bind to
receptors for AGE and initiate reactive oxygen species
production (15, 147). Indeed, AGEs have been shown to
increase intracellular generation of reactive oxygen species
in mesangial cells (121). Similarly, it has been shown that
high glucose results in lipid peroxidation in isolated
gers (42).
Reactive oxygen species can activate most of the known
signal transduction pathways (135). In diabetes, protein
kinase C (PKC) (83) and mitogen-activated protein kinases
(MAPKs) (50, 65, 137) are activated by high glucose and in-
duce renal injury. Reactive oxygen species activate PKC
through redox changes in sulfhydryl groups of cysteine-rich
regions of PKC (37, 39). On the other hand, PKC produces
reactive oxygen species and subsequent lipid peroxidation
(41). Hydrogen peroxide has been shown to signicantly in-
crease mRNA expression and protein synthesis of TGF-1
(58) and bronectin (44, 58) by mesangial cells. Depletion of
cellular antioxidant capacity exaggerates TGF-1 expression
 CHAPTER 92 Oxidants in Progressive Kidney Disease 2609

TABLE 10 Oxidants in Diabetic Vascular Disease

A hydroxyl radical-like species oxidizes artery wall proteins in diabetic monkey
Reactive oxygen species
o Activate aldose reductase pathway
o Induce diacylglycerol pathway
o Activate protein kinase C
o Induce advanced glycation end products
MDA in aortic smooth muscle cell is induced by hyperglycemia

Source: Pennathur S, Wagner JD, Leeuwenburgh C, Litwak KN, Heinecke JW. A hy-
droxyl radical-like species oxidizes cynomolgus monkey artery wall proteins in early diabetic
vascular disease. J Clin Invest 2001;107:853860; Nishikawa T, Edelstein D, Brownlee M.
The missing link: A single unifying mechanism for diabetic complications. Kidney Int.
2000;58(Suppl 77):S26S30; Sharpe PC, Liu W-H, Yue KKM, et al. Glucose-induced
oxidative stress in vascular contractile cells. Diabetes 1998;47:801809.

TABLE 11 Oxidants in Diabetic Nephropathy: In Vitro Studies

High glucose results in
o Reactive oxygen species generated by mesangial cells (101)
o Lipid peroxidation in isolated glomeruli which is prevented by hydroxyl radical scavengers (96)
Antioxidants prevent glucose-induced
o Activation of protein kinase C (PKC) and NK-
B (101)
o Upregulation of transforming growth factor (TGF)-1
o Upregulation of bronectin
o Upregulation of endothelin-1 (98)

Oxidants in diabetic nephropathy: in vivo studies

Glomeruli isolated from diabetic rats
o Have increased production of oxidants including superoxide and hydrogen peroxide (9798, 128)
o Have increased expression of heme-oxygenase, which is prevented by anti-oxidants (128)
o Have lipid peroxides and 8-OHdG (96)
Antioxidants prevent functional and morphological changes of diabetes (117119, 124127, 128)
Selenium-decient diet causes an increase in albuminuria, glomerular sclerosis in diabetic rats and an increase in
TGF-1 (99)
Diabetic nodular lesions in humans stain positive for malondialdehyde (95)

in glomeruli isolated from both control and diabetic rats (110)
and PAI-1 expression in mesangial cells cultured under both
control and high glucose (46).
Antioxidants have been shown to inhibit several biologi-
cal processes in glomeruli induced by high glucose that have
been implicated in diabetic nephropathy. Structurally differ-
ent antioxidants suppress high-glucose-induced cytosolic
reactive oxygen species generation (44) and high-glucose-
induced PKC activation in rat mesangial cells (131), proxi-
mal tubular cells (103), and the glomeruli of streptozotocin-
induced diabetic rats (47, 48, 84). Antioxidants also prevent
upregulation of TGF-1 (45, 131) and bronectin (131)
and activation of transcription factors NF-
B and AP-1 in of TGF-1 and ECM (extra cellular matrix), and PKC
mesangial cells (44). High-glucose-induced collagen pro-
duction in rat mesangial cells was effectively prevented by
two antioxidants: taurine (139) and vitamin E (138). These
data provide evidence that reactive oxygen species generated
by glucose metabolism may act as integral signaling mole-
cules under high glucose as in other membrane receptor
signaling (44).
In in vivo studies, glomeruli isolated from diabetic rats
increased production of superoxide and hydrogen peroxide
(19, 68). The higher endothelin (ET-1) in glomeruli iso-
lated from diabetic rats is markedly attenuated by reactive
oxygen species scavengers as well as the iron chelator def-
eroxamine (19). Kidneys from diabetic rats exhibit lipid
peroxides and 8-OHdG (42). In a study published in the
Journal of Clinical Investigation, diabetic nodular lesions in
humans stained positive for malondialdehyde, an index of
lipid peroxidation (56, 85). Additional support comes
from studies in which antioxidants prevent glomerular
and renal hypertrophy, albuminuria, glomerular expression
activation in experimental diabetes (21, 22, 47, 48, 72, 73,
84). Reddi et al. have shown that a selenium-decient diet
caused an increase in albuminuria, glomerular sclerosis,
and plasma glucose levels in both normal and diabetic rats,
and that TGF-1 is a pro-oxidant and selenium de-
ciency increases oxidative stress via this growth factor
(110).
2610 SECTION IV Progression of Renal Disease
In an in vivo study, Koya et al. examined the role of oxi-
dants in a model of diabetes. There was enhanced generation
of oxidants as measured by 2 ,7 -dichlorouorescin uores-
cence in glomeruli from diabetic rats compared with nondia-
betic rats. Although the mRNA expression of catalase, gluta-
thione peroxidase, and Cu/Zn superoxide dismutase 2 weeks
after the induction of diabetes was not signicantly different
from that in control rats, mRNA and protein expression of
heme oxygenase was markedly induced in diabetic glomeruli.
Antioxidant treatment with vitamin E or probucol almost
completely normalized heme oxygenase overexpression in
diabetic glomeruli, supporting the existence of oxidative
stress in the glomeruli of early diabetes. Furthermore, anti-
oxidant treatment normalized diabetes-induced renal dys-
function such as albuminuria and glomerular hypertension
and glomerular pathologies (Table 11) (70).
ROLE OF OXIDANTS AND IRON
IN PROGRESSIVE KIDNEY DISEASE
The evidence for the role of oxidants in progressive kidney
disease has been reviewed and consists of the demonstration
of enhanced production of oxidants, evidence that oxidants
induce similar morphological and functional changes as seen
in progressive kidney disease, and the benecial effects of
antioxidants (Table 12) (53). The role of inammatory cells
in progressive kidney disease has also been reviewed (97).
This section of the chapter emphasizes the role of iron be-
cause of the possibility of using iron chelators in preventing
progression. The data supporting the role of iron in models
of progressive renal disease consist of demonstration of in-
creased iron in the kidney in these models of progressive
kidney disease; enhanced oxidant generation, which pro-
vides a mechanism by which iron can be mobilized; and,
more directly, the benecial effect of iron-decient diets and
iron chelators (Table 12). Rats with proteinuria have in-
creased iron content in proximal tubular cells, and iron ac-
cumulation was the only independent predictor of both
functional and structural damage (51). Similarly, it has been
shown that there is a substantial iron accumulation associ-
ated with increased cortical malondialdehyde in proximal
tubular cells in the remnant kidney, suggesting reactive oxy-
gen species generation. Iron accumulation has also been
studied in human chronic renal disease (88).
The sources of increased iron in the kidney have not
been well-delineated, but Alfrey et al. have suggested that
urinary transferrin provides a potential source of iron. Glo-
merular injury of any type impairs glomerular permselec-
tivity, thereby leading to the leakage of proteins, including
transferrin, into the urinary space. At a pH below 6.5, iron
has been shown to be dissociated from transferrin in urine.
As pH decreases as urine courses along the nephron, iron
is released from transferrin (2, 20), thus providing a source
of iron that could act on renal tubular epithelial cells or be
absorbed into the tubules. Information about other poten-
tial sources, including intracellular sources of iron in the
kidney, is available for only acute models of renal injury.
Thus, mitochondria have been suggested as sources of iron
in gentamycin nephrotoxicity, whereas cytochrome C has
been shown to be an important source of catalytic iron in
ischemic and toxic injury (7).
For iron to be important in causing renal injury, it is also
important to demonstrate increased generation of oxidants.
The oxidants would then play a role in mobilizing iron as
well as interacting with the mobilized iron to generate
highly reactive metabolites. Nath and colleagues have car-
ried out a series of studies that have provided compelling
evidence for the role of oxidants in progressive renal disease
(90, 91). Increased rates of oxygen consumption, which oc-
cur in surviving nephrons, is linked to ammoniagenesis and
increased generation of reactive oxygen species, both of
which have been incriminated in progressive renal injury
(91). It has been shown also that, in weanling rats, diets
decient in selenium and vitamin E enhance ammoniagen-
esis, compromise renal function in the intact kidney, and
induce tubulointerstitial injury (92).
Several studies have examined the effect of an iron-
decient diet or iron chelators on progression of chronic
kidney disease. Alfrey et al. have shown a marked effect of
an iron-decient diet or an iron chelator on preventing the
development of tubulointerstitial disease and renal func-
tional deterioration in nephrotoxic serum nephritis (2, 3).
Remuzzi et al. have shown that rats fed an iron-decient
diet had signicant reduction in proteinuria and developed
less glomerulosclerosis (114). An iron chelator signicantly
reduced iron accumulation and tubular damage in rat rem-
nant kidneys (a model for progressive renal disease) (89).
The precise cellular mechanisms by which oxidants and
iron participate in progression are not known. However,
oxidants and iron have many cellular effects that are poten-
tially important in tubulointerstitial damage, brosis, and
matrix accumulation. For example, it is well established that
oxidants and iron play an important role in cellular injury
and cell death, including apoptosis. Thus conceivably they
could play a role in tubular atrophy and loss of cells, which
is a common feature of progressive renal disease. In addition,
lipid peroxidation has been shown to be important in induc-
tion of collagen gene expression (57) and may thus contrib-
ute to renal brosis.
CONCLUSIONS
A sufcient body of in vitro and in vivo information exists
to postulate that oxidants appear to be important media-
tors in glomerular pathophysiology and in progressive
kidney disease. Nonetheless the multifaceted nature of tis-
sue injury makes it almost a certainty that the cooperative
and sometimes complex interactions between different in-
jurious mechanisms are important in the nal expression of
injury.
 CHAPTER 92 Oxidants in Progressive Kidney Disease 2611

TABLE 12 Oxidants and Iron in Progressive Kidney Disease

Oxidative Stress in Progression of Kidney Injury (53)
Generation of reactive oxygen species
Oxidative stress induces similar functional and morphological changes
Antioxidants protect against progression

Role of Iron in Progressive Renal Disease

An increased amount of iron has been shown in the kidneys of
animals (51,94)
and humans (88) with kidney disease

Progression of renal failure in nephrotoxic nephritis model is prevented by an

iron-decient diet (2)
iron chelator (3)

Source: Haugen E, Nath KA. The involvement of oxidative stress in the progression of renal injury. Blood Purif
1999;17:5865; Nankivell BJ, Chen J, Boadle RA, Harris DCH. The role of tubular iron accumulation in the
remnant kidney. J Am Soc Nephrol 1994;4:15981607; Nankivell BJ, Boadle RA, Harris DCH. Iron accumulation
in human chronic renal disease. Am J Kid Dis 1992;20:580584; Alfrey AC. Toxicity of tubule uid iron in the
nephrotic syndrome. Am J Physiol 1992;263:F637F641; Alfrey AC, Froment DH, Hammond WS. Role of iron
in the tubulo-interstitial injury in nephrotoxic serum nephritis. Kidney Int 1989;36:753759.

4. Ardaillou R, Baud L. Interactions between glomerular autocoids. Sem Nephrol 1991;11:

While the collective information on the role of oxi-
dants and iron derived from models of glomerular disease
and progressive renal failure is impressive, there is virtu-
ally no information on the potential role of these mecha-
nisms in human disease. There are many differences be-
tween animal models of glomerular disease and glomerular
disease in humans. For example, the animal model of
minimal change disease is a toxic model whereas the
mechanism of minimal change disease in humans is not
known. Similarly, the anti-Fx1A antibody which is used
for the animal model of membranous nephropathy has
been difcult to demonstrate in human membranous ne-
phropathy.
Indeed, the lessons from animal models of acute renal
failure have been disappointing when attempting to
translate to human disease. Nonetheless, there is at least
evidence for the presence of increased oxidative stress
in chronic kidney disease (54, 55, 59, 98, 141). In addi-
tion, in a recent study a metal chelator (EDTA) was
shown to retard progression (77). The authors concluded
that this benecial effect was related to chelating lead
(which can participate in free radical reactions), but may
have been due to chelation of iron (101). There is a suf-
cient body of evidence to indicate that the role of oxidants
and iron in progression as well as other complications
associated with CKD need to be critically evaluated
in human studies.
References
1. Adler S, Stahl RAK, Baker PJ, Chen YP, Pritzl PM, Couser WG. Biphasic effect of oxygen
radicals on prostaglandin production by rat mesangial cells. Am J Physiol 1987;252:
F743F749.
2. Alfrey AC. Toxicity of tubule uid iron in the nephrotic syndrome. Am J Physiol 1992;263:
F637F641.
3. Alfrey AC, Froment DH, Hammond WS. Role of iron in the tubulo-interstitial injury in
nephrotoxic serum nephritis. Kidney Int 1989;36:753759.
340345.
5. Babior BM. Oxygen-dependent microbial killing by phagocytes (second of two parts). N
Engl J Med 1978;298:721725.
6. Bakker WW, Baller JFW, Hardonk MJ. Decrease of glomerular ATPase activity induced by
adriamycin is mediated by oxygen free radical species. Kidney Int 1987;31:10451046.
7. Baliga R, Ueda N, Walker PD, Shah SV. Oxidant mechanisms in toxic acute renal failure.
Am J Kidney Dis 1997;29:465477.
8. Basci A, Wallin JD, Shah SV. Effect of stimulated neutrophils on cyclic nucleotide content
in isolated rat glomeruli. Am J Physiol 1987;252:F429F436.
9. Baud L, Ardaillou R. Reactive oxygen species: production and role in the kidney. Am J Physiol
1986;251:F765F776.
10. Baud L, Fouqueray B, Philippe C, Amrani A. Tumor necrosis factor alpha and mesangial
cells. Kidney Int 1992;41:600603.
11. Baud L, Fouqueray B, Philippe C, Ardaillou R. Reactive oxygen species as glomerular auto-
coids. J Am Soc Nephrol 1992;2:S132S138.
12. Baud L, Nivez M-P, Chansel D, Ardaillou R. Stimulation by oxygen radicals of prostaglandin
production by rat renal glomeruli. Kidney Int 1981;20:332339.
13. Beaman M, Birtwistle R, Howie AJ, Michael J, Adu D. The role of superoxide anion and
hydrogen peroxide in glomerular injury induced by puromycin aminonucleoside in rats. Clin
Sci 1987;73:329332.
14. Bertolatus JA, Klinzman D, Bronsema DA, Ridnour L, Oberley LW. Evaluation of the role
of reactive oxygen species in doxorubicin hydrochloride nephrosis. J Lab Clin Med 1991;
118:435445.
15. Bierhaus A, Chevion S, Chevion M, Hofmann M, Quehenberger P, Illmer T, Luther T,
Berentshtein E, Tritschler H, Muller M, Wahl P, Ziegler R, Nawroth PP. Advanced glycation
end product-induced activation of NF-kB is suppressed by a-lipoic acid in cultured endothe-
lial cells. Diabetes 1997;46:14811490.
16. Boyce NW, Holdsworth SR. Hydroxyl radical mediation of immune renal injury by desfer-
rioxamine. Kidney Int 1986;30:813817.
17. Boyce NW, Tipping PG, Holdsworth SR. Glomerular macrophages produce reactive oxygen
species in experimental glomerulonephritis. Kidney Int 1989;35:778782.
18. Brownlee M. Advanced protein glycosylation in diabetes and aging. Annu Rev Med 1995;
46:223234.
19. Chen H-C, Guh J-Y, Shin S-J, Tsai J-H, Lai Y-H. Reactive oxygen species enhances
endothelin1 production of diabetic rat glomeruli in vitro and in vivo. J Lab Clin Med
2000;135:309315.
20. Cooper MA, Buddington B, Miller NL, Alfrey AC. Urinary iron speciation in nephrotic
syndrome. Am J Kidney Dis 1995;25:314319.
21. Craven PA, Derubertis FR, Kagan VE, Melhem M, Studer RK. Effects of supplementation
with vitamin C or E on albuminuria, glomerular TGF-b, and glomerular size in diabetes.
J Am Soc Nephrol 1997;8:14051414.
22. Craven PA, Melhem MF, Phillips SL, DeRubertis FR. Overexpression of Cu2/Zn2 super-
oxide dismutase protects against early diabetic glomerular injury in transgenic mice. Diabetes
2001;50:21142125.
23. Cross CE, Halliwell B, Borish ET, Pryor WA, Ames BN, Saul RL, McCord JM, Harman D.
Oxygen radicals and human disease. Ann Intern Med 1987;107:526545.
24. Cybulsky AV, Lieberthal W, Quigg RJ, Rennke HG, Salant DJ. A role for thromboxane in
complement-mediated glomerular injury. Am J Pathol 1987;128:4551.
25. Diamond JR, Bonventre JV, Karnovsky MJ. A role for oxygen free radicals in aminonucleo-
side nephrosis. Kidney Int 1986;29:478483.
26. Dousa TP. Cyclic nucleotides in renal pathophysiology. In: Brenner BM, Stein JH, eds.
Contemporary Issues in Nephrology, Vol. IV. New York: Churchill Livingstone; 1979:251285.
2612 SECTION IV Progression of Renal Disease
27. Dousa TP, Shah SV, Abboud HE. Potential role of cyclic nucleotides in glomerular patho-
physiology. In: Hamet P, Sands H, eds. Advances in Cyclic Nucleotide Research, Vol. 12. New
York: Raven Press; 1980:285299.
28. Duque I, Garcia-Escribano C, Rodriguez-Puyol M, Diez-Marques ML, Lopez-Novoa JM,
Arribas I, Hernando L, Rodriguez-Puyol D. Effects of reactive oxygen species on cultured rat
mesangial cells and isolated rat glomeruli. Am J Physiol 1992;263F466F473.
29. Duque I, Puyol MR, Ruiz P, Gonzalez-Rubio M, Marques MLD, Puyol DR. Calcium chan-
nel blockers inhibit hydrogen peroxide-induced proliferation of cultured rat mesangial cells.
J Pharmacol Exp Therap 1993;267:612616.
30. Dworkin LD, Ichikawa I, Brenner BM. Hormonal modulation of glomerular function. Am J
Physiol 1983;244:F95F104.
31. El Nahas AM. Mechanisms of experimental and clinical renal scarring. In: Davison AM,
Cameron JS, Grunfeld JP, Kerr DNS, Ritx E, Winearls CG, eds. Oxford Textbook of Clinical
Nephrology, 2nd ed. New York: Oxford University Press; 1998;17491788.
32. Falk RJ, Terrell RS, Charles LA, Jennette JC. Anti-neutrophil cytoplasmic autoantibodies
induce neutrophils to degranulate and produce oxygen radicals in vitro. Proc Natl Acad Sci
U S A 1990;87:41154119.
33. Fantone JC, Ward PA. Role of oxygen-derived free radicals and metabolites in leukocyte-
dependent inammatory reactions. Am J Pathol 1982;107:397418.
34. Freeman BA, Crapo JD. Biology of disease: free radicals and tissue injury. Lab Invest 1982;47:
412426.
35. Fridovich I. The biology of oxygen radicals: the superoxide radical is an agent of oxygen
toxicity; superoxide dismutases provide an important defense. Science 1978;201:875880.
36. Giardino I, Edelstein D, Brownlee M. BCL2 expression or antioxidants prevent hypergly-
cemia-induced formation of intracellular advanced glycation endproducts in bovine endothe-
lial cells. J Clin Invest 1996;97:14221428.
37. Gopalkrishna R, Anderson WB. Reversible oxidative activation and inactivation of protein ki-
nases C by the mitogen/tumor promotor periodate. Arch Biochem Biophys 1991;285:382387.
38. Grone HJ, Grone EF, Malle E. Immunohistochemical detection of hypochlorite-modied
proteins in glomeruli of human membranous glomerulonephritis. Lab Invest 2002;82:514.
39. Gschwendt M, Kittstein W, Marks F. Protein kinase C activation by phorbol esters: do cys-
teine rich regions and pseudosubstrate motifs play a role? Trends Biochem Sci 1991;16:
167169.
40. Guidet B, Shah SV. Enhanced in vivo H2O2 generation by rat kidney in glycerol-induced
renal failure. Am J Physiol 1989;257:F440F445.
41. Ha H, Endou H. Lipid peroxidation in isolated rat nephron segments. Am J Physiol 1992;263:
F201F207.
42. Ha H, Kim KH. Role of oxidative stress in the development of diabetic nephropathy. Kidney
Int 1995;48(Suppl 51):S18S21.
43. Ha H, Lee HB. Oxidative stress in diabetic nephropathy: Basic and clinical information.
Curr Diab Rep 2001;1:282287.
44. Ha H, Lee HB. Reactive oxygen species as glucose signaling molecules in mesangial cells
cultured under high glucose. Kidney Int 2000;58(Suppl 77):S19S25.
45. Ha H, Lee SH, Kim KH. Effects of rebamipide in a model of experimental diabetes and on
the synthesis of transforming growth factor-beta and bronectin, and lipid peroxidation in-
duced by high glucose in cultured mesangial cells. J Pharmacol Exp Ther 1997;281:1457
1462.
46. Ha H, Seo J, Lee EA, Kim YS. Reactive oxygen species mediates upregulation of plasmino-
gen activator inhibitor1 secretion by mesangial cells cultured under high glucose. J Am Soc
Neph 2001;12:836A.
47. Ha H, Yu M-R, Choi YJ, Lee HB. Activation of protein kinase C-d and C-e by oxidative
stress in early diabetic rat kidney. Am J Kidney Dis 2001;38(Suppl 1):S204S207.
48. Ha H, Yu M-R, Kim KH. Melatonin and taurine reduce early glomerulopathy in diabetic
rats. Free Rad Biol Med 1999;26:944950.
49. Halliwell B, Gutteridge JMC. Role of free radicals and catalytic metal ions in human disease:
an overview. Meth Enzymol 1990;186:185.
50. Haneda M, Araki S-I, Togawa M, et al. Activation of MAPK cascade in diabetic glomeruli
and mesangial cells cultured under high glucose. Kidney Int 1997;52(Suppl 60):S60S69.
51. Harris DC, Tay C, Nankivell BJ. Lysosomal iron accumulation and tubular damage in rat
puromycin nephrosis and ageing. Clin Exp Pharmacol Physiol 1994;21:7381.
52. Hartnett ME, Stratton RD, Browne RW, Rosner BA, Lanham RJ, Armstrong D. Serum mark-
ers of oxidative stress and severity of diabetic retinopathy. Diabetes Care 2000;23:234240.
53. Haugen E, Nath KA. The involvement of oxidative stress in the progression of renal injury.
Blood Purif 1999;17:5865.
54. Himmelfarb J, Hakim RM. Oxidative stress in uremia. Curr Opin Nephrol Hypertens 2003;12:
593598.
55. Himmelfarb J, Stenvinkel P, Ikizler TA, Hakim RM. The elephant in uremia: oxidant stress
as a unifying concept of cardiovascular disease in uremia. Kidney Int 2002;62:152438.
56. Horie K, Miyata T, Maeda K, Miyata S, Sugiyama S, Sakai H, van Ypersele de Strihou C,
Monnier VM, Witztum JL, Kurokawa K. Immunohistochemical colocalization of glycoxida-
tion products and lipid peroxidation products in diabetic renal glomerular lesions. J Clin
Invest 1997;100:29953004.
57. Houglum K, Brenner DA, Chojkier M. D-a-Tocopherol inhibits collagen a1 (I) gene expres-
sion in cultured human broblasts. Modulation of constitutive collagen gene expression by
lipid peroxidation. J Clin Invest 1991;87:22302235.
58. Iglesias-de la Cruz MC, Ruiz-Torres P, Alcami J, Diez-Marques L, Ortega-Velazquez R,
Chen S, Rodriguez-Puyol M, Ziyadeh FN, Rodriguez-Puyol D. Hydrogen peroxide in-
creases extracellular matrix mRNA through TGF-b in human mesangial cells. Kidney Int
2001;59:8795.
59. Ikizler TA, Morrow JD, Roberts LJ, Evanson JA, Becker B, Hakim RM, Shyr Y, Himmelfarb
J. Plasma F2-isoprostane levels are elevated in chronic hemodialysis patients. Clin Nephrol
2002;58:190197.
60. Ishii H, Jirousek MR, Koya D, et al. Amelioration of vascular dysfunctions in diabetic rats by
an oral PKC beta inhibotor. Science 1996;272:728731.
61. Ishii h, Koya D, King GL. Protein kinase C activation and its role in the development of
vascular complications in diabetes mellitus. J Mol Med 1998;76:2131.
62. Johnson RJ, Couser WG, Chi EY, Adler S, Klebanoff SJ. New mechanism for glomerular
injury. J Clin Invest 1987;79:13791387.
63. Johnson RJ, Guggenheim SJ, Klebanoff SJ, Ochi RF, Wass A, Baker P, Schulze M, Couser WG.
Morphologic correlates of glomerular oxidant injury induced by the myeloperoxidase-hydrogen
peroxide-halide system of the neutrophil. Lab Invest 1988;5:294301.
64. Kakita N, Sasaguri Y, Kato S, Morimatsu M. Induction of gelatinolytic neutral proteinase
secretion by lipid peroxide in cultured mesangial cells. Nephron 1993;63:9499.
65. Kang SW, Adler SG, La Page J, et al. p38 MAPK and MAPK kinase 3/6 mRNA and ac-
tivities are increased in early diabetic glomeruli. Kidney Int 2001;60:S543S552.
66. Kashihara N, Watanabe Y, Makino H, Wallner EI, Kanwar YS. Selective decreased de novo
synthesis of glomerular proteoglycans under the inuence of reactive oxygen species. Proc
Natl Acad Sci U S A 1992;89:63096313.
67. Kawaguchi M, Yamada M, Wada H, Okigaki T. Roles of active oxygen species in glomerular
epithelial cell injury in vitro caused by puromycin aminonucleoside. Toxicology 1992;72:
329340.
68. Kitching AR, Ruger BM, Davis PF. Oxidant stress in the kidney in experimental diabetes
mellitus. Kidney Int 1997;51:1314.
69. Klebanoff SJ. Oxygen metabolites and the toxic properties of phagocytes. Ann Intern Med
1980;93:480489.
70. Koya D, Hayashi K, Kitada M, Kashiwagi A, Kikkawa R, Haneda M. Effects of antioxidants
in diabetes-induced oxidative stress in the glomeruli of diabetic rats. J Am Soc Nephrol 2003;
14:S250S253.
71. Koya D, King GL. Protein kinase C activation and the development of diabetic complica-
tions. Diabetes 1998;47:859866.
72. Koya D, Lee I-K, Ishii H, Kanoh H, King GL. Prevention of glomerular dysfunction in dia-
betic rats by treatment with d-a-tocopherol. J Am Soc Nephrol 1997;8:426435.
73. Lal MA, Korner A, Matsuo Y, Zelenin S, Chen SXJ, Jaremko G, DiBona GF, Eklof A-C,
Aperia A. Combined antioxidant and COMT inhibitor tratment reverses renal abnormalities
in diabetic rats. Diabetes 2000;49:13811389.
74. Lampert MB, Weiss SJ. The chlorinating potential of the human monocyte. Blood 1983;62:
645651.
75. Lee AY, Chung SK, Chung SS. Demonstration that polyol accumulation is responsible for
diabetic cataract by the use of transgenic mice expressing the aldose reductase gene in the
lens. Proc Natl Acad Sci U S A 1995;92:27802784.
76. Lianos EA, Andres GA, Dunn MJ. Glomerular prostaglandin and thromboxane synthesis in
rat nephrotoxic serum nephritis. J Clin Invest 1983;72:14391448.
77. Lin J-L, Lin-Tan D-T, Hsu K-H, Yu C-C. Environmental lead exposure and progression of
chronic renal diseases in patients without diabetes. N Engl J Med 2003;348:277286.
78. Malle E, Buch T, Grone H-J. Myeloperoxidase in kidney disease. Kidney Int 2003;64:
19561967.
79. Matteucci E, Giampietro O. Oxidative stress in families of type I diabetic patients. Diabetes
Care 2001;24:167168.
80. McCord JE, Wong K, Stokes SH, Petrone WF, English D. Superoxide and inammation: a
mechanism for the anti-inammatory activity of superoxide dismutase. Acta Physiol Scan
1980;492:2530.
81. McCord JM. Oxygen-derived free radicals in postischemic tissue injury. N Engl J Med 1985;
312:159163.
82. McCord JM, Fridovich I. The biology and pathology of oxygen radicals. Ann Intern Med
1978;89:122127.
83. Meier M, King GL. Protein kinase C activation and its pharmacological inhibition in vascu-
lar disease. Vasc Med 2000;5:173185.
84. Melhem MF, Craven PA, Derubertis FR. Effects of dietary supplementation of a-lipoic acid
on early glomerular injury in diabetes mellitus. J Am Soc Nephrol 2001;12:124133.
85. Miyata T, Sugiyama S, Suzuki D, Inagi R, Kurokawa K. Increased carbonyl modication by
lipids and carbohydrates in diabetic nephropathy. Kidney Int 1999;56(Suppl 71):S54S56.
86. Monnier VM. Transition metals redox: reviving an old plot for diabetic vascular disease.
J Clin Invest 2001;107:799801.
87. Morrow JD, Hill KE, Burk RF, Nammour TM, Badr KF, Roberts LJ. A series of prostaglan-
din F2-like compounds are produced in vivo in humans by a non-cyclooxygenase, free radi-
cal-catalyzed mechanism. Proc Natl Acad Sci U S A 1990;87:93839387.
88. Nankivell BJ, Boadle RA, Harris DCH. Iron accumulation in human chronic renal disease.
Am J Kidney Dis 1992;20:580584.
89. Nankivell BJ, Chen J, Boadle RA, Harris DCH. The role of tubular iron accumulation in the
remnant kidney. J Am Soc Nephrol 1994;4:15981607.
90. Nath KA, Croatt AJ, Hostetter TH. Oxygen consumption and oxidant stress in surviving
nephrons. Am J Physiol 1990;258:F1354F1362.
91. Nath KA, Fischereder M, Hostetter TH. The role of oxidants in progressive renal injury.
Kidney Int 1994;45(Suppl 45):S111S115.
92. Nath KA, Salahudeen AK. Induction of renal growth and injury in the intact rat kidney by
dietary deciency of antioxidants. J Clin Invest 1990;86:11791192.
93. Nishikawa T, Edelstein D, Brownlee M. The missing link: A single unifying mechanism for
diabetic complications. Kidney Int 2000;58(Suppl 77):S26S30.
94. Nishikawa T, Edelstein D, Du XL, Yamagishi S-i, Matsumura T, Kaneda Y, Yorek MA, Beebe
D, Oates PJ, Hammes H-P, Giardino I, Brownlee M. Normalizing mitochondrial superoxide
production blocks three pathways of hyperglycaemic damage. Nature 2000;404:787790.
95. Nitenberg A, Pycha F, Ledoux S, Sachs R, J-R. A, Valensi P. Coronary artery responses to
physiological stimuli are improved by deferoxamine but not by L-Arginine in non-insulin-
dependent diabetic patients with angiographically normal coronary arteries and no other risk
factors. Circulation 1998;97:736743.
96. NKF. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classica-
tion, and stratication, IV: denition and classication of stages of chronic kidney disease.
Am J Kidney Dis 2002;39(Suppl 1):S46S75.

97. Noronha IL, Fujihara CK, Zatz R. The inammatory component in progressive renal dis-
easeare interventions possible? Nephrol Dial Transplant 2002;17:363368.
98. Oberg BP, McMenamin E, Lucas FL, McMonagle E, Morrow J, Ikizler TA, Himmelfarb J.
Increased prevalence of oxidant stress and inammation in patients with moderate to severe
chronic kidney disease. Kidney Int 2004;65:10091016.
99. Oberle GP, Niemeyer J, Thaiss F, Schoeppe W, Stahl RAK. Increased oxygen radical
and eicosanoid formation in immune-mediated mesangial cell injury. Kidney Int 1992;42:
6974.
100. Okasora T, Takikawa T, Utsunomiya Y, Senoh I, Hayashibara H, Shiraki K, Kasagi T,
Shimizu F. Suppressive effect of superoxide dismutase on adriamycin nephropathy. Nephron
1992;60:199203.
101. Owda AK, Alam MG, Shah SV. Environmental lead exposure and chronic renal disease.
N Engl J Med 2003;348:1810.
102. Park L, Raman KG, Lee KJ, et al. Suppression of accelerated diabetic atherosclerosis by the
soluble receptor for advanced glycation endproducts. Nat Med 1998;4:10251031.
103. Park S-H, Choi H-J, Lee J-H, Woo C-H, Kim J-H, Han H-J. High glucose inhibits renal
proximal tubule cell proliferation and involves PKC, oxidative stress, and TGF-b1. Kidney Int
2001;59:16951705.
104. Pennathur S, Wagner JD, Leeuwenburgh C, Litwak KN, Heinecke JW. A hydroxyl radical-
like species oxidizes cynomolgus monkey artery wall proteins in early diabetic vascular dis-
ease. J Clin Invest 2001;107:853860.
105. Poelstra K, Hardonk MJ, Koudstaal J, Bakker WW. Intraglomerular platelet aggregation and
experimental glomerulonephritis. Kidney Int 1990;37:15001508.
106. Qian M, Liu M, Eaaton JW. Transition metals bind to glycated proteins forming redox active
glycochelates: Implications for the pathogenesis of certain diabetic complications. Biochem
Biophys Res Comm 1998;250:385389.
107. Radeke HH, Cross AR, Hancock JT, Jones OTG, Nakamura M, Kaever V, Resch K. Func-
tional expression of NADPH oxidase components (a- and b-subunits of cytochrome b558 and
45-kDa avoprotein) by intrinsic human glomerular mesangial cells. J Biol Chem 1991;266:
2102521029.
108. Radeke HH, Meier B, Topley N, Floge J, Habermehl GG, Resch K. Interleukin 1-a and
tumor necrosis factor-a induce oxygen radical production in mesangial cells. Kidney Int 1990;
37:767775.
109. Rahman MA, Emancipator SS, Sedor JR. Hydroxyl radical scavengers ameliorate proteinuria
in rat immune complex glomerulonephritis. J Lab Clin Med 1988;112:619626.
110. Reddi AS, Bollineni JS. Selenium-decient diet induces renal oxidative stress and injury via
TGF-b1 in normal and diabetic rats. Kidney Int 2001;59:13421353.
111. Rehan A, Johnson KJ, Kunkel RG, Wiggins RC. Role of oxygen radicals in phorbol myristate
acetate-induced glomerular injury. Kidney Int 1985;27:503511.
112. Rehan A, Johnson KJ, Wiggins RC, Kunkel RG, Ward PA. Evidence for the role of oxygen
radicals in acute nephrotoxic nephritis. Lab Invest 1984;51:396403.
113. Rehan A, Wiggins RC, Kunkel RG, Till GO, Johnson KJ. Glomerular injury and proteinuria
in rats after intrarenal injection of cobra venom factor. Am J Pathol 1986;123:5766.
114. Remuzzi A, Puntorieri S, Brugnetti B, Bertani T, Remuzzi G. Renoprotective effect of low
iron diet and its consequence on glomerular hemodynamics. Kidney Int 1991;39:647652.
115. Remuzzi G, Imberti L, Rossini M, Morelli C, Carminati C, Cattaneo GM, Bertani T. In-
creased glomerular thromboxane synthesis as a possible cause of proteinuria in experimental
nephrosis. J Clin Invest 1985;75:94101.
116. Rhee SG. Redox signaling: hydrogen peroxide as intracellular messenger. Exp Mol Med 1999;
31:5359.
117. Santini SA, Marra G, Giardina B, Cotroneo P, Mordente A, Martorana GE, Manto A,
Ghirlanda G. Defective plasma antioxidant defenses and enhances susceptibility to lipid
peroxidation in uncomplicated IDDM. Diabetes 1997;46:18531858.
118. Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton BF, Hamm LL, McCullough
PA, Kaskike BL. Kidney disease as a risk factor for development of cardiovascular disease: a
statement from the American Heart Association Councils on Kidney in Cardiovascular
Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Preven-
tion. Circulation 2003;108:21542169.
119. Schreck R, Baeuerle PA. A role for oxygen radicals as second messengers. Trends Cell Biol
1991;1:3942.
120. Schreck R, Rieber P, Baeuerle PA. Reactive oxygen intermediates as apparently widely used
messengers in the activation of the NF-KB transcription factor and HIV1. EMBO J 1991;
10:22472258.
121. Scivittaro V, Ganz MB, Weiss MF. AGEs induce oxidative stress and activate protein kinase
c-beta (II) in neonatal mesangial cells. Am J Physiol Renal Physiol 2000;289:F787F793.
CHAPTER 92 Oxidants in Progressive Kidney Disease 2613
122. Sedor JR, Abboud HE. Hydrogen peroxide stimulates PGE2 synthesis by cultured rat me-
sangial cells. Kidney Int 1986;29:291.
123. Shah SV. Effect of enzymatically generated reactive oxygen metabolites on the cyclic nucleo-
tide content in isolated rat glomeruli. J Clin Invest 1984;74:393401.
124. Shah SV. Light emission by isolated rat glomeruli in response to phorbol myristate acetate.
J Lab Clin Med 1981;98:4657.
125. Shah SV. Role of reactive oxygen metabolites in experimental glomerular disease. Kidney Int
1989;35:10931106.
126. Shah SV, Baricos WH, Basci A. Degradation of human glomerular basement membrane by
stimulated neutrophils. Activation of a metalloproteinase/s by reactive oxygen metabolites.
J Clin Invest 1987;79:2531.
127. Sharpe PC, Liu W-H, Yue KKM, McMaster D, Catherwood MA, McGinty AM, Trimble
ER. Glucose-induced oxidative stress in vascular contractile cells. Diabetes 1998;47:801
809.
128. Shin CS, Moon BS, Park KS, Kim SY, Park SJ, Chung MH, Lee HK. Serum 8-hydroxy-
guanine levels are increased in diabetic patients. Diabetes Care 2001;24:733737.
129. Sima AA, Prashar A, Zhang WX, Chakrabarti S, Greene DA. Preventive effect of long-term
aldose reductase inhibition (ponalrestat) on nerve conduction and sural nerve structure in the
spontaneously diabetic Bio-Breeding rat. J Clin Invest 1990;85:14101420.
130. Stahl R, Disser M, Hora K, Schlondorff D. Increased expression of monocyte chemoattrac-
tant protein in glomeruli from rats with anti Thy1 glomerulonephritis. J Am Soc Nephrol
1992;3:616.
131. Studer RK, Craven PA, Derubertis FR. Antioxidant inhibition of protein kinase C-signaled
increase in transforming growth factor-beta in mesangial cells. Metabolism 1997;46:918925.
132. Szczech LA, Lazar IL. Projecting the United States ESRD population: Issues regarding
treatment of patients with ESRD. Kidney Int 2004;66(Suppl 90):S3S7.
133. Takahashi K, Nammour TM, Fukunaga M, Ebert J, Morrow JD, Roberts LJ, Hoover RL,
Badr KF. Glomerular actions of a free radical-generated novel prostaglandin, 8-epi-
prostaglandin F2a, in the rat. J Clin Invest 1992;90:136141.
134. Thakur V, Walker PD, Shah SV. Evidence suggesting a role for hydroxyl radical in puromy-
cin aminonucleoside-induced proteinuria. Kidney Int 1988;34:494499.
135. Thannickal VJ, Fanburg BL. Reactive oxygen species in cell signaling. Am J Physiol Lung Cell
Mol Physiol 2000;279:L1005L1028.
136. Toledano MB, Leonard WJ. Modulation of transcription factor NF-kB binding activity by
oxidation-reduction in vitro. Proc Natl Acad Sci U S A 1991;88:43284332.
137. Tomlinson dR. Mitogen-activated protein kinases as glucose transducers for diabetic compli-
cations. Diabetologia 1999;42:12711281.
138. Trachtman H. Vitamin E prevents glucose-induced lipid peroxidation and increased collagen
production in cultured rat mesangial cells. Microvasc Res 1994;47:232239.
139. Trachtman H, Futterweit S, Bienkowski RS. Taurine prevents glucose-induced lipid peroxi-
dation and increased collagen production in cultured rat mesangial cells. Biochem Biophys Res
Comm 1993;191:759765.
140. Ueda N, Guidet B, Shah SV. Measurement of intracellular generation of hydrogen peroxide
by rat glomeruli in vitro. Kidney Int 1994;45:788793.
141. Vaziri ND. Roles of oxidative stress and antioxidant therapy in chronic kidney disease and
hypertension. Cur Opin Nephrol Hyperten 2004;13:9399.
142. Vissers MCM, Winterbourn CC. The effect of oxidants on neutrophil-mediated degradation
of glomerular basement membrane collagen. Biochim Biophys Acta 1986;889:277286.
143. Weiss SJ. Oxygen, ischemia and inammation. Acta Physiol Scand 1986;126(Suppl 548):937.
144. Weiss SJ, LoBuglio AF. Biology of disease: phagocyte-generated oxygen metabolites and
cellular injury. Lab Invest 1982;47:518.
145. Weiss SJ, Regiani S. Neutrophils degrade subendothelial matrices in the presence of alpha1-
proteinase inhibitor. Cooperative use of lysosomal proteinases and oxygen metabolites. J Clin
Invest 1984;73:12971303.
146. Xue JL, Ma JZ, Louis TA, Collins AJ. Forecast of the number of patients with end-stage
renal disease in the United States to the year 2010. J Am Soc Nephrol 2001;12:27532758.
147. Yan SD, Schmidt AM, Anderson GM, Zhang J, Brett J, Zou YS, Pinsky D, Stern D. En-
hanced cellular oxidant stress by the interaction of advanced glycation end products with their
receptors/binding proteins. J Biol Chem 1994;269:98899897.
148. Yoshioka T, Ichikawa I. Glomerular dysfunction induced by polymorphonuclear leukocyte-
derived reactive oxygen species. Am J Physiol 1989;257:F53F59.
149. Yoshioka T, Ichikawa I, Fogo A. Reactive oxygen metabolites cause massive, reversible pro-
teinuria and glomerular sieving defect without apparent ultrastructural abnormality. J Am Soc
Nephrol 1991;2:902912.