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Organelle stress, such as mitochondrial or endoplasmic reticulum damage, plays a crucial role in the pathogenesis of acute kidney injury (AKI). Further, persistent organelle stress, which causes metabolic abnormality followed by inflammation and fibrosis, is an important mediator of AKI-to-CKD transition. Organelle stress closely links to the derangement of organelle cross talk. Organelles intricately interact with each other under the physiological conditions to maintain their function each other and subsequent cell fate. Organelle stress and their cross talk are now a focus of intensive researches in the field of AKI as they are in the field of CKD.

Previously acute kidney injury (AKI) had been believed to be a transient event, and recovery from AKI had been thought to lead to no consequences. However, recent epidemiological studies have shown that even if there is complete recovery of the kidney function, AKI can eventually result in chronic kidney disease (CKD) and eventually in end-stage kidney disease in the long term. Transition of AKI to CKD is mediated by multiple mechanisms, including aberrant cell cycle arrest and hypoxia. Hypoxia of the kidney is induced by rarefaction of the peritubular capillaries after AKI episodes, and induces inflammation and fibrosis. It should also be noted that epigenetic changes are closely related to hypoxia, and epigenetic changes induced by hypoxia, called “hypoxic memory” can explain the AKI-to-CKD transition in the long term after complete recovery from the initial AKI episode. Targeting hypoxia and subsequent epigenetic changes are promising strategies to block the transition from AKI to CKD.

AST-120 (kremezin; Kureha Chemical, Tokyo, Japan) is an oral spherical carbonaceous adsorbent, which was approved for clinical use in Japanese chronic kidney disease (CKD) patients in 1991. It adsorbs indole, the precursor of indoxyl sulfate, in the intestines and prevents indoxyl sulfate production. Indoxyl sulfate, initially identified as a major uremic toxin that causes uremic symptoms, contributes to CKD progression. Since AST-120 decreases serum indoxyl sulfate in a dose-dependent manner, multicenter prospective trials have been conducted in Japan in the 1980s; these trials were mostly in favor of the efficacy of AST-120 in delaying the initiation of dialysis in patients with advanced stage CKD. Many animal studies support the effects of AST-120 on renal outcomes as well as on cardiovascular complications. However, there are yet no reports that unequivocally demonstrate the improvement of hard renal endpoints and/or cardiovascular endpoints. This commentary briefly reviews the major outcomes of the recent clinical trials on AST-120.

Complement factor D, a complement system serine protease, circulating in vivo as its active form, accumulates in patients with chronic renal failure. The pathophysiological role of this active protease in these patients was examined by studies on activities of excess factor D on 10 synthetic peptide substrates for some usual serine proteases. The most sensitive of these substrates to factor D was Boc-Gln-Ala-Arg-MCA, which is used as a substrate for trypsin. The proteolytic activity of factor D (2.17 unit/mg/h) on this substrate was estimated to be 10(-5)-fold that of trypsin (2.18 x 10(5) unit/mg/h). The activities of factor D on other synthetic substrates were lower. Thus the proteolytic activity of factor D is considered to be very specific for its natural substrate, complement factor B bound with C3b, even when it is highly accumulated in vivo. The inhibitory effects of some serine protease inhibitors used clinically (nafamostat mesilate, sepinostat mesilate, camostat mesilate and gabexate mesilate) on the proteolytic activity of factor D on its natural substrate, factor B, were also investigated. Of these synthetic compounds, nafamostat mesilate was the most effective inhibitor (ID50:25 microM) of the activity of factor D on factor B.