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Converging evidence suggests that damage to podocytes plays a key role in progression towards glomerulosclerosis, in particular as the primary cause of all forms of focal segmental glomerulosclerosis (FSGS), the most common glomerular disease leading to end-stage renal disease. Any damage occurring to the complex architecture of specialized proteins that constitute the podocyte foot processes, essential to the highly specialized functions of podocytes, leads inevitably to loss of function in the glomerular filtration barrier, and ultimately to proteinuria. Recent studies have also highlighted that a reduction of the podocyte number in a damaged glomerulus is a critical factor for the development of proteinuria and glomerulosclerosis. As long as the podocyte loss is limited, restitution or repair is possible, which shows that the glomerular architecture can be remodeled. However, mature podocytes have limited capacity to divide and display all the phenotypic and functional features of highly specialized, terminally differentiated cells. A potential mechanism for podocyte replacement might be stem-cell-based regeneration, since it has been established that the developmental source of podocytes are resident renal progenitors. Podocyte damage could then be potentially repaired by a stem cell population resident in the kidney.

Recent evidence suggests that injury to the renal vasculature may play an important role in the pathogenesis of both chronic and acute ischemic kidney injury. Early alterations in peritubular capillary blood flow during reperfusion have been documented and associated with loss of normal endothelial cell function. In addition, ischemia induces alterations in endothelial cells that may promote inflammation and procoagulant activity, thus contributing to vascular congestion. Reduction of the microvasculature density increases hypoxia-mediated fibrosis and alters proper hemodynamics, which may lead to hypertension. This may play a critical role in the progression of chronic kidney disease following initial recovery from ischemia/reperfusion-induced acute kidney injury. The turnover and replacement of endothelial cells is therefore an important mechanism in the maintenance of vascular integrity also in the kidney. It is becoming clear that impaired vascular repair mechanisms as a result of a reduced number and/or impaired function of endothelial progenitor cells may contribute to renal disease. Moreover, investigators have begun to identify potential mechanisms responsible for the loss of function of endothelial progenitors in renal disease. In allografts, persistent injury results in excessive turnover of graft vascular endothelial cells. Moreover, chronic damage elicits a response that is associated with the recruitment of both leukocytes and endothelial progenitors, facilitating an overlapping process of inflammation and angiogenesis. In conclusion, angiogenesis and endothelial cell turnover play a pivotal role in renal disease and allograft rejection. Manipulation of these processes might have important implications for the development of novel therapeutic strategies in the near future.

Cytokines are soluble factors that are critical for the pathophysiology of the immune system and exhibit other important functions. Cytokines produced by type 1 helper T (Th1) lymphocytes, such as interferon (IFN)-g, play a pathogenic role in proliferative glomerulonephrites (GN), as well as in the acute rejection of kidney allografts. Cytokines produced by type 2 Th (Th2) lymphocytes, such as interleukin (IL)-4, IL-5, and IL-13), predominate in membranous GN and in minimal change disease. More recently, the pathogenic role of some members of the family of chemotactic cytokines (chemokines) in different nephropathies and in the acute and chronic rejection of kidney allografts has also been demonstrated. In particular, the chemokine MCP1/CCL2 has been found to be expressed in the kidneys of subjects with tubulo-interstitial nephritis and seems to play an important role in the sclerotic evolution of both inflammatory and metabolic nephropathies. Interactions between IP-10/CXCL10, Mig/CXCL9 and I-TAC/CXCL11 and their shared receptor, CXCR3, seem to be responsible not only for Th1 cell infiltration in acute allograft rejection and in proliferative GN, but also for mesangial cell proliferation typical of the latter condition. In proliferative GN, mesangial cells indeed express both these chemokines and their receptor. Moreover, in the kidneys of subjects suffering from chronic allograft nephropathy, IP-10/CXCL10, Mig/CXCL9 and I-TAC/CXCL11 have been found to be produced by and to act on the proxymal tubular epithelial cells, endothelial cells and smooth muscle vessel cells, suggesting their possible role in both the genesis of tubular atrophy and allograft artheriosclerosis.