Hypoxia of the Renal Medulla -- Its Implications for Disease

doi:10.1056/NEJM199503093321006

Volume 332:647-655		March 9, 1995		Number 10

Hypoxia of the Renal Medulla — Its Implications for Disease

Mayer Brezis, M.D., and Seymour Rosen, M.D.

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In land mammals, a major task of the kidney is to reabsorb waterto allow survival in a dry environment. Water conservation isenhanced by the renal medulla, which concentrates the urineto a level up to four times the osmolality of plasma. To producethis unique gradient of osmolality, the medulla has a countercurrentsystem of vessels and tubules that dictates active reabsorptionof sodium in a milieu poor in oxygen (Figure 1).¹ In this review,we describe how hypoxia of the medulla may relate to susceptibilityto acute and chronic renal injury.

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Figure 1. Anatomical and Physiologic Features . . . [Full Text of this Article]

The Renal Medullary Concentrating Mechanism as the Physiologic Basis of Medullary Hypoxia

Adaptive Mechanisms to Minimize Medullary Hypoxia

Prostaglandins and Related Metabolites

Other Vasoactive Mediators

Adenosine

Tubuloglomerular Feedback

Growth Factors

Neuroendocrine and Other Protective Mechanisms

Experimental Amelioration and Exacerbation of Medullary Hypoxia

Synergy of Toxic and Hypoxic Insults in the Kidney

Diversity of Expression of Hypoxic Renal Injury

Cellular, Molecular, and Functional Alterations

Acute Morphologic Lesions in Tubules

Distribution of Gradients of Hypoxia in the Kidney

Structural Expression of Tubular Hypoxic Injury

Chronic Structural Lesions and Intrarenal Hypoxia

Clinical Implications of Medullary Hypoxic Injury

Additional Dangers to the Renal Medulla

Therapeutic Implications

Conclusions

Source Information

From the Department of Medicine, Hadassah University Hospital, Mount Scopus, Jerusalem, Israel (M.B.); and the Department of Pathology, Beth Israel Hospital and Harvard Medical School, Boston (S.R.).

Address reprint requests to Dr. Brezis at the Department of Medicine, Hadassah University Hospital, Mount Scopus, P.O. Box 24035, Jerusalem, Israel, 91240.

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