Pathophysiology of AKI to CKD progression

Yuki Sato, MD, PhD *,† Masahiro Takahashi, MD † and Motoko Yanagita, MD, PhD†,‡

Summary: Acute kidney injury (AKI), defined as a rapid decrease in glomerular filtration rate, is a common and dev-
astating pathologic condition. AKI is associated with significant morbidity and subsequent chronic kidney disease
(CKD) development. Regardless of the initial insult, CKD progression after AKI involves multiple types of cells,
including proximal tubular cells, fibroblasts, and immune cells. Although the mechanisms underlying this AKI to
CKD progression have been investigated extensively over the past decade, therapeutic strategies still are lacking.
One of the reasons for this stems from the fact that AKI and its progression toward CKD is multifactorial and variable
because it is dependent on patient background. In this review, we describe the current understanding of AKI and its
maladaptive repair with a focus on proximal tubules and resident fibroblasts. Subsequently, we discuss the unique
pathophysiology of AKI in the elderly, highlighting our recent finding of age-dependent tertiary lymphoid tissues.
Semin Nephrol 40:206−215 Ó 2020 Elsevier Inc. All rights reserved.
Keywords: Acute kidney injury, proximal tubule, fibroblast, tertiary lymphoid tissues, chronic inflammation

A
cute kidney injury (AKI) is a common patho-
logic condition characterized by a steep decrease
in glomerular filtration.1 AKI is caused by vari-
ous common pathologic conditions, including dehydra-
tion and sepsis. The incidence of AKI has increased over
past decades.2 One study reported that the prevalence of
non−dialysis-requiring AKI was more than 5,000 cases
per million per year.3 Moreover, a significant proportion
of AKI survivors progressed to chronic kidney disease
*Medical Innovation Center, TMK Project, Kyoto University, Kyoto,
Japan
yDepartment of Nephrology, Graduate School of Medicine, Kyoto
University, Kyoto, Japan
zInstitute for the Advanced Study of Human Biology, Kyoto Univer-
sity, Kyoto, Japan
Financial support: Supported by the Japan Agency for Medical
Research and Development under grants 19gm1210009 (Agency for
Medical Research and Development−Core Research for Evolutional
Science and Technology), JP19gm5010002, and JP19gm0610011
(M.Y.); by grants from the TMK Project, Grant-in-Aids for Scientific
Research B (26293202, 17H04187), a Grant in Aid for Scientific
Research on Innovative Areas “Stem Cell Aging and Disease” from
the Ministry of Education, Culture, Sports, Science and Technology
of Japan (17H05642), a Grant-in-Aid for Young Scientists (B) from
the Japan Society for the Promotion of Science, the Translational
Research program, Strategic Promotion for practical application of
INnovative medical Technology from the Agency for Medical
Research and Development, grants from the Uehara Memorial Foun-
dation, Takeda Science Foundation, and the Sumitomo Foundation.
This work also was supported in part by the World Premier Interna-
tional Research Center Initiative, Ministry of Education, Culture,
Sports, Science and Technology, Japan.
Conflict of interest statement: Yuki Sato is employed by the TMK Proj-
ect; and Motoko Yanagita has received research grants from Astel-
las, Chugai, Daiichi Sankyo, Fujiyakuhin, Kyowa Hakko Kirin,
Mitsubishi Tanabe, MSD, Nippon Boehringer Ingelheim, and Torii.
Address reprint requests to Motoko Yanagita, MD, Department of
Nephrology, Graduate School of Medicine, Kyoto University, 54
Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan. E-mail:
motoy@kuhp.kyoto-u.ac.jp
0270-9295/ - see front matter
© 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.semnephrol.2020.01.011
(CKD) or end-stage renal disease (ESRD). Bucaloiu
et al4 reported that approximately 50% of hospital-asso-
ciated AKI patients who had recovered successfully
from AKI and were discharged were newly diagnosed
with CKD during the median follow-up period of
3.3 years. In another cohort from North America, the rel-
ative hazard risk of chronic dialysis in patients who had
recovered from dialysis-requiring AKI was 3.23 com-
pared with controls. Thus, AKI now is recognized as a
significant risk factor for CKD and ESRD.5
Although a number of molecules and pathways have
been identified as involved in AKI and its progression by
animal studies over past decades, the development of
effective treatment strategies for this AKI to CKD transi-
tion in human beings still is lacking. One of the reasons
for this is the heterogeneity of AKI. AKI occurs in
patients from heterogeneous backgrounds with age,
baseline renal function, and accompanying comorbid-
ities. This may modify the common pathophysiology of
AKI and contribute to its heterogeneity. Importantly, an
increasing number of epidemiologic studies have shown
that aging and CKD significantly increases the risk of
AKI development and its severity.6-8
In this review, we discuss the pathophysiology of AKI
and its progression to CKD, focusing on the mechanisms
underlying maladaptive repair after renal tubule injury.
We also discuss the role of tertiary lymphoid tissues
(TLT) after AKI and their potential influences on mal-
adaptive repair.
PROXIMAL TUBULES AS A PRIMARY TARGET OF
AKI
The kidney is composed of multiple types of differenti-
ated cells with unique characteristics and is responsible
for the maintenance of internal homeostasis. Proximal
tubules are the most popular cell type in the kidney,
occupying almost 90% of the renal cortex. Proximal
tubular cells express various transporters and channels

206 Seminars in Nephrology, Vol 40, No 2, March 2020, pp 206−215

AKI progression to CKD
on the apical surface and reabsorb various vital substan-
ces, including sodium, bicarbonate, glucose, and amino
acids in the glomerular filtrate. In addition, proximal
tubular cells reabsorb intrinsic and extrinsic macromole-
cules through receptor-mediated endocytosis and metab-
olize various substances.9 Interestingly, proximal tubules
mostly depend on fatty acids as their energy source and
generate adenosine triphosphate (ATP) by mitochondrial
b-oxidation. Proximal tubules therefore are rich in the
mitochondria used to perform the task described earlier.
Although renal proximal tubules are essential for
maintaining internal homeostasis, they also are suscepti-
ble to various kinds of cellular stress and are considered
a main target of AKI.10 For instance, proximal tubular
cells are vulnerable to ischemic stress. In the outer
medulla of the kidney, S3 segments of proximal tubules
are particularly susceptible to ischemic AKI because of
their huge burden of sodium reabsorption and the physio-
logically hypoxic microenvironment. Importantly, proxi-
mal tubules have limited glycolytic activity, which also
renders them highly susceptible to ischemic insult.10 In
addition, proximal tubules are highly susceptible to
nephrotoxic substances such as anticancer drugs. For
instance, cisplatin, a platinum-based alkylating antineo-
plastic agent, is taken up by proximal tubules through
both via passive diffusion and active transport, which is
mediated mainly by organic cation transporter 2 on the
basolateral side of proximal tubules. Cisplatin is concen-
trated within the proximal cells and induces proximal
tubule injury in a dose-dependent manner.11
Interestingly, genetic proximal tubule−specific injury
shows several CKD features. By using the inducible
diphtheria toxin receptor system, which induces injury in
the cells expressing Cre recombinase by the administra-
tion of diphtheria toxin, Grgic et al12 showed that Six2-
Cre lineage renal epithelial cell injury resulted in intersti-
tial fibrosis and glomerulosclerosis. By using
Ndrg1CreERT2 mice,13 which label proximal tubules,
we also showed that proximal tubule−specific injury
leads to not only renal fibrosis and reduced Epo produc-
tion, but also glomerulosclerosis and atubular glomer-
uli.14 These studies showed that proximal tubular injury
is both a primary trigger of AKI as well as a potential
determinant of later disease progression, and that the
protection of proximal tubules is essential to preventing
the development of AKI and its progression to CKD.15
INTRINSIC REGENERATIVE POTENTIAL OF
PROXIMAL TUBULE CELLS
Although proximal tubules are susceptible to various cel-
lular stresses, they also have an intrinsic repair capacity,
which minimizes damage and circumvents serious renal
dysfunction. A recent clinical study showed that among
2,922 patients with a single episode of dialysis-requiring
AKI, 13.6% had normalized renal function after 1 year,16
indicating that the kidney has the potential to repair itself,
207
with limitations.17,18 A precise understanding of the cel-
lular and molecular mechanisms for intrinsic repair is
critically important because strategies to harness intrinsic
renal repair have the potential to become novel therapeu-
tic options for AKI to CKD progression.
After injury, tubular cells dedifferentiate, proliferate,
and redifferentiate, leading to the repair of nephrons.
Many investigators have examined the origin of the
tubular cells that replenish the epithelial cells after AKI
in murine models. Humphreys et al19 used Six2-Cre
mice to genetically label almost all of the epithelial cells
of nephrons. They found that despite extensive cell pro-
liferation after ischemic-reperfusion injury, no dilution
of genetic labels was observed after the repair phase.20
These results indicated that surviving epithelial cells
largely contribute to the repair of proximal tubules after
AKI. Subsequently, using Slc34a1-CreERT2, which
labels proximal tubular cells more specifically, the same
group further confirmed that injured proximal tubules
were regenerated mainly through their own prolifera-
tion.21 The Ndrg1-CreERT2 mouse line, which also
labels proximal tubule cells, showed consistent results.13
Interestingly, we found that proximal tubules became
shorter after AKI than before, indicating the limitation
of the regenerative capacity of proximal tubules.13 These
repair processes were exemplified elegantly by a recent
study using the intravital imaging technique. In response
to laser-induced tubular injury, intact adjacent proximal
tubules proliferate and replace the lost cells. Interest-
ingly, during this process, platelet-derived growth factor
(PDGF)-receptor b−positive resident fibroblasts migrate
to the injured site and promote tubular regeneration in a
PDGFb-dependent manner22 because inhibition of
PDGFb hindered the fibroblast migration and tubular
regeneration. These results showed that resident fibro-
blasts are motile and contribute to tubular regeneration
by acting as a mechanical stabilization of the denuded
tubular basement membrane. We also recently reported
that although a-smooth muscle actin (aSMA)-positive
myofibroblasts generally are accepted as a driver of renal
fibrosis, in the early phase of kidney injury, myofibro-
blasts acquire retinoic acid−producing ability and are
actively involved in the repair process of tubular cells,
possibly by promoting tubular cell proliferation.23
Do All Proximal Tubular Cells Have a Similar
Capacity for Regeneration?
Although the elegant lineage tracing studies described
earlier showed that surviving proximal tubular cells are
the origin of renewal proximal tubular cells after injury,
this did not exclude the possibility of an intratubular
stem cell. It remains controversial whether there are any
distinct subpopulations of tubular cells responsible for
regeneration after tubular injury, or if regeneration is a
stochastic process that surviving tubular cells participate
in equally.
208
Recently, Romagnani and colleagues24 addressed this
question using a lineage tracing technique with Confetti
mice. They showed that Pax2-Cre lineage-labeled cells,
which originally reside in the S3 segment in the proximal
tubules and distal tubules and are recognized as a puta-
tive intratubular progenitor population, were resistant to
cell injury and clonally expand after injury, suggesting
the presence of intratubular progenitors. Interestingly,
they also found that in response to injury some tubular
cells showed endocycle-mediated hypertrophy, a state in
which cells undergo DNA synthesis without cell divi-
sion. In contrast, using sequential labeling with thymi-
dine analogs, Humphreys et al25 previously addressed
the same question and showed that after ischemic reper-
fusion injury, intrinsic repair occurred mainly through
the self-duplication of surviving tubular epithelial cells,
not by intratubular progenitor cells. Although the reasons
for the discrepancy among these studies remain unclear,
the reliability of cell proliferation markers such as Ki67
and proliferating cell nuclear antigen in the context of
AKI is questioned and considered one of the reasons.24
To minimize the risk of renal dysfunction, it is reason-
able to think that kidneys have multiple mechanisms for
tissue repair that can vary depending on several factors,
such as disease severity and the initial trigger. Further
studies in various contexts therefore are required to under-
stand the details of mechanisms for intrinsic renal repair.
INJURED PROXIMAL TUBULE AS A DRIVER OF AKI
TO CKD PROGRESSION
Although the kidney has several intrinsic repair capaci-
ties, as described in the previous section, in case of its
failure (eg, chronic kidney injury), these normally effi-
cient repair mechanisms become impaired and several
additional mechanisms trigger maladaptive repair
responses, which lead to CKD progression. Substantial
evidence has shown that injured proximal tubular cells
contribute to AKI to CKD progression by promoting
inflammation and fibrosis.8,26,27 Here, we describe sev-
eral pathologic roles of injured proximal tubules that
underlie the AKI to CKD progression.
Injured Proximal Tubules in G2/M Cell-Cycle Arrest
Promote Renal Inflammation and Fibrosis
Over the past decade, various studies have shown the
humoral communications between injured tubular cells
and interstitial cells, and their roles in regeneration and
fibrosis after injury. Bonventre and colleagues reported
that severe AKI results in tubular cell-cycle arrest at the
G2/M phase of the cell cycle, which secrete various profi-
brotic and proinflammatory factors.26,28 Transforming
growth factor-b and connective tissue growth factor are
well-investigated profibrotic and proinflammatory factors
known to be secreted by injured proximal tubular cells in
G2/M cell-cycle arrest,26 at least partially mediated by
Y. Sato et al.
c-Jun N-terminal kinase signaling, resulting in interstitial
fibrosis.28 Therefore, targeting injured tubules at G2/M
cell-cycle arrest can be a novel therapeutic target and sev-
eral interventions have been documented. For instance,
the pharmacologic inhibition of p53, a key cell-cycle reg-
ulator, as well as histone deacetylase inhibitors, bypassed
G2/M arrest in the injured tubular cells and reduced inter-
stitial fibrosis.28-30 Other groups have shown that specific
inhibitors of cyclin-dependent kinases 4/6, a key mediator
of cell-cycle checkpoint progression from the G1 to S
phase, also are effective to optimize cell-cycle stages of
injured tubules.31,32 In addition, the macrophage migra-
tion factor in renal tubular cells also has been shown to
limit inflammation and fibrosis by abrogating cell-cycle
arrest in renal tubular cells.33
Aberrant Reactivation of the Developmental
Pathway Promotes Fibrosis
Reactivation of some developmental signaling pathways,
such as Wnt, Hedgehog, and Notch, have been shown in
animal models of AKI and renal fibrosis. These activa-
tions likely are induced as part of tubular regeneration
after injury and involved in maladaptive repair.18 For
example, injured tubules express sonic hedgehog, the
most studied ligand of the hedgehog pathway, in response
to injury, and they secrete sonic hedgehog, which binds to
its receptors on interstitial fibroblasts and up-regulates
their expression of profibrotic genes, such as fibronectin
and collagen.34 The Wnt/b-catenin pathway, another
important developmental pathway, also is reactivated in
tubular cells during the acute phase of kidney injury,
which potentially is protective because the proximal
tubule−specific deletion of b-catenin showed aggravated
apoptosis and tubular injury in this phase.35 The sustained
expression of Wnt ligands, however, induced myofibro-
blast transformation and resulted in fibrosis. These studies
show the involvement of the reactivation of developmen-
tal signaling pathways in repair processes after injury,
which eventually can result in maladaptive repair.
Mitochondrial Dysfunction in Injured Proximal
Tubular Cells
Mitochondrial dysfunction increasingly has been recog-
nized as a critical contributor of AKI to CKD progres-
sion.36 Although mitochondria are necessary for several
cellular functions, such as ATP synthesis under physio-
logical conditions, during injury, they also hold several
detrimental roles for cells, such as the production of
reactive oxygen species and the induction of apoptosis.37
Recent studies have shown that most AKIs include vari-
ous degrees of mitochondria dysfunction in tubular epi-
thelial cells.
Mitochondrial injury occurs early in the course of
AKI, especially ischemia-reperfusion injury, and is asso-
ciated with cellular injury. Under ischemic conditions,
AKI progression to CKD
hypoxia disrupts oxidative phosphorylation in mitochon-
dria and causes excessive reactive oxygen species pro-
duction and ATP deficiency, which further damages
various molecules, including DNAs, proteins, and lipids,
resulting in cell death and inflammation. Damaged mito-
chondria also release several danger molecules, such as
DNA and cardiolipin, leading to NOD-, LRR- and pyrin
domain-containing protein 3 inflammasome activation.
Therefore, protecting mitochondrial function is essential
for treating AKI with different etiologies.37,38 It is of
note that mitochondria-specific antioxidant molecules,
such as mitoubiquinone, MitoTEMPO, and SkQR1, also
showed protective effects in experimental models of
ischemic and septic AKI in association with reduced oxi-
dative stress.39-42 Mitochondrial dysfunction also is
involved in CKD progression after AKI. Szeto et al43
reported that mitochondrial dysfunction was observed in
rat proximal tubules 9 months after ischemic AKI and
that the late administration of mitochondrial-protective
molecule SS-31 promoted recovery from CKD.
To maintain a healthy cellular state, mitochondria
constantly are being renewed. Damaged mitochondria
are selectively removed through the process of mitoph-
agy, the autophagic degradation of damaged mitochon-
dria, and the loss of mitochondrial mass is replenished
by mitochondrial biogenesis. Peroxisome proliferator
activated receptor gamma coactivator 1 alpha (PGC-1a)
is a master regulator of mitochondria biogenesis and is
highly expressed in the cortex and outer stripe of the
medulla where the mitochondrial activity is relatively
high.44 Interestingly, overexpression of PGC-1a in tubu-
lar cells increased mitochondrial mass and also showed
renoprotection, not cell death, after ischemic and inflam-
matory kidney injury,45 whereas global PGC-1a knock-
out mice showed severe renal dysfunction in a model of
septic AKI.46 Given that the level of PGC-1a has been
shown to decrease after AKI and increase with repair,
these results showed that PGC-1a is protective in AKI
and is necessary for post-AKI repair. Furthermore, inves-
tigations into the downstream mechanisms of PGC-1a
have shown that de novo NAD+ biosynthesis mediates
renal protection.45 NAD+ is an essential energy carrier
for fatty acid oxidation in mitochondria; b-hydroxybuty-
rate, a breakdown product of fatty acid oxidation, indu-
ces prostaglandin E2, which maintains renal function.45
FIBROBLAST DYSFUNCTION IS A CENTRAL
PATHOGENIC PROCESS IN CKD PROGRESSION
AFTER AKI
Emerging evidence also has shown that a significant
overlap exists between AKI and CKD pathophysiology,
in both of which resident fibroblasts play crucial roles,
suggesting the potentially important contribution of
fibroblasts in the AKI to CKD sequence.47 Despite the
209
Figure 1. Renal fibrosis and inflammatory cell infiltration: two com-
mon pathologic features in injured kidney. aSMA-positive myofibro-
blast accumulation and inflammatory cell infiltration in renal
interstitial space are common pathologic findings in murine injured
kidney. Immunofluorescence of CD45 (green) and aSMA (red)
10 days after unilateral ureteral obstruction. Scale bar: 50 mm.
diverse etiologies and pathophysiology of AKI, patho-
logic changes in the kidney converge on several common
CKD features, including interstitial fibrosis, peritubular
capillary loss, and renal anemia.47-50 Interstitial fibrosis
is a hallmark of CKD and is defined as the accumulation
of extracellular matrix (ECM) and is produced mainly
by aSMA-positive myofibroblasts (Fig. 1). Abnormal
ECM accumulation in the interstitial spaces distorts
organ architecture, disturbs blood supply, and decreases
renal oxygenation. Peritubular capillary loss and renal
anemia also contribute to chronic hypoxia, the final com-
mon pathway to ESRD.51 Interestingly, interstitial fibro-
sis, renal anemia, and peritubular capillary loss are
linked mechanistically, and resident fibroblasts are a cen-
tral player in these conditions.
Resident fibroblasts are spindle-shaped mesenchymal
cells residing in the interstitial space.52 Interestingly, res-
ident fibroblasts in the kidney have the ability to sense
hypoxia and produce erythropoietin (EPO), thereby play-
ing a crucial role in maintaining internal homeostasis.53
During injury, however, the phenotype of fibroblasts
changes dramatically. In our previous study, we showed
that resident fibroblasts in the cortex and the outer
medulla of the kidney are lineage-labeled with P0-Cre,
which labels the migrating neural crest cells. In response
to injury, P0-Cre lineage−labeled fibroblasts transdiffer-
entiate into aSMA-positive myofibroblasts, proliferate
dramatically, and execute fibrosis by producing a large
amount of ECMs (Fig. 2).48 Recently, Humphreys and
colleagues showed that Gli1-Cre lineage−labeled cells
are progenitors of myofibroblasts and can be targeted
therapeutically.54 They showed that the ablation of Gli1-
Cre lineage−labeled cells resulted in a more than 50%
reduction of renal fibrosis in a murine unilateral ureteral
obstruction model.54
210 Y. Sato et al.

Figure 2. Heterogeneous fibroblasts involved in AKI to CKD progression. Resident fibroblasts in the kidney locally
transdifferentiate into several distinct phenotypic fibroblasts in response to their microenvironmental cues. In response
to injury, resident fibroblasts in the kidney transdifferentiate aSMA-positive myofibroblasts at the cost of EPO-produc-
ing ability and execute renal fibrosis. Some of the myofibroblasts acquire retinoic acid (RA)-producing ability. Although
RA derived from myofibroblasts supports tubular regeneration, in aged injured kidney, RA additionally induces p75NTR
expression in fibroblasts and promotes the transdifferentiation of fibroblasts into TLT-associated fibroblasts. RALDH2,
retinaldehyde dehydrogenase 2. Reprinted with permission from Sato and Yanagita,7,53 Nangaku,51 and Sato et al.76

Importantly, during this phenotypic transition into
myofibroblasts, fibroblasts lose the ability to produce
EPO in response to hypoxia (Fig. 2).48 This loss of EPO-
producing ability, however, is reversible by several
agents, including selective estrogen-receptor modula-
tors.48 This is consistent with human clinical data. Broo-
khart et al55 reported that hemodialysis patients living at
high altitudes had a higher hematocrit with a lower dose
of recombinant EPO treatment than hemodialysis
patients at lower altitudes, suggesting that hypoxia-
driven EPO production remains operative to some
extent, even in patients with ESRD. Another example is
that the pharmacologic inhibition of prolyl hydroxylase,
which regulates EPO production by degrading hypoxia-
inducible factor 1a in an oxygen-dependent manner,
prominently increased intrinsic EPO production in
hemodialysis patients, suggesting the reserve capacity of
fibroblasts for EPO production.56 These clinical studies
indicate that EPO-producing cells still exist, even in
ESRD patients, and that the EPO-producing ability is
reversible.
In parallel to CKD progression, peritubular capillary
loss also becomes detectable more commonly.57 Although
pericytes wrap peritubular capillary vessels with their
multiple projections and structurally stabilize them under
normal conditions, during injury, pericytes are detached
from capillary vessels and instead wrap injured tubules,
which make the vessels structurally unstable and leads to
capillary regression and rarefaction.47,50,58
PHENOTYPIC PLASTICITY AND HETEROGENEITY
OF IMMUNE CELLS
In the pathophysiology of kidney injury and repair,
immune cells have a significant influence on the fate of the
injured kidney.7,59,60 Several types of immune cells, such
as monocytes and lymphocytes, are recruited to the site of
injury and can play important roles in both tissue destruc-
tion and tissue repair. Although inflammation is originally
a biological response that is necessary for eradicating
pathogens and promoting tissue repair after injury, excess
and nonresolving inflammation can lead to tissue damage
and fibrosis. Therefore, the balance between proinflamma-
tory and anti-inflammatory immune responses has a signif-
icant impact on the renal outcome after AKI. Here, we
described the role of immune cells in the pathophysiology
of AKI to CKD progression.
Roles of Immune Cells in Kidney Injury and Repair
During the acute phase of AKI, innate immune cells such
as monocytes and neutrophils are recruited in response to
damage-associated molecular patterns released from
necrotic cells. These recruited cells are activated and
release proinflammatory cytokines, such as interleukin
(IL)6 and tumor necrosis factor a, propagating inflamma-
tory responses. Ischemic insult causes an increase in vas-
cular permeability and the aberrant activation of adhesion
molecules, both of which also accelerate the infiltration of
AKI progression to CKD
immune cells. Lymphocytes also are involved in the patho-
physiology. The initially activated tissue-resident mononu-
clear phagocytes take up antigen and move to the draining
lymph nodes, where they present antigen to T cells.61 Sub-
sequently, activated T cells clonally expand with the effec-
tor phenotype and migrate to the kidney,62 where they
release proinflammatory cytokines, such as interferon g,
and promote inflammation.
In contrast to the detrimental roles of immune cells in
the acute phase of injury described earlier, substantial
evidence also has shown the reparative roles of immune
cells in the injured kidneys. For instance, while in the
early phase of AKI, macrophages show the proinflamma-
tory M1 phenotype and exacerbate kidney injury as
described earlier, in the recovery phase of AKI, M1 mac-
rophages switch to the anti-inflammatory M2 phenotype,
which modulates inflammatory responses and promotes
tissue repair.63 Similarly, anti-inflammatory T cells in
the kidney after AKI also have been reported. The most
studied T cell involved in renal repair is the
CD4+CD25+FoxP3+ regulatory T cell.64 Regulatory T
cells counteract proinflammatory responses by contact-
dependent mechanisms and by producing anti-inflamma-
tory IL10, and therefore limit excess inflammation to
promote a reparative process. CD4-CD8- ab T cells also
were suggested to release anti-inflammatory cytokines
and promote kidney recovery.65
UNIQUE PATHOPHYSIOLOGY OF AKI IN THE
ELDERLY
AKI and its progression to CKD or ESRD are more
likely to occur in the elderly. In a retrospective cohort
study that followed up hospitalized patients older than
67 years of age, patients with both AKI and CKD had a
41-fold increase in the development of ESRD compared
with those with no history of either disease.6 Given that
the aging population is growing worldwide and the inci-
dence of AKI also is increasing, it is important to under-
stand precisely what occurs in the aged kidney after
AKI.
Multiple Factors for Increased Susceptibility and
Severity of AKI in the Elderly
Multiple factors have been identified as contributors to
the increased susceptibility of AKI and its CKD progres-
sion in the aged kidney.66,67 First, the presence of age-
dependent structural and functional changes may
increase the susceptibility to AKI. Wiggins and col-
leagues showed that glomerular aging correlates well
with a progressive linear reduction in podocyte density,
which accelerates global glomerulosclerosis.68 A recent
study showed that the number of nephrons decreases
with aging.69 It is reasonable to think that nephron loss
directly confers a higher susceptibility to AKI, and an
211
experimental study showed that a pre-existing reduction
in functional nephrons is associated with CKD progres-
sion after AKI.70 Second, the age-dependent decrease in
regenerative capacity may contribute to maladaptive
repair in the aged kidney. As described in the previous
section, surviving proximal tubular cells proliferate after
injury and repair themselves. With aging, however, the
proliferative capacity of the tubular cells is reduced and
several causative factors have been identified. The
increased expression of zinc-a-glycoprotein, an inhibitor
of epithelial cell proliferation, in proximal tubules in
aged mice has been shown to be involved in this reduced
proliferative capacity.71 Third, age-dependent chronic
inflammation also hinders intrinsic cellular repair after
injury and promotes organ damage.72 Aging results in
chronic low-grade inflammation in the murine and
human kidney.72 One of the reasons for this is the accu-
mulation of senescent cells. Senescent cells are defined
as being in a permanent state of cell-cycle arrest induced
by cellular stress; they develop a senescence-associated
secretory phenotype that entails the release of numerous
biologically active molecules, such as IL6 and matrix
metalloproteinases.73 Senescent cells contribute to age-
dependent inflammation by senescence-associated secre-
tory phenotype,74,75 and also limit the potential for tubu-
lar regeneration after injury because they are unable to
proliferate.
Tertiary Lymphoid Tissues as a Cause for Sustained
Inflammation After AKI in the Elderly
Despite the clinical relevance of AKI in the elderly, the
mechanism underlying the poor prognosis largely was
elusive. To investigate the difference in injury responses
between young and aged kidneys, we induced several
kidney injury models in young and aged mice. Consis-
tent with the clinical evidence, although young kidneys
repair themselves after injury, aged kidneys show renal
fibrosis and sustained inflammation. Unexpectedly, we
found that aged kidneys, but not young kidneys, showed
multiple inflammatory cell aggregates around the
artery.76 The size of aggregates was associated with
impaired renal function and increased expression of
proinflammatory cytokines, such as interferon g and
tumor necrosis factor a, suggesting a possible contribu-
tion to sustained inflammation after injury in the aged
kidney.76 These aggregates are composed mainly of T
and B lymphocytes, both of which proliferate within the
aggregates. This indicates that these inflammatory cell
aggregates are functional and work as tertiary lymphoid
tissues (TLTs) (Fig. 3).76
TLTs are ectopic lymphoid tissues and function as
local sites of lymphocyte activation.77 They can propa-
gate local antigen-specific immune responses, and their
roles can be either beneficial or detrimental depending
on the context. For example, in case of infection, TLTs
212 Y. Sato et al.

tubular basement membrane.81 This study also showed

the clonal expansion and ongoing somatic hypermutation
of B cells in TLTs of lupus nephritis.81

Heterogeneous Fibroblasts Orchestrate TLT

Figure 3. TLT in aged injured kidney. TLT is composed mainly of T
and B lymphocytes and formed around the artery. Immunofluores-
cence of CD3e (green) and B220 (red). Scale bar: 50 mm.
can play protective roles for the host by generating
immune responses to pathogens. In contrast, in the case
of autoimmunity, TLTs contribute to sustained inflam-
mation and local antibody production,77,78 and are detri-
mental for the host organ.77 They also are considered to
function as niches for tumor progenitor cells78,79 and
pathogenic memory T cells.80 TLTs also are induced in
several CKDs, such as lupus nephritis81 and chronic
rejected transplanted kidneys,82 which are not age-
dependent. In an analysis of lupus nephritis, TLTs were
present in more than half of patients, and the existence
of TLTs was associated with the severity of interstitial
inflammation and immune complex deposition in the
Formation
Although TLTs are composed mainly of lymphocytes,
stromal cells (especially fibroblasts) play crucial roles in
the induction and maintenance. In aged injured kidneys,
several fibroblasts with distinct phenotypes are involved
in TLT formation. Most TLTs harbor homeostatic che-
mokines, such as C-X-C motif chemokine ligand 13
(CXCL13) and C-C motif chemokine ligand 19
(CCL19), whose transgenic ectopic expression of these
chemokines in nonlymphoid tissue induce the develop-
ment of functional TLTs.83,84 We found that fibroblasts
inside TLTs in aged injured kidneys exclusively produce
CXCL13 and CCL19, and attract T cells and B cells,
resulting in TLT formation.76 Interestingly, the pheno-
types of fibroblasts inside and outside TLTs totally dif-
fer. In addition to the ability to produce CXCL13 and
CCL19, fibroblasts inside TLTs strongly express the p75
neurotrophin receptor (p75NTR), a neural crest marker.
Interestingly, retinoic acid−producing fibroblasts sur-
round TLTs in the early phase of TLT formation and
induce strong expression of p75NTR in fibroblasts inside
TLTs.76 Some of the p75NTR-positive fibroblasts inside
TLTs lose their p75NTR expression in the later phase of
TLT formation and instead express complement receptor

Figure 4. TLT in murine and human kidney. In murine renal TLT, fibroblasts positive for retinaldehyde dehydrogenase
2 (RALDH2) surround TLTs. In contrast, fibroblasts within TLTs are negative for RALDH2 and instead are strongly
positive for p75NTR, a neural crest marker. Some of the p75NTR+ fibroblasts inside TLT acquire the ability to produce
homeostatic chemokine CXCL13 and CCL19, and drive and maintain TLTs. CD21+/p75NTR- follicular dendritic cells
(FDCs) emerge as an integral part of the fibroblast network within TLT, and peripheral lymph node addressin-positive
high endothelial venule (HEV) also develop within TLTs. Although cellular and molecular components of TLT in human
kidneys are similar to those in murine TLT, p75NTR colocalizes with CD21, and RALDH2+ stromal cells surround
CD21+ FDCs in human renal TLTs. Abbreviations: RA, retinoic acid. Reprinted with permission from Sato and Yana-
gita,7,53 Nangaku,51 and Sato et al.76
AKI progression to CKD
CD21, a marker for follicular dendritic cells. Follicular
dendritic cells are predominantly stromal cells and form
B-cell follicles, which support germinal center responses
in lymphoid tissues.85 McMahon and colleagues recently
confirmed B cell clonal expansion and autoantibody pro-
duction in aged murine renal TLTs.86,87 Interestingly,
we performed a lineage-tracing study to determine the
origin of these distinct phenotypic fibroblasts using P0-
Cre mice, and showed that most were lineage-labeled
with P0-Cre, indicating that fibroblasts from a single
lineage locally diversify into these distinct phenotypic
fibroblasts in response to their microenvironmental cues
(Fig. 2).76
TLTs as a Novel Therapeutic Target for Kidney
Diseases
Importantly, although not specific to TLTs, anti-CD4
monoclonal antibody treatment abolished TLTs and
ameliorated renal fibrosis as well as inflammation, sup-
porting the concept that targeting TLTs is a promising
therapeutic target for AKI to CKD progression in the
elderly.76 Consistently, in autoimmunity, the genetic
depletion of TLT-associated fibroblasts also impairs
TLT formation and reduces lymphocyte activation with
improvement in tissue pathology.88 Age-dependent TLT
formation also is detectable in the human kidney, and
the cellular and molecular components are similar to
those in mice (Fig. 4), suggesting that age-dependent
TLT formation is conserved across species. This similar-
ity is critically important because the discrepancy
between human and rodent kidney has been suspected as
a reason why numerous agents that had shown promising
results in experimental AKI failed to show efficacy in
human patients.20,89
Although renal TLTs are induced in human kidneys
by several factors, such as aging and autoimmunity, sev-
eral studies have yielded inconsistent results and the
clinical relevance remains to be elucidated. One of the
reasons for this is the lack of an established assessment
method for TLTs in human kidneys. Further studies are
required to understand the nature of TLTs in human kid-
neys and to develop a TLT assessment method for deter-
mining the clinical relevance of TLTs in various
pathologic conditions.
CONCLUSIONS
Our expanding knowledge on the AKI to CKD progres-
sion from murine models has improved our understanding
of this pathologic sequence and is providing opportunities
for the development of novel therapeutics. Nonetheless,
no therapeutic interventions have been shown to prevent
CKD progression after AKI, suggesting a gap between
murine and human AKI. Given that the incidence of AKI
is increasing and its burden is tremendous, further
213
research into this field is required, especially in the
elderly, because the world population is aging and the
pathophysiology of AKI in the elderly is unique. A better
understanding of the pathophysiology and heterogeneity
of AKI to CKD progression in human beings is
necessary and will lead to the development of novel thera-
peutics to enhance intrinsic repair and suppress maladap-
tive responses.
ACKNOWLEDGMENTS
Y.S. and M.T. contributed equally.
REFERENCES
1. Lameire NH, Bagga A, Cruz D, De Maeseneer J, Endre Z, Kellum
JA, et al. Acute kidney injury: an increasing global concern. Lan-
cet. 2013;382:170-9.
2. Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu CY. Temporal
changes in incidence of dialysis-requiring AKI. J Am Soc Neph-
rol. 2013;24:37-42.
3. Hsu CY, McCulloch CE, Fan D, Ordo~ nez JD, Chertow GM, Go
AS. Community-based incidence of acute renal failure. Kidney
Int. 2007;72:208-12.
4. Bucaloiu ID, Kirchner HL, Norfolk ER, Hartle JE, Perkins
RM. Increased risk of death and de novo chronic kidney dis-
ease following reversible acute kidney injury. Kidney Int.
2012;81:477-85.
5. Wald R, Quinn RR, Luo J, Li P, Scales DC, Mamdani MM, et al.
Chronic dialysis and death among survivors of acute kidney injury
requiring dialysis. JAMA. 2009;302:1179-85.
6. Ishani A, Xue JL, Himmelfarb J, Eggers PW, Kimmel PL, Molito-
ris BA, et al. Acute kidney injury increases risk of ESRD among
elderly. J Am Soc Nephrol. 2009;20:223-8.
7. Sato Y, Yanagita M. Immune cells and inflammation in AKI
to CKD progression. Am J Physiol Renal Physiol. 2018;315:
F1501-12.
8. He L, Wei Q, Liu J, Yi M, Liu Y, Liu H, et al. AKI on CKD:
heightened injury, suppressed repair, and the underlying mecha-
nisms. Kidney Int. 2017;92:1071-83.
9. Nielsen R, Christensen EI, Birn H. Megalin and cubilin in proxi-
mal tubule protein reabsorption: from experimental models to
human disease. Kidney Int. 2016;89:58-67.
10. Chevalier RL. The proximal tubule is the primary target of injury
and progression of kidney disease: role of the glomerulotubular
junction. Am J Physiol Renal Physiol. 2016;311:F145-61.
11. Kitai Y, Matsubara T, Yanagita M. Onco-nephrology: current
concepts and future perspectives. Jpn J Clin Oncol. 2015;45:
617-28.
12. Grgic I, Campanholle G, Bijol V, Wang C, Sabbisetti VS, Ichi-
mura T, et al. Targeted proximal tubule injury triggers interstitial
fibrosis and glomerulosclerosis. Kidney Int. 2012;82:172-83.
13. Endo T, Nakamura J, Sato Y, Asada M, Yamada R, Takase M,
et al. Exploring the origin and limitations of kidney regeneration.
J Pathol. 2015;236:251-63.
14. Takaori K, Nakamura J, Yamamoto S, Nakata H, Sato Y, Takase
M, et al. Severity and frequency of proximal tubule injury deter-
mines renal prognosis. J Am Soc Nephrol. 2016;27:2393-406.
15. Liu BC, Tang TT, Lv LL, Lan HY. Renal tubule injury: a
driving force toward chronic kidney disease. Kidney Int. 2018;
93:568-79.
16. Stoumpos S, Mark PB, McQuarrie EP, Traynor JP, Geddes
CC. Continued monitoring of acute kidney injury survivors
might not be necessary in those regaining an estimated
214
glomerular filtration rate >60 mL/min at 1 year. Nephrol Dial
Transplant. 2017;32:81-8.
17. Humphreys BD, Cantaluppi V, Portilla D, Singbartl K, Yang L,
Rosner MH, et al. Targeting endogenous repair pathways after
AKI. J Am Soc Nephrol. 2016;27:990-8.
18. Little MH, Kairath P. Does renal repair recapitulate kidney devel-
opment? J Am Soc Nephrol. 2017;28:34-46.
19. Humphreys BD, Valerius MT, Kobayashi A, Mugford JW,
Soeung S, Duffield JS, et al. Intrinsic epithelial cells repair the
kidney after injury. Cell Stem Cell. 2008;2:284-91.
20. de Caestecker M, Humphreys BD, Liu KD, Fissell WH, Cerda J,
Nolin TD, et al. Bridging translation by improving preclinical
study design in AKI. J Am Soc Nephrol. 2015;26:2905-16.
21. Kusaba T, Lalli M, Kramann R, Kobayashi A, Humphreys BD.
Differentiated kidney epithelial cells repair injured proximal
tubule. Proc Natl Acad Sci U S A. 2014;111:1527-32.
22. Schiessl IM, Grill A, Fremter K, Steppan D, Hellmuth MK, Cas-
trop H. Renal interstitial platelet-derived growth factor receptor-b
cells support proximal tubular regeneration. J Am Soc Nephrol.
2018;29:1383-96.
23. Nakamura J, Sato Y, Kitai Y, Wajima S, Yamamoto S, Oguchi A,
et al. Myofibroblasts acquire retinoic acid-producing ability dur-
ing fibroblast-to-myofibroblast transition following kidney injury.
Kidney Int. 2019;95:526-39.
24. Lazzeri E, Angelotti ML, Peired A, Conte C, Marschner JA,
Maggi L, et al. Endocycle-related tubular cell hypertrophy and
progenitor proliferation recover renal function after acute kidney
injury. Nat Commun. 2018;9:1344.
25. Humphreys BD, Czerniak S, DiRocco DP, Hasnain W, Cheema R,
Bonventre JV. Repair of injured proximal tubule does not involve
specialized progenitors. Proc Natl Acad Sci U S A. 2011;
108:9226-31.
26. Ferenbach DA, Bonventre JV. Mechanisms of maladaptive repair
after AKI leading to accelerated kidney ageing and CKD. Nat Rev
Nephrol. 2015;11:264-76.
27. Bonventre JV, Yang L. Cellular pathophysiology of ischemic
acute kidney injury. J Clin Invest. 2011;121:4210-21.
28. Yang L, Besschetnova TY, Brooks CR, Shah JV, Bonventre JV.
Epithelial cell cycle arrest in G2/M mediates kidney fibrosis after
injury. Nat Med. 2010;16:535-43.
29. Cianciolo Cosentino C, Skrypnyk NI, Brilli LL, Chiba T, Novit-
skaya T, Woods C, et al. Histone deacetylase inhibitor enhances
recovery after AKI. J Am Soc Nephrol. 2013;24:943-53.
30. Novitskaya T, McDermott L, Zhang KX, Chiba T, Paueksakon
P, Hukriede NA, et al. A PTBA small molecule enhances
recovery and reduces postinjury fibrosis after aristolochic
acid-induced kidney injury. Am J Physiol Renal Physiol.
2014;306:F496-504.
31. DiRocco DP, Bisi J, Roberts P, Strum J, Wong KK, Sharpless N,
et al. CDK4/6 inhibition induces epithelial cell cycle arrest and
ameliorates acute kidney injury. Am J Physiol Renal Physiol.
2014;306:F379-88.
32. Pabla N, Gibson AA, Buege M, Ong SS, Li L, Hu S, et al. Mitiga-
tion of acute kidney injury by cell-cycle inhibitors that suppress
both CDK4/6 and OCT2 functions. Proc Natl Acad Sci U S A.
2015;112:5231-6.
33. Djudjaj S, Martin IV, Buhl EM, Nothofer NJ, Leng L, Piecychna,
et al. Macrophage migration inhibitory factor limits renal inflam-
mation and fibrosis by counteracting tubular cell cycle arrest. J
Am Soc Nephrol. 2017;28:3590-604.
34. Ding H, Zhou D, Hao S, Zhou L, He W, Nie J, et al. Sonic hedge-
hog signaling mediates epithelial-mesenchymal communication
and promotes renal fibrosis. J Am Soc Nephrol. 2012;23:801-13.
35. Zhou D, Li Y, Lin L, Zhou L, Igarashi P, Liu Y. Tubule-specific
ablation of endogenous b-catenin aggravates acute kidney injury
in mice. Kidney Int. 2012;82:537-47.
Y. Sato et al.
36. Galvan DL, Green NH, Danesh FR. The hallmarks of mitochon-
drial dysfunction in chronic kidney disease. Kidney Int. 2017;92:
1051-7.
37. Bhargava P, Schnellmann RG. Mitochondrial energetics in the
kidney. Nat Rev Nephrol. 2017;13:629-46.
38. Szeto HH. Pharmacologic approaches to improve mitochondrial
function in AKI and CKD. J Am Soc Nephrol. 2017;28:2856-65.
39. Patil NK, Parajuli N, MacMillan-Crow LA, Mayeux PR. Inactiva-
tion of renal mitochondrial respiratory complexes and manganese
superoxide dismutase during sepsis: mitochondria-targeted anti-
oxidant mitigates injury. Am J Physiol Renal Physiol. 2014;306:
F734-43.
40. Dare AJ, Bolton EA, Pettigrew GJ, Bradley JA, Saeb-Parsy K,
Murphy MP. Protection against renal ischemia-reperfusion injury
in vivo by the mitochondria targeted antioxidant MitoQ. Redox
Biol. 2015;5:163-8.
41. Plotnikov EY, Chupyrkina AA, Jankauskas SS, Pevzner IB, Sila-
chev DN, Skulachev VP, et al. Mechanisms of nephroprotective
effect of mitochondria-targeted antioxidants under rhabdomyoly-
sis and ischemia/reperfusion. Biochim Biophys Acta. 2011;1812:
77-86.
42. Plotnikov EY, Pevzner IB, Zorova LD, Chernikov VP, Prusov
AN, Kireev II, et al. Mitochondrial damage and mitochondria-tar-
geted antioxidant protection in LPS-induced acute kidney injury.
Antioxidants (Basel). 2019;8:176.
43. Szeto HH, Liu S, Soong Y, Seshan SV, Cohen-Gould L, Manichev
V, et al. Mitochondria protection after acute ischemia prevents pro-
longed upregulation of IL-1. J Am Soc Nephrol. 2017;28:1437-49.
44. Lynch MR, Tran MT, Parikh SM. PGC1a in the kidney. Am J
Physiol Renal Physiol. 2018;314:F1-8.
45. Tran MT, Zsengeller ZK, Berg AH, Khankin EV, Bhasin MK,
Kim W, et al. PGC1a drives NAD biosynthesis linking oxidative
metabolism to renal protection. Nature. 2016;531:528-32.
46. Tran M, Tam D, Bardia A, Bhasin M, Rowe GC, Kher A, et al.
PGC-1a promotes recovery after acute kidney injury during sys-
temic inflammation in mice. J Clin Invest. 2011;121:4003-14.
47. Mack M, Yanagita M. Origin of myofibroblasts and cellular
events triggering fibrosis. Kidney Int. 2015;87:297-307.
48. Asada N, Takase M, Nakamura J, Oguchi A, Asada M, Suzuki N,
et al. Dysfunction of fibroblasts of extrarenal origin underlies
renal fibrosis and renal anemia in mice. J Clin Invest. 2011;
121:3981-90.
49. Duffield JS. Cellular and molecular mechanisms in kidney fibro-
sis. J Clin Invest. 2014;124:2299-306.
50. Sato Y, Yanagita M. Functional heterogeneity of resident fibro-
blasts in the kidney. Proc Jpn Acad Ser B. 2019;95:468-78.
51. Nangaku M. Chronic hypoxia and tubulointerstitial injury: a final
common pathway to end-stage renal failure. J Am Soc Nephrol.
2006;17:17-25.
52. Sato Y, Yanagita M. Resident fibroblasts in the kidney: a major
driver of fibrosis and inflammation. Inflamm Regen. 2017;37:17.
53. Sato Y, Yanagita M. Renal anemia: from incurable to curable. Am
J Physiol Renal Physiol. 2013;305:F1239-48.
54. Kramann R, Schneider RK, DiRocco DP, Machado F, Fleig S,
Bondzie PA, et al. Perivascular Gli1+ progenitors are key contrib-
utors to injury-induced organ fibrosis. Cell Stem Cell. 2015;
16:51-66.
55. Brookhart MA, Schneeweiss S, Avorn J, Bradbury BD, Rothman
KJ, Fischer M, et al. The effect of altitude on dosing and response
to erythropoietin in ESRD. J Am Soc Nephrol. 2008;19:1389-95.
56. Bernhardt WM, Wiesener MS, Scigalla P, Chou J, Schmieder
RE, G€ unzler V, et al. Inhibition of prolyl hydroxylases
increases erythropoietin production in ESRD. J Am Soc Neph-
rol. 2010;21:2151-6.
57. Ohashi R, Shimizu A, Masuda Y, Kitamura H, Ishizaki M, Sugi-
saki Y, et al. Peritubular capillary regression during the
AKI progression to CKD
progression of experimental obstructive nephropathy. J Am Soc
Nephrol. 2002;13:1795-805.
58. Campanholle G, Ligresti G, Gharib SA, Duffield JS. Cellular
mechanisms of tissue fibrosis. 3. Novel mechanisms of kidney
fibrosis. Am J Physiol Cell Physiol. 2013;304:C591-603.
59. Rabb H, Griffin MD, McKay DB, Swaminathan S, Pickkers P, Ros-
ner MH, et al. Inflammation in AKI: current understanding, key
questions, and knowledge gaps. J Am Soc Nephrol. 2016;27:371-9.
60. D’Alessio FR, Kurzhagen JT, Rabb H. Reparative T lymphocytes
in organ injury. J Clin Invest. 2019;129:2608-18.
61. Dong X, Swaminathan S, Bachman LA, Croatt AJ, Nath KA,
Griffin MD. Antigen presentation by dendritic cells in renal lymph
nodes is linked to systemic and local injury to the kidney. Kidney
Int. 2005;68:1096-108.
62. Maarouf OH, Uehara M, Kasinath V, Solhjou Z, Banouni N, Bah-
mani B, et al. Repetitive ischemic injuries to the kidneys result in
lymph node fibrosis and impaired healing. JCI Insight. 2018;3.
63. Lee S, Huen S, Nishio H, Nishio S, Lee HK, Choi BS, et al. Dis-
tinct macrophage phenotypes contribute to kidney injury and
repair. J Am Soc Nephrol. 2011;22:317-26.
64. Sharma R, Kinsey GR. Regulatory T cells in acute and chronic
kidney diseases. Am J Physiol Renal Physiol. 2018;314:F679-98.
65. Martina MN, Noel S, Saxena A, Bandapalle S, Majithia R, Jie C,
et al. Double-negative ab T cells are early responders to AKI and
are found in human kidney. J Am Soc Nephrol. 2016;27:1113-23.
66. O’Sullivan ED, Hughes J, Ferenbach DA. Renal aging: causes and
consequences. J Am Soc Nephrol. 2017;28:407-20.
67. Schmitt R, Melk A. Molecular mechanisms of renal aging. Kidney
Int. 2017;92:569-79.
68. Naik AS, Afshinnia F, Cibrik D, Hodgin JB, Wu F, Zhang M,
et al. Quantitative podocyte parameters predict human native kid-
ney and allograft half-lives. JCI Insight. 2016;1(7):e86943.
69. Denic A, Lieske JC, Chakkera HA, Poggio ED, Alexander MP,
Singh P, et al. The substantial loss of nephrons in healthy human
kidneys with aging. J Am Soc Nephrol. 2017;28:313-20.
70. Polichnowski AJ, Lan R, Geng H, Griffin KA, Venkatachalam MA,
Bidani AK. Severe renal mass reduction impairs recovery and pro-
motes fibrosis after AKI. J Am Soc Nephrol. 2014;25:1496-507.
71. Schmitt R, Marlier A, Cantley LG. Zag expression during aging
suppresses proliferation after kidney injury. J Am Soc Nephrol.
2008;19:2375-83.
72. Sato Y, Yanagita M. Immunology of the ageing kidney. Nat Rev
Nephrol. 2019;15:625-40.
73. Hernandez-Segura A, Nehme J, Demaria M. Hallmarks of cellular
senescence. Trends Cell Biol. 2018;28:436-53.
74. Hashimoto M, Asai A, Kawagishi H, Mikawa R, Iwashita Y,
Kanayama K, et al. Elimination of p19ARF-expressing cells enhan-
ces pulmonary function in mice. JCI Insight. 2016;1:e87732.
75. Baker DJ, Childs BG, Durik M, Wijers ME, Sieben CJ, Zhong J,
et al. Naturally occurring p16(Ink4a)-positive cells shorten
healthy lifespan. Nature. 2016;530:184-9.
215
76. Sato Y, Mii A, Hamazaki Y, Fujita H, Nakata H, Masuda K, et al.
Heterogeneous fibroblasts underlie age-dependent tertiary lym-
phoid tissues in the kidney. JCI Insight. 2016;1:e87680.
77. Pipi E, Nayar S, Gardner DH, Colafrancesco S, Smith C, Barone
F. Tertiary lymphoid structures: autoimmunity goes local. Front
Immunol. 2018;9:1952.
78. Lehmann-Horn K, Wang SZ, Sagan SA, Zamvil SS, von B€ udingen
HC. B cell repertoire expansion occurs in meningeal ectopic lym-
phoid tissue. JCI Insight. 2016;1:e87234.
79. Finkin S, Yuan D, Stein I, Taniguchi K, Weber A, Unger K, et al.
Ectopic lymphoid structures function as microniches for tumor
progenitor cells in hepatocellular carcinoma. Nat Immunol. 2015;
16:1235-44.
80. Shinoda K, Hirahara K, Iinuma T, Ichikawa T, Suzuki AS, Sugaya
K, et al. Thy1+IL-7+ lymphatic endothelial cells in iBALT pro-
vide a survival niche for memory T-helper cells in allergic airway
inflammation. Proc Natl Acad Sci U S A. 2016;113:E2842-51.
81. Chang A, Henderson SG, Brandt D, Liu N, Guttikonda R, Hsieh
C, et al. In situ B cell-mediated immune responses and tubuloin-
terstitial inflammation in human lupus nephritis. J Immunol. 2011;
186:1849-60.
82. Thaunat O, Field AC, Dai J, Louedec L, Patey N, Bloch MF, et al.
Lymphoid neogenesis in chronic rejection: evidence for a local
humoral alloimmune response. Proc Natl Acad Sci U S A. 2005;
102:14723-8.
83. Luther SA, Lopez T, Bai W, Hanahan D, Cyster JG. BLC expres-
sion in pancreatic islets causes B cell recruitment and lymphotoxin-
dependent lymphoid neogenesis. Immunity. 2000;12:471-81.
84. Luther SA, Bidgol A, Hargreaves DC, Schmidt A, Xu Y, Pan-
iyadi J, et al. Differing activities of homeostatic chemokines
CCL19, CCL21, and CXCL12 in lymphocyte and dendritic cell
recruitment and lymphoid neogenesis. J Immunol. 2002;169:
424-33.
85. Heesters BA, Myers RC, Carroll MC. Follicular dendritic cells:
dynamic antigen libraries. Nat Rev Immunol. 2014;14:495-504.
86. Liu J, Kumar S, Dolzhenko E, Alvarado GF, Guo J, Lu C, et al.
Molecular characterization of the transition from acute to chronic
kidney injury following ischemia/reperfusion. JCI Insight. 2017;2:
e94716.
87. Cippa PE, Liu J, Sun B, Kumar S, Naesens M, McMahon AP. A
late B lymphocyte action in dysfunctional tissue repair follow-
ing kidney injury and transplantation. Nat Commun. 2019;10:
1157.
88. Nayar S, Campos J, Smith CG, Iannizzotto V, Gardner DH, Mour-
cin F, et al. Immunofibroblasts are pivotal drivers of tertiary lym-
phoid structure formation and local pathology. Proc Natl Acad Sci
U S A. 2019;116:13490-7.
89. Okusa MD, Rosner MH, Kellum JA, Ronco C, Acute Dialysis
Quality Initiative XIII Workgroup. Therapeutic targets of human
AKI: harmonizing human and animal AKI. J Am Soc Nephrol.
2016;27:44-8.