Reviews

Uraemic syndrome of chronic kidney

disease: altered remote sensing and
signalling
Sanjay K. Nigam1,2* and Kevin T. Bush1
Abstract | Uraemic syndrome (also known as uremic syndrome) in patients with advanced chronic
kidney disease involves the accumulation in plasma of small-molecule uraemic solutes and
uraemic toxins (also known as uremic toxins), dysfunction of multiple organs and dysbiosis of the
gut microbiota. As such, uraemic syndrome can be viewed as a disease of perturbed inter-organ
and inter-organism (host–microbiota) communication. Multiple biological pathways are affected,
including those controlled by solute carrier (SLC) and ATP-binding cassette (ABC) transporters
and drug-metabolizing enzymes, many of which are also involved in drug absorption, distribution,
metabolism and elimination (ADME). The remote sensing and signalling hypothesis identifies SLC
and ABC transporter-mediated communication between organs and/or between the host and
gut microbiota as key to the homeostasis of metabolites, antioxidants, signalling molecules,
microbiota-derived products and dietary components in body tissues and fluid compartments.
Thus, this hypothesis provides a useful perspective on the pathobiology of uraemic syndrome.
Pathways considered central to drug ADME might be particularly important for the body’s
attempts to restore homeostasis, including the correction of disturbances due to kidney injury
and the accumulation of uraemic solutes and toxins. This Review discusses how the remote
sensing and signalling hypothesis helps to provide a systems-level understanding of aspects of
uraemia that could lead to novel approaches to its treatment.

The term uraemic syndrome refers to various signs and uraemic toxins and are believed to contribute to the
symptoms associated with generalized organ dysfunc- uraemic syndrome. Many uraemic solutes are produced
tion occurring in patients with chronic kidney disease by the dysbiotic gut flora and/or the action of enzymes
(CKD), which results in the accumulation in plasma in organs such as the liver. These solutes are transported
of many protein-bound and water-soluble metabolites, via solute carrier (SLC) and ATP-binding cassette
referred to as uraemic solutes. This complex systemic (ABC) transporters into different organs, where they
metabolic disorder involves metabolic derangements are thought to exert toxic effects or disrupt key signal-
and aberrant signalling events that occur throughout ling and metabolic pathways, before being eliminated
the body, many of which are mediated by uraemic sol- via what remains of the injured proximal tubule2–4.
utes. Accordingly, this disease might best be considered Similar to drugs such as diuretics and nonsteroidal
from a systems biology perspective, especially given anti-inflammatory drugs (NSAIDs), many uraemic sol-
the growing amount of relevant ‘omics’ data as well as the utes are small organic molecules that circulate bound
availability of molecular and cellular functional informa- to plasma proteins, and both groups of molecules are
1
Department of Pediatrics, tion comparing diseased and healthy states. These data transported into tissues and body fluid compartments
University of California San indicate that a multi-organ network of transporters and by members of the SLC and ABC transporter super-
Diego, La Jolla, CA, USA.
drug-metabolizing enzymes (DMEs) plays an impor- families5,6. These transporters, together with phase 1
2
Department of Medicine, tant part in sensing, regulating and/or modulating the and phase 2 DMEs, are prominent in the pharmaco-
University of California San
Diego, La Jolla, CA, USA.
concentrations of these various small-molecule uraemic logical literature owing to their role in drug absorption,
solutes in tissues and body fluids1. distribution, metabolism and excretion (ADME).
*e-mail: snigam@
ucsd.edu In patients with advanced CKD, uraemic solutes A number of these transporters have been identified
https://doi.org/10.1038/ accumulate in the circulation owing to deficient renal as particularly important in the transport of uraemic sol-
s41581-019-0111-1 clearance. Some of these products are considered utes, including in the transport of molecules involved

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 301

Reviews

(OAT1)) and other transporters. Alongside unexpected

Key points
developmental expression patterns17 and the discovery
• The uraemic syndrome (also known as uremic syndrome) associated with chronic of unusual transporter family members (such as OAT6,
kidney disease (CKD) is characterized by complex local and systemic derangements in which seems to be an odorant transporter in olfactory
metabolism and signalling. mucosa18,19), one of the main findings from studies of
• CKD involves aberrant inter-organ (gut–liver–kidney–brain) and inter-organism mice lacking the ability to renally eliminate organic ani-
(host–gut microbiota) remote communication via small molecules, including uraemic ons via OAT1 and/or OAT3 was the presence of many
solutes, metabolites and signalling molecules.
metabolic alterations, including elevated plasma levels of
• Aspects of uraemic syndrome can be considered disordered remote sensing and numerous uraemic solutes, many of which were derived
signalling mediated by a multi-organ network of solute carrier (SLC) and ATP-binding
from the gut microbiota7,8.
cassette (ABC) transporters and drug-metabolizing enzymes (DMEs).
Many SLC and ABC transporter family members
• The remote sensing and signalling hypothesis provides a systems biology framework are evolutionarily highly conserved, multi-specific and
for understanding the role of these transporters and DMEs in small-molecule-mediated
have a wide range of endogenous substrates, including
inter-organ and inter-organism communication.
well-known signalling molecules, such as cAMP, prosta-
• Transported uraemic solutes (including gut-microbiota-derived indoxyl sulfate) can
glandins, bile acids and short-chain fatty acids; metabo-
affect multiple signalling pathways.
lites such as α-ketoglutarate; antioxidants such as urate
• Viewing CKD and uraemic syndrome through the lens of the remote sensing and
and ergothionine; and vitamins or cofactors such as
signalling hypothesis provides fresh perspectives on the metabolic derangements of
CKD that might lead to novel therapies.
pantothenic acid5. Networks of apical (efflux) and/or
basolateral (influx) multi-specific SLC and ABC trans-
porters often work to maintain metabolite homeostasis
in the regulation of key metabolic and signalling path- in concert with closely related (and sometimes also with
ways, antioxidants and mediators of cellular toxicity7,8 unrelated) transporters of limited specificity or relative
(Table 1) . Such transporter-mediated movement of monospecificity. These homeostatic networks can be
uraemic toxins into tissues and body fluids, or from sited within a single organ or involve several organs20.
plasma into proximal tubule cells of the kidney where For example, three multi-specific transporters (OAT1,
they can be eliminated via the urine, generally occurs OAT3 and ABC subfamily G member 2 (ABCG2)) work
via pathways not dissimilar from those involved in the closely with two limited-specificity transporters (URAT1
distribution of drugs. Some of these small organic mole­ (also known as SLC22A12) and GLUT9 (also known as
cules also seem to be toxic to proximal tubule cells9–12 SLC2A9)) to control urate homeostasis21. In the absence
and are thought to be associated with the progression of of end-stage renal disease (ESRD), the bulk of urate
CKD. Hence, information could be transmitted between handling in the kidney is carried out by these and sev-
cells, organs and tissues via the movement of these small eral other transporters. Moreover, multi-specific SLC
organic molecules. This remote communication involves and ABC transporters in the gut, liver and kidney work
multi-specific transporters and other ADME-related in concert with monospecific and oligospecific trans-
proteins that are differentially expressed in the cells porters and DMEs to regulate the homeostasis of bile
that line fluid-containing body compartments, such acids, which are involved in fat digestion and signalling
as the intestine, kidney, liver, muscle and central nerv- via G protein-coupled receptors (GPCRs) and nuclear
ous system (CNS)5,13. Accordingly, uraemic syndrome receptors20 (reviewed elsewhere22–24).
could be viewed as a systemic disease resulting in part Although DMEs were not emphasized in initial
from perturbed inter-organ and inter-organism (that is, descriptions of the remote sensing and signalling
host–microbiota) communication. hypothesis, these enzymes modify various molecules,
The changing profile of uraemic solutes in progres- including drugs and gut-derived metabolites, thereby
sive CKD is both a result of dysregulated local and sys- increasing their solubility (Box 1). As these modifi-
temic homeostasis and a cause of it. In this Review, we cations generate additional signalling molecules and
frame our discussion of uraemic syndrome in the con- putative uraemic toxins, DMEs are intimately con-
text of the remote sensing and signalling hypothesis, nected to remote communication pathways involving
which is more fully elucidated elsewhere1,5,13–15 (Fig. 1). In ADME-related transporters and enzymes. This connec-
essence, this hypothesis emphasizes the central role of tion is particularly important in uraemia, because some
transporters and DMEs in regulating remote communi- of the most important uraemic toxins (including indoxyl
cation between tissues and organs via small organic mole­ sulfate and p-cresol sulfate) are generated as a result of
cules (Figs 1,2). As we argue, many aspects of uraemic the actions of phase 2 DMEs on their microbiota-derived
syndrome can be viewed as disordered remote sensing precursors (indole and p-cresol, respectively), resulting
and signalling. in both cellular toxicity and the potential for diverse
types of cell signalling7,8.
Remote sensing and signalling Thus, a multi-scale, multi-compartment network
The remote sensing and signalling hypothesis was for- of transporters and DMEs is involved in sending and
mulated over a decade ago14,16 to explain the role of receiving information to various tissues and body fluid
SLC and ABC transporters in the physiology of various compartments1,5–8,13–15. This information is transmitted
organ systems, which had been suggested by the results via small organic metabolites (such as α-ketoglutarate,
of metabolomics studies and the phenotypes of mice polyamines, tryptophan metabolites and uric acid) and
with knockout of Slc22a6 (which encodes SLC family signalling molecules (such as prostaglandins, cyclic
22 member 6; also known as organic anion transporter 1 nucleotides, odorants and neurotransmitters) that are

302 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

Table 1 | Transporters in the kidney of importance for uraemic toxins

Transporter name Ligand Tissue expression Examples of drugs Examples of uraemic
polarity interacting with toxins interacting with
Protein Gene
transporter transporter
Basolateral (influx) transporters
OAT1 SLC22A6 Anion Kidney and choroid Probenecid, adefovir Anthranilic acid, indoxyl
plexus and indometacin sulfate and p-cresol sulfate
OAT3 SLC22A8 Anion Kidney, choroid Probenecid, Indoxyl sulfate, p-cresol
plexus and blood– methotrexate and sulfate and CMPF
brain barrier cimetidine
OATP1B1 SLCO1B1 Anion Liver Methotrexate and Kynurenic acid,
lopinavir indole-3-acetic acid and
indoxyl sulfate
OATP1B3 SLCO1B3 Anion Liver Methotrexate and Kynurenic acid,
telmisartan indole-3-acetic acid and
indoxyl sulfate
OATP4C1 SLCO4C1 Anion Kidney Ritonavir, crizotinib Symmetric dimethylarginine,
and saquinavir guanidine succinate and
trans-aconitate
OCT1 SLC22A1 Cation Kidney and liver Metformin, TMAO and methylguanidine
ganciclovir and
aciclovir
OCT2 SLC22A2 Cation Kidney Metformin, TMAO, putrescine and
cimetidine and methylguanidine
lamivudine
Apical (efflux) transporters
MRP2 ABCC2 Anion Kidney, intestine Probenecid, Anthranilic acid, indoxyl
and liver methotrexate and sulfate and p-cresol sulfate
amoxicillin
MRP4 ABCC4 Anion Kidney, liver and Methotrexate, Anthranilic acid, indoxyl
blood–brain barrier cefotaxime and sulfate and p-cresol sulfate
furosemide
MATE1 SLC47A1 Cation Kidney and liver Metformin, TMAO and creatinine
cimetidine and
topotecan
MATE2K SLC47A2 Cation Kidney Metformin, TMAO and creatinine
cimetidine and
topotecan
BCRP ABCG2 Anion Kidney, intestine, Methotrexate, Uric acid, indoxyl sulfate,
liver and blood– gefitinib and imatinib hippuric acid and kynurenic
brain barrier acid
CMPF, 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid; MATE1, multi-drug and toxin extrusion protein 1; MATE2K , 2K splice
variant of MATE2; OAT, organic anion transporter ; OATP, organic anion-transporting polypeptide; OCT, organic cation transporter ;
TMAO, trimethylamine-N-oxide.

substrates of SLC and ABC transporters (Figs 1,2). These Furthermore, several of the metabolites and sig-
metabolites and signalling molecules, in turn, feed into nalling molecules transported into and out of various
well-known metabolic pathways, modulate kinase activ- body fluids and tissues have the ability to interact with
ity and/or bind to GPCRs (including metabolite GPCRs) other organisms. Remote communication consisting of
and nuclear receptors. This organization also extends to unidirectional or bidirectional transport of metabolites
intracellular pathways that affect transcription, signal- and signalling molecules across an epithelial, endothe-
ling, protein trafficking and macromolecular interac- lial or similar barrier can occur between individuals
tions (including transporter–cytoskeleton interactions). of the same species, via breast milk, amniotic fluid or
Together, this network involves over 100 ADME-related urine; between the host and gut microbiota; or between
proteins, which are encoded by genes that are differen- different microbiota species1,5,7. All these remote com-
tially and highly expressed in epithelial cells (Fig. 2), such munication examples could be relevant to ESRD in
as those in the kidney, liver, gut and pancreas, and in certain contexts, although (as discussed below) most
non-epithelial cells, such as the endothelial cells of the attention has been paid to bidirectional communication
blood–brain barrier and circulating cells. This network between the host and the gut microbiota in patients with
is considered to act in parallel with the neuroendocrine ESRD25,26. Inter-organ communication involves both
system, growth factors and cytokines, as well as being well-defined physiological pathways, such as transport
analogous to these classic homeostatic systems. of bile acids and nutrients via the gut–liver–kidney axis,

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 303

Reviews

Steady-state inter-organ and Disordered inter-organ and

inter-organism communication inter-organism communication

Brain Brain
Heart Heart

Kidney
injury
Pancreas Pancreas
Muscle Muscle

Gut Liver Gut Liver

Kidney Kidney

• Kidney injury
• Diminished
tubular secretion
Gut microbiota Gut microbiota dysbiosis

Gut–liver–kidney axis Metabolites Signalling molecules Other small circulating molecules

Fig. 1 | Aberrant inter-organ and inter-organism communication contributes to uraemic syndrome. According to the
remote sensing and signalling hypothesis, illustrated here from the perspective of the kidney, steady-state communication
between the kidney and other organs and body fluids involves the movement of metabolites, signalling molecules and other
small circulating molecules via solute carrier (SLC) and ATP-binding cassette (ABC) transporters. These transporters are
expressed in many tissues, including the kidney, liver, pancreas, brain, intestine and muscle. Therefore, injury to the kidney
leads to diminished tubular secretion and results in disordered remote communication. Some of these molecules can
regulate the expression (via nuclear receptor activation) and/or function of SLC and ABC transporters or phase 1 and phase 2
drug-metabolizing enzymes (DMEs) in distinct cells, tissues and organs, thereby effecting local and global physiological
alterations, accompanied by dysbiosis of gut microbiota (including the loss or gain of some bacterial strains). The multi-
specificity of some ABC and SLC transporters, together with their different and modifiable tissue expression and/or trafficking,
might help to restore homeostasis after organ dysfunction and injury. The differences in colour of the symbols representing
metabolites, signalling molecules and other small circulating molecules that interact with transporters represent alterations
in the concentration and/or identity of these compounds under physiological versus pathological conditions.

and those occurring in pathological states. Although in settings such as renal impairment) because this
DMEs and transporters have been identified and charac- system is thought to be of comparable importance to
terized in virtually every tissue of the body, inter-organ the neuro­endocrine, growth factor and cytokine sys-
communication in the context of uraemia involves the tems in the resetting of homeostatic mechanisms after
brain, muscle, pancreas, gut, liver and heart, among perturbation or injury1,5,7. However, the hypothesis
other tissues. The composition of metabolites, signalling also emphasizes the critical interconnections between
molecules, antioxidants, nutrients, vitamins and cofac- transporter-based mechanisms and other homeostatic
tors in body fluids found in epithelium-lined compart- systems. For example, organic anion-transporting poly-
ments, including cerebrospinal fluid (CSF), bile, urine, peptides (OATPs) are transporters of thyroid hormones
plasma, amniotic fluid, breast milk and ocular fluid, is and knocking out an OATP family member in the mouse
partly or largely regulated by SLC and ABC transport- brain capillary endothelium leads to an underdeveloped
ers. For example, the choroid plexus (which regulates CNS32. Similarly, expression of OAT3 in pancreatic
the metabolite composition of CSF) is morphologi- β-cells is necessary for transport of 3-carboxy-4-methyl-
cally and functionally similar to the proximal tubule27, 5-propyl-­2-furanpropanoic acid (CMPF), a uraemic
and this similarity extends to the expression of OATs and solute that is involved in the regulation of insulin secre-
organic cation transporters (OCTs)28. The reader should tion33. A defect in this pathway has been linked to human
keep in mind that, in the setting of ESRD, the composi- gestational diabetes.
tion and volume of these various body fluids can change This multi-scale systems biology model comprises
substantially29,30 and that other compartments (includ- inter-organism communication, whole-organism home-
ing interstitial, peritoneal and pericardial spaces) can ostasis, organs, tissues, body fluids and transporter-
become important27,31. expressing cells. This model incorporates many points
The remote sensing and signalling hypothesis empha- of potential regulation and dysregulation, including
sizes the homeostatic role of SLC and ABC multi-specific, transporter trafficking, phosphorylation, transcription
monospecific or oligospecific transporters (particularly and transporter–cytoskeletal associations. The model

304 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

Blood Urine Blood Bile

OATP4C1, OAT4, URAT1, OCT1, OAT2, Phase 1 and

OCT2, OAT1, Phase 1 and PEPT1, PEPT2, OATP1B1, OATP1B3, phase 2
OAT2 and phase 2 OCTN1 and OATP2B1, OAT7 DMEs
OAT3 DMEs OCTN2 and NTCP
P-gp, BSEP, BCRP,
MRP2 and MATE1
OAT7
OAT4, MRP2,
Kidney MRP4, MATE1, OSTα–OSTβ
proximal MATE2K, P-gp,
tubule OCTN1 and Hepatocyte
OCTN2
MRP3, MRP4 and MRP6

Gut Liver

Kidney Gut–liver–kidney axis

Blood Intestine Gut lumen

Phase 1 and OATP, PEPT1,

OCT1 phase 2 ASBT and MCT1
DMEs
MRP3

OSTα–OSTβ MRP2, BCRP

Enterocyte and P-gp
Gut microbiota

Fig. 2 | The gut–liver–kidney axis. Within the remote sensing and signalling communication network, the gut–liver–kidney
axis drives the absorption, distribution, metabolism and excretion of small molecules, including endogenous metabolites,
signalling molecules, products of the gut microbiota, nuclear receptors and antioxidants. Products derived from gut microbiota
that cross the intestinal barrier are removed from the blood by solute carrier (SLC) and ATP-binding cassette (ABC) transporters
on hepatocytes, where they (and other small molecules) are metabolized by phase 1 and phase 2 drug-metabolizing enzymes
(DMEs). Ultimately, many of these products are cleared from the body via the kidney in the urine through the action of SLC and
ABC transporters on the proximal tubule cells. Some transporters in different tissues are thought to function in both directions.
MATE1, multi-drug and toxin extrusion protein 1; MATE2K, 2K splice variant of MATE2; OAT, organic anion transporter; OATP,
organic anion-transporting polypeptide; OCT, organic cation transporter; P-gp, P-glycoprotein.

also includes multiple points for sensing of metabo- and metabolomic data from transporter-knockout
lites, signalling molecules, antioxidants, nutrients and mice, in vitro data and computational reconstruction of
other molecules, including, but not limited to, nuclear meta­bolic networks34–36. Nevertheless, the elucidation
receptors and transcription factors, GPCRs, kinases of meta­bolic and signalling networks incorporating
and sensors involved in redox pathways. Indeed, many multiple transporters in health and disease should be
of the established and probable in vivo endogenous sub- possible in the next few years. We emphasize that this
strates for SLC and ABC multi-specific transporters are is an iterative process informed by the publication of
believed to have essential roles in activating and modu- ever-more comprehensive omics data, new functional
lating these sensing mechanisms, which in turn can reg- data and improved tools for data integration and network
ulate the expression and/or function of DMEs as well as reconstruction. Therefore, the publication of accurate
that of the transporters themselves5. networks of this kind is probably years away, particularly
As yet, not enough integrated data are available to for complex diseases such as human CKD. This goal is
accurately represent this model in healthy individuals, likely to be more tractable in animal models of CKD.
much less in patients with uraemia or CKD. However,
networks based on a single transporter (such as OAT1, Remote sensing and signalling in CKD
which is one of the most important uraemic toxin trans- In animal models of CKD, declining renal function is
porters) that include all the numerous metabolites and associated with altered renal expression of many SLC
signalling molecules with which the transporter interacts and ABC transporters. Furthermore, changes occur in
have been developed. Building such networks is com- the gene expression and/or function of ADME-related
plicated, as it involves the integration of transcriptomic proteins (namely, multi-specific transporters and DMEs)

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 305

Reviews

Box 1 | Xenobiotic absorption, distribution, metabolism and elimination Other multi-specific transporters also show
increased expression in the gut and liver in response
After intestinal absorption, xenobiotic metabolism modifies the chemical structure to impaired renal function37. By contrast, many DMEs
of potentially hazardous compounds, including exogenous drugs and toxins and show opposing changes in expression in the gut and
endogenous metabolites and signalling molecules. This biotransformation increases liver45–48 as well as decreased functional activity45 in
the water solubility of lipophilic compounds, which facilitates their excretion from the
this setting. Interestingly, some of these DME changes
body. Hepatocytes are the primary site of xenobiotic metabolism, but it also occurs in
cells of the gastrointestinal tract, lungs, kidneys and skin179,180. can be reversed by renal transplantation49. As DMEs
Phase 1 xenobiotic metabolism involves the introduction or unmasking of a functional are involved in the generation of many uraemic toxins
group through the action of various drug-metabolizing enzymes (DMEs), including (including indoxyl sulfate), the decrease in expression
oxidases, reductases, hydrolases and hydroxylases. The most important enzyme family and/or activity of some DMEs might be a mechanism for
involved in biotransformation is the cytochrome P450 superfamily179,180. Xenobiotics decreasing the organism’s uraemic toxin burden.
can also undergo phase 2 metabolism, in which conjugation reactions attach species The expression of genes encoding nuclear receptors
such as acetyl groups, methyl groups, glutathione, sulfate, glucuronic acid and such as nuclear receptor subfamily 1 group I member 2
glycine179,180. The resulting compounds are generally very polar and can be rapidly (PXR) and hepatocyte nuclear factor 4α (HNF4α) is
eliminated from the body.
also decreased in animal models of CKD45. These pro-
Some solute carrier (SLC) and ATP-binding cassette (ABC) transporters in tissues such
teins are sometimes considered master regulators of the
as the gut, liver and kidney are key to the absorption, distribution, metabolism and
elimination (ADME) not only of xenobiotics but also of metabolites, signalling molecules, expression of many ADME-related genes and as such
nutrients and antioxidants. Sometimes, transporter-mediated ADME is referred to as are potential sensors in a remote sensing and signalling
phase 3 xenobiotic metabolism179,181–183. For example, in the liver, transporter-mediated network5,50–54. Decreased expression of these nuclear
uptake clears xenobiotics from blood into hepatocytes182,183. The biotransformed receptors could explain the decreases in the expres-
metabolites of these xenobiotics are directly secreted into bile by ABC transporters sion of certain DMEs but probably does not explain
expressed on the canalicular membrane and excreted via the gut (although some the observed increases in transporter expression. Other
metabolites are resorbed back into the blood from the intestine)180. In addition, some transcription factors, such as the aryl hydro­carbon
biotransformed metabolites are transported from hepatocytes into the blood by ABC receptor (AHR), probably regulate the expression of
transporters expressed on the basolateral cell membrane. Once in the systemic multi-specific transporters, such as P-glycoprotein
circulation, these metabolites — some of which are active and/or toxic (for example,
(P-gp), apparently involved in resetting the system in
indoxyl sulfate) — can access other organs and body fluids via other SLC and ABC
transporters. Ultimately, they are cleared from the blood and eliminated in the urine the presence of renal impairment55,56.
via the SLC transporters organic anion transporter 1 (OAT1), OAT3 and organic cation Analyses of omics data indicate considerable alter-
transporter 2 (OCT2) and the ABC transporters P-glycoprotein, multidrug resistance- ation in the gene expression and/or activity of trans-
associated protein 2 (MRP2; also known as canalicular multispecific organic anion porters and other ADME-related proteins involved in
transporter 1) and MRP4 on renal proximal tubule cells. remote sensing and signalling in the setting of renal
insufficiency. Some of these alterations might be inter-
preted as an attempt to reset homeostasis by decreas-
in the liver and intestine as well as other tissues37. Some ing levels of uraemic toxins such as indoxyl sulfate and
of these changes could be viewed as compensatory urate40. This interpretation, together with the many
efforts to preserve homeostasis. Indeed, the changes changes in expression and/or function of multi-specific
in expression and/or function of the efflux transporter, transporters and DMEs across tissues, suggests that
ABCG2, in the intestine in the setting of ESRD might resetting of the inter-organ and inter-organism commu-
be an example of such a compensatory response. Abcg2- nication network occurs to preserve homeostasis in the
knockout mice subjected to adenine-induced CKD setting of ESRD.
not only displayed impaired survival compared with
wild-type controls but also had substantially increased The example of indoxyl sulfate
plasma concentrations of uraemic toxins, including A growing body of research relates to the toxic, meta-
indoxyl sulfate (a substrate of ABCG2)38. Patients with bolic and signalling effects of individual uraemic tox-
ESRD who have dysfunctional variants of ABCG2 have ins, such as albumin-bound indoxyl sulfate, which is
substantially elevated plasma levels of uric acid39, also one of the main uraemic toxins implicated in uraemic
considered a uraemic toxin. These data support the syndrome9–12,57. Indoxyl sulfate is not optimally cleared
notion that increased expression or activity of ABCG2 during dialysis, and considerable translational and clin-
(largely in the intestine) is a compensatory mechanism ical research has focused on strategies to reduce serum
that decreases plasma levels of indoxyl sulfate and urate levels of this molecule in patients with CKD57–64.
via their excretion into the gut lumen in the setting of Indoxyl sulfate is part of an inter-organism (microbiota–
renal insufficiency38–43. Importantly, the gut microbiota host) and inter-organ (gut, liver, kidney and brain)
also undergoes changes in response to the increased communication network regulated by transporters and
uric acid load, including the growth of bacteria that DMEs (Fig. 3). Indole is produced by the gut microbiota as
produce uricase44, an enzyme involved in the reduction a result of the metabolism of tryptophan. Once absorbed
of uric acid to allantoin. Together with the findings in across the intestinal wall into the blood, indole is taken up
mice described above, these data suggest that intestinal by hepatocytes, where it is metabolized first to indoxyl by
ABCG2 (in addition to its role in the increased excre- hepatic DMEs (namely, CYP2E1) and then to indoxyl sul-
tion of uric acid and indoxyl sulfate in CKD) plays an fate by sulfotransferases65. Indoxyl sulfate is then secreted
important part in inter-organism remote sensing and back into the blood by hepatocyte transporters, where-
signalling through its transport of uric acid and other upon it interacts with various tissues, organs and body
uraemic toxins. fluids, largely via SLC and ABC transporters.

306 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

a Intestines b Liver Blood vessel

Gut microbiota
converts tryptophan Indole
to indole
Circulating
indoxyl
sulfate
(90%
albumin-
Intestinal bound)
Indole and other epithelium Indole Indoxyl
microbial products sulfate

Indoxyl
Indole Blood
vessel
Hepatocyte

c Various cell types in heart, brain, liver and muscle

Immune d Proximal tubule
system
Blood vessel Albumin-bound
indoxyl sulfate
in blood
Albumin-bound AHR
indoxyl sulfate Proximal tubule epithelium
in blood

Indoxyl sulfate Urine

Transcription of various genes,
including those encoding
phase 1 and phase 2 DMEs

Fig. 3 | The role of indoxyl sulfate in inter-organism and inter-organ remote communication. a | Indole is created in
the lumen of the gut, via the metabolism of tryptophan by the gut microbiota, and absorbed across the gut wall into the
blood. b | Circulating indole is taken up by hepatocytes, where it is metabolized first to indoxyl and then to indoxyl sulfate.
Indoxyl sulfate is transported back into the circulation where the majority of it circulates bound to albumin and where it is
distributed to and interacts with other organs, such as the brain, immune system and muscle, and with the gut microbiota.
c | Indoxyl sulfate gains access to tissues and cells, where it signals through the aryl hydrocarbon receptor (AHR), leading
to alterations in the expression of a number of genes in these tissues. d | Indoxyl sulfate is ultimately excreted by the
kidney via solute carrier (SLC) and ATP-binding cassette (ABC) transporters located in the basolateral (such as organic
anion transporter 1 (OAT1) and OAT3) and apical (such as multidrug resistance-associated protein 4 (MRP4)) membranes
of proximal tubule cells (influx and efflux transporters are indicated by blue and purple barrels, respectively).

In vitro data indicate that indoxyl sulfate can partici- of UGT1A1 and UGT1A6 (encoding the phase 2
pate in or at least affect numerous intracellular signalling DMEs UDP-glucuronosyltransferase 1-1 and UDP-
pathways, including those involving transcription factors glucuronosyltransferase 1-6, respectively) in primary
(such as AHR) and various kinases66–74. Indoxyl sulfate is human hepatocytes69,76. This uraemic toxin also regulates
ultimately cleared from the blood via OAT1 and OAT3 the expression of hepatic P-gp via binding to AHR in
transporters expressed on the basolateral membrane of rodent and cell culture models of CKD55. The observa-
kidney proximal tubule cells7,8. This uraemic solute is tion that patients with CKD who have high plasma levels
then secreted into the tubular lumen via apical efflux of indoxyl sulfate also show increased hepatic meta­
transporters (although precisely which transporters are bolism of ciclosporin, a P-gp substrate, suggests that this
involved remains unclear at present) and eliminated increased expression is likely to be clinically relevant55.
from the body in urine. However, high levels of indoxyl These data are consistent with the notion that remote
sulfate seem to exert toxicity in proximal tubule cells as communication between the failing kidney and the
well as cells of the vasculature and CNS57. Movement of liver occurs via one or more uraemic toxins, which act
indoxyl sulfate into these cells is probably mediated by through nuclear receptor signalling. In addition to acti-
OAT3 and other transporters75. vation of AHR, indoxyl sulfate can also activate nuclear
Moreover, AHR (to which indoxyl sulfate binds67,76) factor-κB (NF-κB) and mitogen-activated protein kinase
regulates the expression of members of the cytochrome (MAPK) signalling pathways in macrophages, as demon-
P450 family, other DMEs and transporters77,78. At con­ strated by increased phosphorylation of p38 MAPKs,
centrations observed in the serum of patients with urae- c-Jun N-terminal kinases (JNKs) and the NF-κB p65 sub­
mia, indoxyl sulfate activates expression of CYP1A1, unit70,79. However, the relevance of many of these intriguing
CYP1A2 and CYP1B1 genes, as well as expression findings remains to be determined in human CKD.

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 307

Reviews

Indoxyl sulfate is but one example of a well-studied gut dysbiosis is a typical feature of CKD and is chara­
uraemic solute or toxin involved in inter-organ and/or cterized by increases in bacterial species involved in
inter-organism communication. Later in this article, we the production of several gut-derived uraemic toxins65,
discuss other examples. many of which can alter the function and expression
of transporters and DMEs and potentially contribute to
ADME networks in resetting homeostasis the progression of CKD65. These bacteria are believed
Under physiological circumstances, numerous to communicate not only with the host but also among
multi-specific, oligospecific and monospecific transport- themselves96, in part through transporters that are evo­
ers, DMEs and their substrates function as a regulated lutionarily related to the ABC and SLC transporters
local and systemic small-molecule remote communi- involved in inter-organ communication within the host.
cation network that is closely linked to the neuroendo- Therefore, bidirectional communication seems to oper-
crine, autonomic, growth factor and cytokine systems ate between the gut microbiota and the host, mediated
traditionally associated with homeostasis (Figs 1,2,4). by small-molecule metabolites derived from the gut
As with other homeostatic systems, the ADME-related microbiota. These metabolites alter the expression and
remote sensing and signalling network adapts to help function of transporters and DMEs in the kidney, liver
the organism recover from or compensate for distur- and other tissues, leading to the accumulation of urae-
bances1,5,13–15 (Fig. 4). For example, in a rodent model of mic toxins in the blood. In addition, changes in the host
obesity-associated renal disease, diminished function ADME-protein-related signalling and communication
of OAT3 was caused by its reduced expression at the plasma network in the progressively failing kidney will, in turn,
membrane, possibly owing to increased internalization probably lead to further alterations in the gut micro­
of OAT3 (ref.80). Feeding a probiotic to these rodents pre- biota. The mechanisms of gut dysbiosis are not well
vented renal damage and resulted in increased activity understood, and it is possible that the types and amounts
of OAT3 at the plasma membrane. This observation was of uraemic toxins arising from the gut microbiota could
interpreted by the authors as an instance of remote sens- differ depending on the cause and stage of CKD.
ing and signalling between the intestine, gut microflora Intriguingly, many microbiota-derived uraemic sol-
and kidney80. utes have well-characterized roles in normal and aber-
Therefore, regulation of the expression of SLC and rant signalling pathways (kynurenine)97, carbohydrate
ABC transporters (as well as DMEs) results in a highly metabolism (CMPF)98, redox state (urate)99 and cell
adaptable system5,15,81–83 capable of responding to acute proliferation (polyamines)100 and are also considered to
or chronic perturbations of homeostasis, such as occur be uraemic toxins, suggesting that they have a dual toxic
in CKD and acute AKI (Fig. 4). For example, the inter- and regulatory or metabolic function. This duality might
nalization, degradation, membrane trafficking and hold important clues for understanding the pathophysio­
cytoskeletal association of transporters are affected by logy of CKD at a systems level and for understanding
post-translational modifications, any of which could the complex metabolic aberrations that characterize the
modify their function and cell surface expression in uraemic syndrome in patients with different types and
response to changing levels of substrate, such as are stages of kidney disease. The efficacy of interventions
seen in CKD81,83. In addition, covalent modifications aimed at influencing the gut microbiota might differ
might also affect protein–protein interactions involv- according to the type and stage of renal disease.
ing the transporters. For example, OAT1 seems to exist
as a functional homo-oligomer, and the association OAT1 and OAT3 knockout metabolomics
of OAT1 into homo-oligomers might be dynamic83,84. The prototypic OAT, OAT1 (originally identified by us in
The expression of OAT4 and other transporters also mice as NKT101), is the main probenecid-sensitive trans-
seems to be regulated by PDZ domain-containing porter of para-aminohippurate in the kidney102,103. The
proteins85–91. OAT1 pathway has been extremely well studied from
As discussed above, the functioning of this remote the viewpoint of renal physiology, toxicology and phar-
communication network is likely to be altered in patients macokinetics13,15 because it is the route through which
with CKD and early uraemia. Indeed, many of the com- many toxins, protein-bound antibiotics, NSAIDs, diu-
ponents of this network (including multi-specific trans- retics and antiviral agents are eliminated102,104–108. For
porters, transporters of limited specificity and DMEs) example, mercury, a highly toxic environmental pollut-
show altered expression in the kidney, gut, liver and ant, is conjugated to glutathione or cystathione and then
other tissues in the presence of renal dysfunction. eliminated from the circulation via OAT1 (refs109–111).
OAT1 also seems to be a major transporter of indoxyl
Gut dysbiosis and remote communication sulfate7,8,112.
Many uraemic toxins are derived from the gut micro- Much of our understanding of the role of OAT1
flora66,92–94, and numerous reviews have highlighted the and OAT3 is based on data from Slc22a6-knockout and
role of the gut microbiota as a source of uraemic toxins Slc22a8-knockout mouse models5,13,15. Metabolomic
in patients with CKD25,65,94,95. Here, however, we focus data and other studies in these mice indicate that OAT1
on the gut dysbiosis associated with CKD as an indi- directly and indirectly influences a wide range of meta-
cator of disordered host–microbiota communication. bolic pathways via transport of many metabolites (such
It is becoming increasingly clear that the relationship as α-ketoglutarate, urate and pantothenic acid) and
between the gut microbiota and the host is very compli- signalling molecules, including prostaglandins, cyclic
cated, particularly in the setting of CKD. For example, nucleotides, fatty acids and odorants7,34,35.

308 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

Δ Levels of uraemic
Impaired solutes in plasma Altered cellular processes
Kidney injury renal function Δ Uraemic toxins in plasma in many organs and tissues

Systemic homeostasis Perturbed homeostasis

Steady-state Disordered
inter-organ and inter-organ and
inter-organism inter-organism
communication communication
(eubiosis) (dysbiosis)

system
Neuroendocrine
system
and cytokine
Growth factor
system
transporter
SLC and ABC

nervous system
Autonomic
system
Neuroendocrine
system
and cytokine
Growth factor
system
transporter
SLC and ABC

nervous system
Autonomic

Resetting homeostasis

Reset
homeostasis Δ SLC and ABC
Optimization transporter system
• New set points for • Changes in DME activity
metabolite levels, • Changes in transporter
signalling molecules regulation and activity
and antioxidants
• Compensatory
system
Neuroendocrine
system
and cytokine
Growth factor
system
transporter
SLC and ABC

nervous system
Autonomic

changes in gene
expression and
regulation

Fig. 4 | A remote sensing and signalling system maintains homeostasis in the steady state and resets homeostasis
following perturbations due to kidney dysfunction and microbiota dysbiosis. Small molecules with informational
content are important in transmitting signals to remote tissues and/or organs in the maintenance of homeostasis.
In essence, the small-molecule substrates of multi-specific solute carrier (SLC) and ATP-binding cassette (ABC) transporters
act in concert with other transporters of limited specificity, as well as with phase 1 and phase 2 drug-metabolizing
enzymes (DMEs), as part of a highly flexible inter-organ and inter-organism communication network. Under physiological
conditions, this network works in concert with other systems to maintain steady-state homeostasis. Injury to the kidney
resulting in diminished kidney function and reduced tubular secretion can lead to the accumulation of uraemic solutes
and uraemic toxins in plasma. The increased levels of these small molecules can lead to alterations in cell functions and
processes in multiple tissues and organs, resulting in perturbed homeostasis. The components of this network optimize
metabolic pathways, signalling pathways, the control of redox status and other mechanisms necessary for homeostasis in
different tissues and body fluid compartments, as well as in different organisms. This system is intertwined with and works
in parallel with other homeostatic mediators, such as growth factors, cytokines and the neuroendocrine and
vasoregulatory systems. The flexibility of the system enables homeostasis to be restored or reset at a new (presumably
compensatory) set point despite the presence or progression of renal disease. Sliders in each picture represent the set
points of each of the homeostatic systems, which are altered following organ injury and adjusted during the resetting of
homeostasis. The coloured scale and arrow represent the homeostatic setting in the various stages.

Although plasma levels of indoxyl sulfate display a identified thus far interact with OAT1 and/or OAT3
major increase in Slc22a6-knockout mice7,8, OAT1 also (Table 2), as well as with other SLC family 22 mem-
transports other uraemic solutes, including p-cresol bers92,93,114. Single-nucleotide polymorphisms (SNPs) in
sulfate, kynurenine and hippurate7,8. These molecules SLC22A6 are associated with human CKD and have been
(and many others, including kynurenate, indolelactate suggested to affect the ability of the kidney to handle
and xanthurenate) are also transported by the closely uraemic toxins115.
related transporter OAT3, which is also found on the
basolateral surface of the proximal tubule8,20. OAT1 and Other uraemic solute transporters
OAT3 have partly overlapping specificities for metabo- OCT2 (encoded by SLC22A2) transports cationic urae-
lites, signalling molecules and gut microbiota products, mic solutes, including polyamines (putrescine, spermine
including uraemic toxins8,15,108,113. Many other uraemic and spermidine) and creatinine116, although some of
solutes thought to be of relevance to CKD or uraemia these cationic or zwitterionic molecules can also, to a
are transported from blood to urine by OAT1 and limited degree, be transported by OATs34,117.
OAT3, including CMPF, 1-methylguanosine and urate7,8. Another member of SLC family 22, OAT2 (encoded
Indeed, a substantial fraction of all uraemic solutes by SLC22A7), is expressed on erythrocytes118,119. OAT2

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 309

Reviews

seems to be responsible for transporting indoxyl sulfate uraemic toxins kynurenate and indoxyl sulfate inhibit
into erythrocytes, where it induces cell death owing to OATP1B1-mediated and OATP1B3-mediated transport
the production of reactive oxygen species (ROS) via the of methotrexate in a dose-dependent manner127.
NADPH oxidase-dependent pathway113,119. Several uraemic toxins (including CMPF, hippu-
OATP4C1, a member of the OATP family (encoded ric acid, indole-3-acetate and indoxyl sulfate) inhibit
by SLCO4C1), transports a somewhat different set of OATP1B1-mediated uptake of an active metabolite of
uraemic solutes120. Transgenic mice that overexpress irinotecan in cells engineered to stably express this trans-
human SLCO4C1 display decreased plasma levels of porter128. These findings might partially explain why
some uraemic toxins, including asymmetric dimethy­ the half-life of this drug metabolite, which is normally
larginine, guanidine succinate and trans-aconitate, excreted in bile, is increased in patients with ESRD128.
compared with wild-type controls120. Together, these data provide evidence for potential
Transp or t of t he cationic uraemic toxin drug–metabolite interactions at the level of the trans-
trimethylamine-N-oxide (TMAO), which is strongly porters in non-renal tissues, a phenomenon that seems
associated with cardiovascular morbidity121,122, is likely to be exacerbated in uraemia. Indeed, the data also
to be mediated by OCT2 and several ABC transport- support the notion that non-OAT transporters (such
ers123. TMAO accumulates in the plasma of Slc22a8- as OATPs) are important for the movement of uraemic
knockout mice, although whether TMAO is actually toxins into non-renal tissue.
transported by OAT3 is not clear8. The apical (luminal) Under physiological circumstances, the expression of
efflux of cationic uraemic solutes probably involves the phase 1 and phase 2 DMEs and transporters is regulated,
SLC47 family of transporters, including multi-drug and at least in part, by the gut microbiota129–133. Therefore,
toxin extrusion protein 1 (MATE1) and the 2K splice not surprisingly, many gut-derived uraemic toxins
variant of MATE2 (MATE2K)124–126. In general, however, have adverse effects on the expression and function of
the apical efflux transporters for uraemic solutes are not phase 1 and phase 2 DMEs and transporters65. Patients
well studied. with CKD are routinely treated with many drugs134,135
(an average of 12 different medications135) that require
Pharmacokinetic implications DMEs and transporters for ADME. Uraemic-toxin-
Patients with CKD show diminished transport of drugs mediated alterations in the function or expression of
that are normally excreted in bile as well as increased DMEs and transporters have the potential to drastically
levels of uraemic toxins. These observations suggest affect biotransformation, leading to increased drug
that these toxins compete with the drugs for transport half-lives and plasma levels.
via OATP1B1 and OATP1B3, which are expressed Moreover, to the extent that uraemia is partly a
in the sinusoidal membrane of hepatocytes as well as remote sensing and signalling disorder involving
other non-renal tissues127. In support of this notion, the multi-specific SLC and ABC drug transporters, it fol-
lows that drug–metabolite interactions resulting from
competition for transporters, such as those described
Table 2 | Some uraemic toxins that interact with OAT1 and/or OAT3
above, can exert widespread and unpredictable effects
Metabolite In vivo metabolomicsa In vitro interaction on metabolism and signalling in patients with kidney
OAT1 OAT3 OAT1 OAT3 disease 6,15. As CKD progresses and uraemic toxins
CMPF NS ✓ ✓ ✓ continue to accumulate, drug–metabolite interac-
tions involving transporters and/or DMEs can become
Creatinine ✓ ✓ ✓ ✓
more prevalent and more deleterious, potentially con-
Cysteine ✓ NS ✓ ✓ tributing to new and/or increased drug toxicities65.
Hypoxanthine NS NS ✓ ✓ For example, competition between paracetamol and
Indoleacetate NS ✓ ✓ ✓
p-cresol for liver sulfotransferases not only leads to
increased glucuronidation of paracetamol, instead of
Indoxyl sulfate ✓ ✓ ✓ ✓ its sulfation, but also leads to the production of toxic
Kynurenate ✓ NS ✓ ✓ metabolites of this analgesic owing to shunting of
paracetamol to a different metabolic enzyme65,136. In
Kynurenine ✓ ✓ ✓ ND
addition, sulfated conjugates of morinidazole are dra-
N2,N2-dimethylguanosine ✓ NS ND ND matically increased in the plasma of patients with CKD,
N6-methyladenosine ✓ NS ND ND leading to increased drug exposure, perhaps because
Orotate ✓ NS ND ND this drug competes with uraemic toxins for OAT3-
mediated uptake in the proxi­mal tubule137. Similarly,
p-Cresol sulfate NS ✓ ✓ ✓ administration of NSAIDs that inhibit OAT1-mediated
Putrescine NS ✓ ND ND and OAT3-mediated transport (namely, ketoprofen and
S-Adenosylhomocysteine ✓ NS ND ND diclofenac)138,139 markedly decreases the renal clearance
of indoxyl sulfate. The resulting increase in systemic
Trimethylamine-N-oxide NS ✓ ND ND
exposure to this uraemic toxin140 could have important
Uric acid ✓ ✓ ✓ ✓ clinical ramifications.
CMPF; 3-carboxy-4-methyl-5-propyl-2-furanpropanoic acid; ND, not done; NS, no significant Furthermore, the OAT1 and OAT3 metabolic net-
change; OAT, organic anion transporter. aPlasma and urine levels of each metabolite were
compared in Slc22a6-knockout and Slc22a8-knockout mice, both versus wild-type mice. Data works extrapolated from omics data obtained in healthy
compiled from several studies, including refs7,102,184,185. individuals suggest that OAT-transported drugs affect

310 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

a broad range of metabolic pathways beyond those expression of anti-inflammatory genes in adipose tis-
involved in transporter-level drug–metabolite compe- sue151. Kynurenic acid also suppresses weight gain and
tition34–36. Although similar metabolic networks have improves glucose tolerance in animals fed a high-fat
not yet been constructed to reflect the changes resulting diet151. Some of these findings might be relevant to the
from uraemia, a similarly wide range of pathways is likely uraemic syndrome.
to be affected by OAT-transported drugs5. A detailed Another uraemic toxin, CMPF (which is transported
catalogue of all potential drug–metabolite interactions into pancreatic islet cells by OAT3) is involved in insulin
occurring as a result of competition between drugs and secretion, and this mechanism seems to become aberrant
uraemic solutes at the transporter level is greatly needed in the setting of gestational diabetes33. Administration of
to provide a sound basis for drug dosing in the setting CMPF to mice fed a high-fat diet not only prevented
of renal disease6. insulin resistance but also inhibited the activity of
The reader should also keep in mind that transport- acetyl-CoA carboxylase and induced long-term reduc-
ers are important therapeutic targets and that almost tions in the expression of several genes (namely, Acaca,
one-third of the top 200 most frequently prescribed Acacb, Srebp1 and Cyp7a1) involved in the regulation
drugs depend upon active secretion in the proximal of lipogenesis and glucose metabolism152. These gene
tubule of the kidney for elimination141. Thus, although expression changes were correlated with increased lev-
drug–drug interactions occur even in patients with- els of fibroblast growth factor 21 and alterations in the
out renal impairment, they are likely to be even more expression of components of the mechanistic target of
important in patients with CKD owing to the presence rapamycin (mTOR) pathway152.
of high levels of uraemic solutes. Many uraemic solutes Similar to indoxyl sulfate, p-cresol sulfate can affect
also compete with administered drugs and with each many intracellular kinase pathways, including those
other for transporters and DMEs65. Hence, drug–drug involving cAMP and MAPKs, after being transported
interactions, drug–uraemic solute interactions and urae- into cells153,154. For example, osteoblasts exposed to
mic solute–uraemic solute interactions are likely to be p-cresol sulfate showed evidence of intracellular oxi-
very complicated6. dative stress, including an increase in ROS that could
be inhibited by probenecid (presumably reflecting the
Remote signalling by uraemic solutes involvement of an OAT) and activation of the JNK or
Several uraemic solutes that are toxic to cells and tissues p38 MAPK pathways leading to apoptotic cell death153.
at high concentrations also directly affect or participate Likewise, treatment of human renal proximal tubular
in signalling pathways at low concentrations, some of epithelial cells with indoxyl sulfate not only induced
which are discussed below. However, we emphasize that ROS production but also activated the MAPK, NF-κB
much of the data come from experiments performed p65 and RACα serine/threonine-protein kinase (AKT)
using solute concentrations that differ from those signalling pathways155.
occurring at the relevant tissue site in uraemia. Much Polyamines that accumulate in patients with CKD,
more data need to be obtained on local levels of urae- such as spermidine, spermine and putrescine, are impli-
mic toxins, as well as the cellular expression and func- cated in many cellular pathways including apoptosis; cell
tion of their putative targets, to assess which particular division, differentiation and proliferation; and signal
pathways are likely to be affected in patients with renal transduction156,157. For example, activation of eukaryotic
disease. Nevertheless, the available reports give an indi- translation initiation factor 5A1 (eIF5A1) requires the
cation of potential mechanisms by which uraemic toxins unusual post-translational modification of a lysine resi-
can modulate a wide range of metabolic pathways and due at position 50 to hypusine, an essential mechanism
signalling events. for control of cell proliferation that is dependent upon
Kynurenic acid is a ligand of both AHR and GPCR 35 spermidine158. Binding of polyamines such as spermine
(GPR35)142–144 and is important in CNS signalling both to inwardly rectifying K+ (Kir) channels also modulates
under physiological conditions and in disorders such as cell proliferation159.
depression, schizophrenia and Alzheimer disease144–146. Uraemic solutes potentially affect a wide array of
Kynurenic acid is synthesized via the kynurenine path- other signalling pathways. For example, redox potential
way (through which >95% of dietary tryptophan is is altered by urate, as are signalling events160–162. In vas-
metabolized147) from kynurenine, an intermediate of cular smooth muscle cells, urate activates p38 MAPKs,
tryptophan metabolism, by the gut microflora. In the ERK1 and ERK2 (also known as MAPK3 and MAPK1,
CNS, kynurenic acid is thought to act as an antagonist of respectively), as well as the transcription factors NF-κB
N-methyl-d-aspartate, kainite and α-amino-3-hydroxy-­ and activator protein 1 (AP-1), leading to increased cell­
5-methyl-4-isoxazolepropionic acid receptors148, as well ular proliferation and a pro-inflammatory phenotype163.
as the α7-nicotinic receptor146. Pathways involving nitric oxide are affected by asym-
Outside the CNS, kynurenic acid affects a number of metric and symmetric dimethylarginines as well as some
metabolic and immune system pathways. For example, guanidine compounds164–166. For example, asymmetric
this uraemic toxin modulates immune cell function149,150 dimethylarginine is an inhibitor of nitric oxide synthase
and attenuates the increases in expression and produc- and directly competes with arginine for the binding site
tion of tumour necrosis factor induced by treatment of this enzyme, leading to a reduction in nitric oxide
with lipopolysaccharide145. Kynurenic acid-mediated formation. Symmetric dimethylarginine perturbs nitric
GPR35 signalling also regulates energy metabolism by oxide concentration by inhibiting arginine entry into
stimulating lipid metabolism, thermogenesis and the cells via amino acid transporters167.

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 311

Reviews

Another uraemic toxin, 4-ethylphenyl sulfate local or systemic toxin levels and might help to amelio-
(a benzoate-derived compound), is one of several gut- rate uraemic syndrome. Some anionic uraemic solutes
derived uraemic toxins that show substantially increased (such as hippurate and benzoate) contribute to chronic
levels in plasma, liver, heart and kidneys in a rat model metabolic acidosis in patients with CKD, and dimin-
of CKD168. Interestingly, this compound accumulates ishing blood levels of these compounds could attenuate
in plasma in a mouse model of autism (which could this symptom.
be reversed by inoculation with the gut bacterium Several published studies indicate that dispro-
Bacteroides fragilis)169; moreover, administration of portionately high tubular secretion, including of
4-ethylphenyl sulfate induces anxiety-like behaviour in OAT-transported uraemic toxins, probably occurs in
wild-type mice169. This uraemic toxin is a component patients with impaired renal function3,173–176. The dis-
of the urine of male rats, and both 4-ethylphenyl sulfate proportionately active residual function of the proximal
and its unconjugated form, 4-ethylphenol, are thought tubule indicates its probable importance in regulating
to participate in pheromonal communication170. Taken uraemic toxin levels and thereby uraemia-induced
together, these data suggest that this uraemic toxin is metabolism. Therefore, residual function (and par-
involved in inter-organism and inter-organ remote ticularly OAT activity) in the proximal tubule might be
sensing and signalling. especially important in patients with declining kidney
function in CKD — not only for eliminating uraemic
Clinical implications toxins and drugs but also for regulating systemic meta­
The remote sensing and signalling hypothesis addresses bolism, possibly via remote communication between the
the roles of drug transporters and DMEs in inter-organ proximal tubule and other organs and/or the gut micro-
and inter-organism communication via small organic biota. We speculate that there could be a period early
mole­cules in health and disease. These small organic mole­ in the development of uraemic syndrome when local
cules include metabolites, signalling molecules, gut and systemic aberrations are subtle and affect a limited
microbiota products, antioxidants, vitamins and dietary number of disparate metabolic and signalling path-
components1,5,13–15. Within the conceptual framework of ways. This situation might be analogous to metabolic
the remote sensing and signalling hypothesis, uraemia syndrome, which is a potentially reversible precursor
can be considered a disorder of inter-organism and to the development of type 2 diabetes mellitus. Perhaps
inter-organ communication mediated by multi-specific early uraemic syndrome might be similarly amenable
SLC and ABC transporters that are involved in normal to drug-based or dietary interventions that selectively
metabolism and signalling as well as in the restoration target specific metabolic and signalling pathways.
of homeostasis. However, as uraemia progresses, similar or different but
Ultimately, this conceptual framework might lead overlapping sets of molecules might cause overt cellular
to the development of a formal biological understand- toxicity and further progression of CKD and pleiotropi­
ing of uraemia at a systems biology level and new cally affect many aspects of metabolism and signalling.
approaches to the treatment of uraemia. For example, In this situation, approaches that target multiple pathways
inter-organism communication might be modulated by might be necessary.
treatment with prebiotics and probiotics, which affect Among patients with similar levels of renal dys-
the gut microbiota171 and would presumably reduce lev- function, who will get uraemic syndrome and which
els of gut-microbiota-derived uraemic toxins. Another tissues will primarily be affected is difficult to predict.
approach is to perturb inter-organism communication This difficulty might, in substantial part, be a function
by oral administration of agents that absorb uraemic tox- of the specific SLC influx and ABC efflux transporters
ins, such as AST-120 (ref.172). Moreover, given that urae- expressed in susceptible tissue, their levels of expres-
mia can be considered a disorder of specific meta­bolic sion at the cell surface and the functional capacity of
and signalling pathways, these pathways (as is the case these transporters. Thus, we might expect that SNPs or
for other complex metabolic diseases) might be amena- combinations of SNPs that determine either the level of
ble not only to nutritional therapy but also to specific expression (non-coding SNPs) or the function (coding
targeting by drugs that are already approved for use in SNPs) of a transporter might adversely affect the hand­
other settings. Alone or in combination, these strategies ling of uraemic toxins177,178. Patients with ESRD on
could, perhaps quite rapidly, be translated into novel dialysis bearing SNPs in ABCG2 (Q126X, rs72552713;
approaches in the clinic. and Q141K, rs22331142) that impair the function of
Another potential approach involves modulating the corresponding protein, a renal and intestinal trans-
the expression or function of transporters located in the porter, not only had significantly higher serum levels of
proximal tubule, perhaps through drugs that affect key urate than patients with normal versions of the protein
transcriptional regulators of these transporters, with the but also required earlier initiation of dialysis39. A sin-
goal of enhancing the renal excretion of uraemic toxins. gle SNP in OAT1 has also been associated with CKD115.
In this regard, it is worth noting that OATs, OCTs and As net levels of uraemic toxins depend on influx as well as
other transporters seem to be regulated by nuclear recep- efflux, the function of both influx and efflux transporters
tors and transcription factors, including the hepato­ needs to be considered178.
cyte nuclear factors HNF1α and HNF4α51,52. Strategies The links between these drug transporters and phase 1
that lower the levels of uraemic toxins in various tissues and phase 2 DMEs provide another opportunity to
and body fluid compartments by targeting influx (SLC) alter the levels of toxic uraemic solutes, many of which
or efflux (mostly ABC) transporters are expected to alter are substrates for DMEs. The function and/or expression

312 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

of phase 1 or phase 2 DMEs could potentially be modu- to the resetting of homeostasis associated with the loss of
lated by enzyme activators and/or inhibitors or nuclear other renal functions. These other renal functions might
receptor agonists that regulate DME expression and or might not directly involve transporters or DMEs but
thereby affect local or systemic levels of toxic uraemic could still be indirectly related to ADME via growth
solutes. Given the plethora of DMEs, which are likely to factor, cytokine and neuroendocrine pathways.
act on dozens of clinically important uraemic solutes, Moreover, many gut-microbiota-derived uraemic
many potential targets can be explored. solutes also function as signalling molecules. These sig-
Finally, it is obvious from the complexity of the meta­ nalling molecules regulate or modulate the expression
bolic networks constructed around OAT1 and other of genes encoding ADME-related proteins via their
transporters34,35 that uraemic toxins might not simply effects on nuclear receptors, GPCRs, kinases and redox
compete directly for transport with drugs and physio- status. Accordingly, these small molecules transmit
logically beneficial metabolites. Rather, the competition critical situational (homeostatic) information back and
between drugs, key endogenous metabolites and urae- forth between cells (including between organelles), tis-
mic toxins could lead to unexpected and complex cas- sues and organs (that is, the intestine, liver, kidney and
cade effects. These will be important to define in future brain) and between organisms (namely, the host and gut
studies on the role of OATs and other uraemic toxin microbiota). Thus, from the perspective of the remote
transporters in regulating metabolic networks in both sensing and signalling hypothesis, the failing kidney and
healthy states and in CKD. worsening uraemic syndrome profoundly influence both
inter-organism and inter-organ small-molecule remote
Conclusions communication. The many changes in expression and/or
A characteristic feature of kidney failure and the uraemic function of multi-specific transporters and DMEs across
syndrome is the accumulation of protein-bound and free tissues in the setting of CKD suggest that alterations in
small molecules in plasma. Many are endogenous com- this inter-organ and inter-organism communication net-
pounds derived from cellular metabolism but others are work represent an attempt to preserve homeostasis in
derived from the gut microbiota, which also undergoes this pathophysiological setting. As this network of genes
dramatic changes in response to the host’s loss of kidney and proteins is also involved in drug ADME, perturba-
function. Dysbiosis of the gut microbiota leads to tions of remote sensing and signalling are likely to be
increased production of existing as well as new uraemic further exacerbated by the many pharmacological agents
solutes and toxins. ADME of many of these compounds administered to patients with CKD owing to increased
is mediated by a complex network of SLC and ABC competition between these drugs and uraemic solutes
transporters and DMEs. Consequently, dynamic changes for transporters that are part of the ADME network.
occur in transporter-mediated and DME-mediated Understanding the uraemic syndrome from the systems
small-molecule remote communication between the gut biology perspective of the remote sensing and signalling
microbiota and the failing kidney (and possibly other hypothesis could have important clinical ramifications.
organs). In other words, the reduced elimination and For example, implicit in this framework is the idea that
plasma accumulation of these small molecules, driven early in the development of kidney failure and uraemic
by the progressively failing kidney, as well as their con- syndrome, the number of ADME pathways affected by
tinued generation by the gut microbiota, reset the ‘nor- alterations in remote communication and sensing might
mal’ levels of these substrates for the network of SLC and be limited and therefore could be specifically targeted to
ABC transporters and DMEs involved in their ADME. forestall full-blown uraemia.
This resetting of the system (which probably involves
organs other than the failing kidney) occurs in addition Published online 6 February 2019

1. Wu, W., Dnyanmote, A. V. & Nigam, S. K. Remote 8. Wu, W., Bush, K. T. & Nigam, S. K. Key role for the 14. Ahn, S. Y. & Nigam, S. K. Toward a systems level
communication through solute carriers and ATP organic anion transporters, OAT1 and OAT3, in the understanding of organic anion and other multispecific
binding cassette drug transporter pathways: in vivo handling of uremic toxins and solutes. Sci. Rep. drug transporters: a remote sensing and signaling
an update on the remote sensing and signaling 7, 4939 (2017). hypothesis. Mol. Pharmacol. 76, 481–490 (2009).
hypothesis. Mol. Pharmacol. 79, 795–805 (2011). 9. Kim, S. H., Yu, M. A., Ryu, E. S., Jang, Y. H. & Kang, D. H. 15. Nigam, S. K. et al. The organic anion transporter
2. Liu, X. & Dai, C. Advances in understanding and Indoxyl sulfate-induced epithelial-to-mesenchymal (OAT) family: a systems biology perspective.
management of residual renal function in patients transition and apoptosis of renal tubular cells as novel Physiol. Rev. 95, 83–123 (2015).
with chronic kidney disease. Kidney Dis. 2, 187–196 mechanisms of progression of renal disease. Lab. Invest. 16. Kaler, G. et al. Structural variation governs substrate
(2017). 92, 488–498 (2012). specificity for organic anion transporter (OAT)
3. Lowenstein, J. & Grantham, J. J. Residual renal 10. Sun, C. Y., Chang, S. C. & Wu, M. S. Uremic toxins homologs. Potential remote sensing by OAT family
function: a paradigm shift. Kidney Int. 91, 561–565 induce kidney fibrosis by activating intrarenal members. J. Biol. Chem. 282, 23841–23853 (2007).
(2017). renin-angiotensin-aldosterone system associated 17. Pavlova, A. et al. Developmentally regulated
4. Shafi, T., Mullangi, S., Toth-Manikowski, S. M., epithelial-to-mesenchymal transition. PLOS ONE 7, expression of organic ion transporters NKT (OAT1),
Hwang, S. & Michels, W. M. Residual kidney function: e34026 (2012). OCT1, NLT (OAT2), and ROCT. Am. J. Physiol. Renal
implications in the era of personalized medicine. 11. Bolati, D., Shimizu, H., Higashiyama, Y., Nishijima, F. Physiol. 278, F635–F643 (2000).
Semin. Dial. 30, 241–245 (2017). & Niwa, T. Indoxyl sulfate induces epithelial-to- 18. Kaler, G. et al. Olfactory mucosa-expressed
5. Nigam, S. K. What do drug transporters really do? mesenchymal transition in rat kidneys and human organic anion transporter, Oat6, manifests high
Nat. Rev. Drug Discov. 14, 29–44 (2015). proximal tubular cells. Am. J. Nephrol. 34, 318–323 affinity interactions with odorant organic anions.
6. Nigam, S. K. et al. Handling of drugs, metabolites, (2011). Biochem. Biophys. Res. Commun. 351, 872–876
and uremic toxins by kidney proximal tubule drug 12. van den Brand, J. A. et al. Uremic solutes in (2006).
transporters. Clin. J. Am. Soc. Nephrol. 10, chronic kidney disease and their role in progression. 19. Monte, J. C., Nagle, M. A., Eraly, S. A. & Nigam, S. K.
2039–2049 (2015). PLOS ONE 11, e0168117 (2016). Identification of a novel murine organic anion
7. Wikoff, W. R., Nagle, M. A., Kouznetsova, V. L., 13. Nigam, S. K. The SLC22 transporter family: transporter family member, OAT6, expressed in
Tsigelny, I. F. & Nigam, S. K. Untargeted metabolomics a paradigm for the impact of drug transporters olfactory mucosa. Biochem. Biophys. Res. Commun.
identifies enterobiome metabolites and putative uremic on metabolic pathways, signaling, and disease. 323, 429–436 (2004).
toxins as substrates of organic anion transporter 1 Annu. Rev. Pharmacol. Toxicol. 58, 663–687 20. Bush, K. T., Wu, W., Lun, C. & Nigam, S. K. The drug
(Oat1). J. Proteome Res. 10, 2842–2851 (2011). (2018). transporter OAT3 (SLC22A8) and endogenous

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 313

Reviews

metabolite communication via the gut-liver-kidney Expert Opin. Drug Metab. Toxicol. 10, 11–23 71. Muteliefu, G. et al. Indoxyl sulfate promotes vascular
axis. J. Biol. Chem. 292, 15789–15803 (2017). (2014). smooth muscle cell senescence with upregulation
21. Nigam, S. K. & Bhatnagar, V. The systems biology of 48. Ladda, M. A. & Goralski, K. B. The effects of CKD on ofp53, p21, and prelamin A through oxidative stress.
uric acid transporters: the role of remote sensing and cytochrome P450-mediated drug metabolism. Am. J. Physiol. Cell Physiol. 303, C126–C134 (2012).
signaling. Curr. Opin. Nephrol. Hypertens. 27, Adv. Chronic Kidney Dis. 23, 67–75 (2016). 72. Mozar, A. et al. Uremic toxin indoxyl sulfate inhibits
305–313 (2018). 49. Michaud, J. et al. Effect of hemodialysis on human vascular smooth muscle cell proliferation.
22. Li, T. & Apte, U. Bile acid metabolism and signaling in hepatic cytochrome P450 functional expression. Ther. Apher. Dial. 15, 135–139 (2011).
cholestasis, inflammation, and cancer. Adv. Pharmacol. J. Pharmacol. Sci. 108, 157–163 (2008). 73. Shimizu, H., Hirose, Y., Nishijima, F., Tsubakihara, Y.
74, 263–302 (2015). 50. Ma, X., Idle, J. R. & Gonzalez, F. J. The pregnane X & Miyazaki, H. ROS and PDGF-β [corrected] receptors
23. Chiang, J. Y. Recent advances in understanding bile receptor: from bench to bedside. Expert Opin. Drug are critically involved in indoxyl sulfate actions that
acid homeostasis. F1000Res. 6, 2029 (2017). Metab. Toxicol. 4, 895–908 (2008). promote vascular smooth muscle cell proliferation
24. Molinaro, A., Wahlstrom, A. & Marschall, H. U. 51. Martovetsky, G., Bush, K. T. & Nigam, S. K. and migration. Am. J. Physiol. Cell Physiol. 297,
Role of bile acids in metabolic control. Kidney versus liver specification of SLC and ABC drug C389–C396 (2009).
Trends Endocrinol. Metab. 29, 31–41 (2018). transporters, tight junction molecules, and 74. Yamamoto, H. et al. Indoxyl sulfate stimulates
25. Evenepoel, P., Poesen, R. & Meijers, B. The gut–kidney biomarkers. Drug Metab. Dispos. 44, 1050–1060 proliferation of rat vascular smooth muscle cells.
axis. Pediatr. Nephrol. 32, 2005–2014 (2017). (2016). Kidney Int. 69, 1780–1785 (2006).
26. Wing, M. R., Patel, S. S., Ramezani, A. & Raj, D. S. 52. Martovetsky, G., Tee, J. B. & Nigam, S. K. 75. Mair, R. D., Sirich, T. L. & Meyer, T. W. Uremic toxin
Gut microbiome in chronic kidney disease. Hepatocyte nuclear factors 4α and 1α regulate kidney clearance and cardiovascular toxicities. Toxins 10,
Exp. Physiol. 101, 471–477 (2016). developmental expression of drug-metabolizing E226 (2018).
27. Spector, R., Robert Snodgrass, S. & Johanson, C. E. enzymes and drug transporters. Mol. Pharmacol. 84, 76. Schroeder, J. C. et al. The uremic toxin 3-indoxyl
A balanced view of the cerebrospinal fluid composition 808–823 (2013). sulfate is a potent endogenous agonist for the human
and functions: focus on adult humans. Exp. Neurol. 53. Staudinger, J. L. et al. The nuclear receptor PXR is a aryl hydrocarbon receptor. Biochemistry 49,
273, 57–68 (2015). lithocholic acid sensor that protects against liver 393–400 (2010).
28. Stieger, B. & Gao, B. Drug transporters in the central toxicity. Proc. Natl Acad. Sci. USA 98, 3369–3374 77. Esser, C. & Rannug, A. The aryl hydrocarbon
nervous system. Clin. Pharmacokinet. 54, 225–242 (2001). receptor in barrier organ physiology, immunology, and
(2015). 54. Xie, W. et al. Humanized xenobiotic response in toxicology. Pharmacol. Rev. 67, 259–279 (2015).
29. Jabbari, B. & Vaziri, N. D. The nature, consequences, mice expressing nuclear receptor SXR. Nature 406, 78. Roman, A. C., Carvajal-Gonzalez, J. M., Merino, J. M.,
and management of neurological disorders in chronic 435–439 (2000). Mulero-Navarro, S. & Fernandez-Salguero, P. M.
kidney disease. Hemodial. Int. 22, 150–160 (2018). 55. Santana Machado, T. et al. Indoxyl sulfate upregulates The aryl hydrocarbon receptor in the crossroad of
30. Seifter, J. L. & Samuels, M. A. Uremic encephalopathy liver P-glycoprotein expression and activity through signalling networks with therapeutic value.
and other brain disorders associated with renal failure. aryl hydrocarbon receptor signaling. J. Am. Pharmacol. Ther. 185, 50–63 (2017).
Semin. Neurol. 31, 139–143 (2011). Soc. Nephrol. 29, 906–918 (2018). 79. Wakamatsu, T. et al. Indoxyl sulfate promotes
31. Ebah, L. M. et al. Subcutaneous interstitial pressure 56. Xu, C., Li, C. Y. & Kong, A. N. Induction of phase I, II macrophage IL-1β production by activating aryl
and volume characteristics in renal impairment and III drug metabolism/transport by xenobiotics. hydrocarbon receptor/NF-κ/MAPK cascades, but the
associated with edema. Kidney Int. 84, 980–988 Arch. Pharm. Res. 28, 249–268 (2005). NLRP3 inflammasome was not activated. Toxins 10,
(2013). 57. Leong, S. C. & Sirich, T. L. Indoxyl sulfate — review of E124 (2018).
32. Mayerl, S. et al. Transporters MCT8 and OATP1C1 toxicity and therapeutic strategies. Toxins 8, E358 80. Wanchai, K. et al. Probiotic Lactobacillus paracasei
maintain murine brain thyroid hormone homeostasis. (2016). HII01 protects rats against obese-insulin
J. Clin. Invest. 124, 1987–1999 (2014). 58. Camacho, O. et al. Effect of a sustained difference in resistance-induced kidney injury and impaired renal
33. Prentice, K. J. et al. The furan fatty acid metabolite hemodialytic clearance on the plasma levels of p-cresol organic anion transporter 3 function. Clin. Sci. 132,
CMPF is elevated in diabetes and induces beta cell sulfate and indoxyl sulfate. Nephrol. Dial. Transplant. 1545–1563 (2018).
dysfunction. Cell Metab. 19, 653–666 (2014). 31, 1335–1341 (2016). 81. Czuba, L. C., Hillgren, K. M. & Swaan, P. W.
34. Ahn, S. Y. et al. Linkage of organic anion transporter-1 59. Poesen, R. et al. The influence of prebiotic Post-translational modifications of transporters.
to metabolic pathways through integrated “omics”- arabinoxylan oligosaccharides on microbiota derived Pharmacol. Ther. 192, 88–99 (2018).
driven network and functional analysis. J. Biol. Chem. uremic retention solutes in patients with chronic 82. Murray, M. & Zhou, F. Trafficking and other
286, 31522–31531 (2011). kidney disease: a randomized controlled trial. regulatory mechanisms for organic anion transporting
35. Liu, H. C. et al. An organic anion transporter 1 (OAT1)- PLOS ONE 11, e0153893 (2016). polypeptides and organic anion transporters that
centered metabolic network. J. Biol. Chem. 291, 60. Chiavaroli, L., Mirrahimi, A., Sievenpiper, J. L., modulate cellular drug and xenobiotic influx and that
19474–19486 (2016). Jenkins, D. J. & Darling, P. B. Dietary fiber effects are dysregulated in disease. Br. J. Pharmacol. 174,
36. Wu, W. et al. Multispecific drug transporter Slc22a8 in chronic kidney disease: a systematic review 1908–1924 (2017).
(Oat3) regulates multiple metabolic and signaling and meta-analysis of controlled feeding trials. 83. Xu, D. & You, G. Loops and layers of post-translational
pathways. Drug Metab. Dispos. 41, 1825–1834 Eur. J. Clin. Nutr. 69, 761–768 (2015). modifications of drug transporters. Adv. Drug Deliv.
(2013). 61. Cha, R. H. et al. A randomized, controlled trial of oral Rev. 116, 37–44 (2017).
37. Liu, B. et al. Metabolic enzyme system and transport intestinal sorbent AST-120 on renal function 84. Hong, M. et al. Human organic anion transporter
pathways in chronic kidney diseases. Curr. Drug deterioration in patients with advanced renal hOAT1 forms homooligomers. J. Biol. Chem. 280,
Metab. 19, 568–576 (2018). dysfunction. Clin. J. Am. Soc. Nephrol. 11, 559–567 32285–32290 (2005).
38. Takada, T. et al. Identification of ABCG2 as an (2016). 85. Miyazaki, H. et al. Modulation of renal apical
exporter of uremic toxin indoxyl sulfate in mice and as 62. Rossi, M. et al. Synbiotics easing renal failure organic anion transporter 4 function by two PDZ
a crucial factor influencing CKD progression. Sci. Rep. by improving gut microbiology (SYNERGY): domain-containing proteins. J. Am. Soc. Nephrol. 16,
8, 11147 (2018). a randomized trial. Clin. J. Am. Soc. Nephrol. 11, 3498–3506 (2005).
39. Matsuo, H. et al. Hyperuricemia in acute 223–231 (2016). 86. Endou, H. & Anzai, N. Urate transport across the
gastroenteritis is caused by decreased urate 63. Schulman, G. et al. Randomized placebo-controlled apical membrane of renal proximal tubules.
excretion via ABCG2. Sci. Rep. 6, 31003 (2016). EPPIC trials of AST-120 in CKD. J. Am. Soc. Nephrol. Nucleosides Nucleotides Nucleic Acids 27, 578–584
40. Bhatnagar, V. et al. Analysis of ABCG2 and other 26, 1732–1746 (2015). (2008).
urate transporters in uric acid homeostasis in chronic 64. Sirich, T. L., Plummer, N. S., Gardner, C. D., 87. Zhang, Q., Pan, Z. & You, G. Regulation of human
kidney disease: potential role of remote sensing and Hostetter, T. H. & Meyer, T. W. Effect of increasing organic anion transporter 4 by protein kinase C and
signaling. Clin. Kidney J. 9, 444–453 (2016). dietary fiber on plasma levels of colon-derived solutes NHERF-1: altering the endocytosis of the transporter.
41. Jing, J. et al. Genetics of serum urate concentrations in hemodialysis patients. Clin. J. Am. Soc. Nephrol. 9, Pharm. Res. 27, 589–596 (2010).
and gout in a high-risk population, patients with 1603–1610 (2014). 88. Xue, P., Crum, C. M. & Thibodeau, P. H. Regulation of
chronic kidney disease. Sci. Rep. 8, 13184 (2018). 65. Prokopienko, A. J. & Nolin, T. D. Microbiota-derived ABCC6 trafficking and stability by a conserved
42. Takada, T. et al. ABCG2 dysfunction increases serum uremic retention solutes: perpetrators of altered C-terminal PDZ-like sequence. PLOS ONE 9, e97360
uric acid by decreased intestinal urate excretion. nonrenal drug clearance in kidney disease. Expert Rev. (2014).
Nucleosides Nucleotides Nucleic Acids 33, 275–281 Clin. Pharmacol. 11, 71–82 (2018). 89. Schaletzki, Y. et al. Several adaptor proteins promote
(2014). 66. Vanholder, R., Schepers, E., Pletinck, A., Nagler, E. V. intracellular localisation of the transporter MRP4/
43. Yano, H., Tamura, Y., Kobayashi, K., Tanemoto, M. & Glorieux, G. The uremic toxicity of indoxyl sulfate ABCC4 in platelets and haematopoietic cells.
& Uchida, S. Uric acid transporter ABCG2 is increased and p-cresyl sulfate: a systematic review. J. Am. Thromb. Haemost. 117, 105–115 (2017).
in the intestine of the 5/6 nephrectomy rat model of Soc. Nephrol. 25, 1897–1907 (2014). 90. Ferreira, C. et al. The scaffold protein PDZK1
chronic kidney disease. Clin. Exp. Nephrol. 18, 50–55 67. Kaminski, T., Michalowska, M. & Pawlak, D. Aryl modulates expression and function of the organic
(2014). hydrocarbon receptor (AhR) and its endogenous anion transporting polypeptide 2B1. Eur. J.
44. Pahl, M. V. & Vaziri, N. D. The chronic kidney agonist - indoxyl sulfate in chronic kidney disease. Pharm. Sci. 120, 181–190 (2018).
disease–colonic axis. Semin. Dial. 28, 459–463 Postepy Hig. Med. Dosw. 71, 624–632 (2017). 91. Venot, Q. et al. A PDZ-like motif in the biliary
(2015). 68. Gao, H. & Liu, S. Role of uremic toxin indoxyl sulfate in transporter ABCB4 interacts with the scaffold protein
45. Velenosi, T. J., Fu, A. Y., Luo, S., Wang, H. the progression of cardiovascular disease. Life Sci. EBP50 and regulates ABCB4 cell surface expression.
& Urquhart, B. L. Down-regulation of hepatic CYP3A 185, 23–29 (2017). PLOS ONE 11, e0146962 (2016).
and CYP2C mediated metabolism in rats with 69. Liu, H., Narayanan, R., Hoffmann, M. & Surapaneni, S. 92. Vanholder, R. et al. The role of EUTox in uremic toxin
moderate chronic kidney disease. Drug Metab. Dispos. The uremic toxin indoxyl-3-sulfate induces CYP1A2 in research. Semin. Dial. 22, 323–328 (2009).
40, 1508–1514 (2012). primary human hepatocytes. Drug Metab. Lett. 10, 93. Zhao, Y. Y. Metabolomics in chronic kidney disease.
46. Naud, J., Nolin, T. D., Leblond, F. A. & Pichette, V. 195–199 (2016). Clin. Chim. Acta 422, 59–69 (2013).
Current understanding of drug disposition in kidney 70. Wu, Y., Han, X., Wang, L., Diao, Z. & Liu, W. 94. Lau, W. L., Savoj, J., Nakata, M. B. & Vaziri, N. D.
disease. J. Clin. Pharmacol. 52, 10S–22S (2012). Indoxyl sulfate promotes vascular smooth muscle cell Altered microbiome in chronic kidney disease:
47. Philips, B. J., Lane, K., Dixon, J. & Macphee, I. calcification via the JNK/Pit-1 pathway. Ren. Fail. 38, systemic effects of gut-derived uremic toxins. Clin. Sci.
The effects of acute renal failure on drug metabolism. 1702–1710 (2016). 132, 509–522 (2018).

314 | MAY 2019 | volume 15 www.nature.com/nrneph

 Reviews

95. Mahmoodpoor, F., Rahbar Saadat, Y., Barzegari, A., 119. Dias, G. F. et al. Indoxyl sulfate, a uremic toxin, 141. Morrissey, K. M., Stocker, S. L., Wittwer, M. B., Xu, L.
Ardalan, M. & Zununi Vahed, S. The impact of gut stimulates reactive oxygen species production and & Giacomini, K. M. Renal transporters in drug
microbiota on kidney function and pathogenesis. erythrocyte cell death supposedly by an organic development. Annu. Rev. Pharmacol. Toxicol. 53,
Biomed. Pharmacother. 93, 412–419 (2017). anion transporter 2 (OAT2) and NADPH oxidase 503–529 (2013).
96. Vogt, S. L., Pena-Diaz, J. & Finlay, B. B. Chemical activity-dependent pathways. Toxins 10, E280 (2018). 142. DiNatale, B. C. et al. Kynurenic acid is a potent
communication in the gut: effects of microbiota- 120. Toyohara, T. et al. SLCO4C1 transporter eliminates endogenous aryl hydrocarbon receptor ligand
generated metabolites on gastrointestinal bacterial uremic toxins and attenuates hypertension and renal thatsynergistically induces interleukin-6 in the
pathogens. Anaerobe 34, 106–115 (2015). inflammation. J. Am. Soc. Nephrol. 20, 2546–2555 presence of inflammatory signaling. Toxicol. Sci. 115,
97. Kennedy, P. J., Cryan, J. F., Dinan, T. G. & (2009). 89–97 (2010).
Clarke, G. Kynurenine pathway metabolism and 121. Subramaniam, S. & Fletcher, C. Trimethylamine 143. Wang, J. et al. Kynurenic acid as a ligand for orphan
the microbiota-gut-brain axis. Neuropharmacology N-oxide: breathe new life. Br. J. Pharmacol. 175, G protein-coupled receptor GPR35. J. Biol. Chem.
112, 399–412 (2017). 1344–1353 (2018). 281, 22021–22028 (2006).
98. Xu, L. et al. Furan fatty acids — beneficial or harmful 122. Tang, W. H. et al. Gut microbiota-dependent 144. Wirthgen, E., Hoeflich, A., Rebl, A. & Gunther, J.
to health? Prog. Lipid Res. 68, 119–137 (2017). trimethylamine N-oxide (TMAO) pathway contributes Kynurenic acid: the Janus-faced role of an
99. El Ridi, R. & Tallima, H. Physiological functions and to both development of renal insufficiency and immunomodulatory tryptophan metabolite and its link
pathogenic potential of uric acid: a review. J. Adv. Res. mortality risk in chronic kidney disease. Circ. Res. 116, to pathological conditions. Front. Immunol. 8, 1957
8, 487–493 (2017). 448–455 (2015). (2017).
100. Bae, D. H., Lane, D. J. R., Jansson, P. J. & 123. Teft, W. A. et al. Identification and characterization 145. Moroni, F., Cozzi, A., Sili, M. & Mannaioni, G.
Richardson, D. R. The old and new biochemistry of of trimethylamine-N-oxide uptake and efflux Kynurenic acid: a metabolite with multiple actions and
polyamines. Biochim. Biophys. Acta Gen. Subj. 1862, transporters. Mol. Pharm. 14, 310–318 (2017). multiple targets in brain and periphery. J. Neural
2053–2068 (2018). 124. Masuda, S. et al. Identification and functional Transm. 119, 133–139 (2012).
101. Lopez-Nieto, C. E. et al. Molecular cloning and characterization of a new human kidney-specific H+/ 146. Schwarcz, R., Bruno, J. P., Muchowski, P. J. & Wu, H. Q.
characterization of NKT, a gene product related to organic cation antiporter, kidney-specific multidrug Kynurenines in the mammalian brain: when physiology
the organic cation transporter family that is almost and toxin extrusion 2. J. Am. Soc. Nephrol. 17, meets pathology. Nat. Rev. Neurosci. 13, 465–477
exclusively expressed in the kidney. J. Biol. Chem. 2127–2135 (2006). (2012).
272, 6471–6478 (1997). 125. Motohashi, H. & Inui, K. Organic cation transporter 147. Fujigaki, H., Yamamoto, Y. & Saito, K. L-Tryptophan-
102. Eraly, S. A. et al. Decreased renal organic anion OCTs (SLC22) and MATEs (SLC47) in the human kynurenine pathway enzymes are therapeutic target
secretion and plasma accumulation of endogenous kidney. AAPS J. 15, 581–588 (2013). for neuropsychiatric diseases: focus on cell type
organic anions in OAT1 knock-out mice. J. Biol. Chem. 126. Nies, A. T., Koepsell, H., Damme, K. & Schwab, M. differences. Neuropharmacology 112, 264–274
281, 5072–5083 (2006). Organic cation transporters (OCTs, MATEs), in (2017).
103. Sweeney, D. E. et al. Functional maturation of drug vitroand in vivo evidence for the importance in drug 148. Schwarcz, R. & Stone, T. W. The kynurenine pathway
transporters in the developing, neonatal, and therapy. Handb. Exp. Pharmacol. 201, 105–167 and the brain: challenges, controversies and promises.
postnatal kidney. Mol. Pharmacol. 80, 147–154 (2011). Neuropharmacology 112, 237–247 (2017).
(2011). 127. Sato, T., Yamaguchi, H., Kogawa, T., Abe, T. & Mano, N. 149. Mandi, Y. & Vecsei, L. The kynurenine system and
104. Nagle, M. A. et al. Analysis of three-dimensional Organic anion transporting polypeptides 1B1 and immunoregulation. J. Neural Transm. 119, 197–209
systems for developing and mature kidneys clarifies 1B3 play an important role in uremic toxin handling (2012).
the role of OAT1 and OAT3 in antiviral handling. and drug-uremic toxin interactions in the liver. 150. Stone, T. W., Stoy, N. & Darlington, L. G. An expanding
J. Biol. Chem. 286, 243–251 (2011). J. Pharm. Pharm. Sci. 17, 475–484 (2014). range of targets for kynurenine metabolites of
105. Nagle, M. A., Wu, W., Eraly, S. A. & Nigam, S. K. 128. Katsube, Y. et al. Cooperative inhibitory effects tryptophan. Trends Pharmacol. Sci. 34, 136–143
Organic anion transport pathways in antiviral of uremic toxins and other serum components (2013).
handling in choroid plexus in Oat1 (Slc22a6) and on OATP1B1-mediated transport of SN-38. 151. Agudelo, L. Z. et al. Kynurenic acid and Gpr35
Oat3 (Slc22a8) deficient tissue. Neurosci. Lett. 534, Cancer Chemother. Pharmacol. 79, 783–789 regulate adipose tissue energy homeostasis and
133–138 (2013). (2017). inflammation. Cell Metab. 27, 378–392 (2018).
106. Truong, D. M., Kaler, G., Khandelwal, A., Swaan, P. W. 129. Fu, Z. D., Selwyn, F. P., Cui, J. Y. & Klaassen, C. D. 152. Prentice, K. J. et al. CMPF, a metabolite formed
& Nigam, S. K. Multi-level analysis of organic anion RNA-seq profiling of intestinal expression of upon prescription omega-3-acid ethyl ester
transporters 1, 3, and 6 reveals major differences in xenobiotic processing genes in germ-free mice. supplementation, prevents and reverses steatosis.
structural determinants of antiviral discrimination. Drug Metab. Dispos. 45, 1225–1238 (2017). EBioMedicine 27, 200–213 (2018).
J. Biol. Chem. 283, 8654–8663 (2008). 130. Selwyn, F. P., Cheng, S. L., Klaassen, C. D. & Cui, J. Y. 153. Tanaka, H. et al. p-Cresyl sulfate induces osteoblast
107. Vallon, V. et al. Overlapping in vitro and in vivo Regulation of hepatic drug-metabolizing enzymes in dysfunction through activating JNK and p38 MAPK
specificities of the organic anion transporters OAT1 germ-free mice by conventionalization and probiotics. pathways. Bone 56, 347–354 (2013).
and OAT3 for loop and thiazide diuretics. Am. J. Drug Metab. Dispos. 44, 262–274 (2016). 154. Yang, K. et al. Indoxyl sulfate induces oxidative stress
Physiol. Renal Physiol. 294, F867–F873 (2008). 131. Selwyn, F. P. et al. Developmental regulation of and hypertrophy in cardiomyocytes by inhibiting the
108. VanWert, A. L., Gionfriddo, M. R. & Sweet, D. H. drug-processing genes in livers of germ-free mice. AMPK/UCP2 signaling pathway. Toxicol. Lett. 234,
Organic anion transporters: discovery, pharmacology, Toxicol. Sci. 147, 84–103 (2015). 110–119 (2015).
regulation and roles in pathophysiology. Biopharm. 132. Claus, S. P. et al. Colonization-induced host–gut 155. Park, J. S., Choi, H. I., Bae, E. H., Ma, S. K.
Drug Dispos. 31, 1–71 (2010). microbial metabolic interaction. mBio 2, e00271–10 & Kim, S. W. Paricalcitol attenuates indoxyl sulfate-
109. Rubino, F. M. Toxicity of glutathione-binding metals: (2011). induced apoptosis through the inhibition of MAPK,
a review of targets and mechanisms. Toxics 3, 20–62 133. Meinl, W., Sczesny, S., Brigelius-Flohe, R., Blaut, M. Akt, and NF-kB activation in HK-2 cells.
(2015). & Glatt, H. Impact of gut microbiota on intestinal and Korean J. Intern. Med. 34, 146–155 (2019).
110. Torres, A. M., Dnyanmote, A. V., Bush, K. T., Wu, W. hepatic levels of phase 2 xenobiotic-metabolizing 156. Pegg, A. E. Functions of polyamines in mammals.
& Nigam, S. K. Deletion of multispecific organic enzymes in the rat. Drug Metab. Dispos. 37, J. Biol. Chem. 291, 14904–14912 (2016).
anion transporter Oat1/Slc22a6 protects against 1179–1186 (2009). 157. Ramani, D., De Bandt, J. P. & Cynober, L. Aliphatic
mercury-induced kidney injury. J. Biol. Chem. 286, 134. Jansen, J., Jankowski, J., Gajjala, P. R., Wetzels, J. F. M. polyamines in physiology and diseases. Clin. Nutr. 33,
26391–26395 (2011). & Masereeuw, R. Disposition and clinical implications 14–22 (2014).
111. Zalups, R. K. Molecular interactions with mercury in of protein-bound uremic toxins. Clin. Sci. 131, 158. Park, M. H., Nishimura, K., Zanelli, C. F. &
the kidney. Pharmacol. Rev. 52, 113–143 (2000). 1631–1647 (2017). Valentini, S. R. Functional significance of eIF5A
112. Wikoff, W. R. et al. Metabolomics analysis reveals 135. Manley, H. J. et al. Medication prescribing patterns in and its hypusine modification in eukaryotes.
large effects of gut microflora on mammalian blood ambulatory haemodialysis patients: comparisons of Amino Acids 38, 491–500 (2010).
metabolites. Proc. Natl Acad. Sci. USA 106, USRDS to a large not-for-profit dialysis provider. 159. Weiger, T. M. & Hermann, A. Cell proliferation,
3698–3703 (2009). Nephrol. Dial. Transplant. 19, 1842–1848 (2004). potassium channels, polyamines and their interactions:
113. Liu, H. C. et al. Molecular properties of drugs 136. Clayton, T. A., Baker, D., Lindon, J. C., Everett, J. R. & a mini review. Amino Acids 46, 681–688 (2014).
interacting with SLC22 transporters OAT1, OAT3, Nicholson, J. K. Pharmacometabonomic identification 160. Tassone, E. J. et al. Uric acid impairs insulin
OCT1, and OCT2: a machine-learning approach. of a significant host-microbiome metabolic interaction signaling by promoting ENPP1 binding to insulin
J. Pharmacol. Exp. Ther. 359, 215–229 (2016). affecting human drug metabolism. Proc. Natl Acad. receptor in human umbilical vein endothelial cells.
114. Rhee, E. P. et al. Metabolite profiling identifies Sci. USA 106, 14728–14733 (2009). Front. Endocrinol. 9, 98 (2018).
markers of uremia. J. Am. Soc. Nephrol. 21, 137. Kong, F. et al. Increased plasma exposures of 161. Spiga, R. et al. Uric acid is associated with
1041–1051 (2010). conjugated metabolites of morinidazole in renal inflammatory biomarkers and induces inflammation
115. Sun, C. Y. et al. A novel SNP in the 5’ regulatory region failure patients: a critical role of uremic toxins. via activating the NF-κB signaling pathway in HepG2
of organic anion transporter 1 is associated with Drug Metab. Dispos. 45, 593–603 (2017). cells. Arterioscler. Thromb. Vasc. Biol. 37,
chronic kidney disease. Sci. Rep. 8, 8085 (2018). 138. Cihlar, T. & Ho, E. S. Fluorescence-based assay for the 1241–1249 (2017).
116. Schophuizen, C. M. et al. Cationic uremic toxins affect interaction of small molecules with the human renal 162. Liang, W. Y. et al. Uric acid promotes chemokine
human renal proximal tubule cell functioning through organic anion transporter 1. Anal. Biochem. 283, and adhesion molecule production in vascular
interaction with the organic cation transporter. 49–55 (2000). endothelium via nuclear factor-κB signaling.
Pflugers Arch. 465, 1701–1714 (2013). 139. Khamdang, S. et al. Interactions of human organic Nutr. Metab. Cardiovasc. Dis. 25, 187–194 (2015).
117. Ahn, S. Y., Eraly, S. A., Tsigelny, I. & Nigam, S. K. anion transporters and human organic cation 163. Filiopoulos, V., Hadjiyannakos, D. & Vlassopoulos, D.
Interaction of organic cations with organic anion transporters with nonsteroidal anti-inflammatory New insights into uric acid effects on the progression
transporters. J. Biol. Chem. 284, 31422–31430 drugs. J. Pharmacol. Exp. Ther. 303, 534–539 and prognosis of chronic kidney disease. Ren. Fail. 34,
(2009). (2002). 510–520 (2012).
118. Sager, G., Smaglyukova, N. & Fuskevaag, O. M. 140. Yu, C. P. et al. Effects of nonsteroidal anti-inflammatory 164. Kielstein, J. T., Fliser, D. & Veldink, H. Asymmetric
The role of OAT2 (SLC22A7) in the cyclic nucleotide drugs on the renal excretion of indoxyl sulfate, a dimethylarginine and symmetric dimethylarginine:
biokinetics of human erythrocytes. J. Cell. Physiol. nephro-cardiovascular toxin, in rats. Eur. J. Pharm. axis of evil or useful alliance? Semin. Dial. 22,
233, 5972–5980 (2018). Sci. 101, 66–70 (2017). 346–350 (2009).

NATuRe RevIewS | NEPhrOLOGy volume 15 | MAY 2019 | 315

Reviews

165. De Deyn, P. P., Vanholder, R. & D’Hooge, R. Nitric 174. Lowenstein, J. & Grantham, J. J. The rebirth of 183. Petzinger, E. & Geyer, J. Drug transporters in
oxide in uremia: effects of several potentially toxic interest in renal tubular function. Am. J. Physiol. pharmacokinetics. Naunyn Schmiedebergs Arch.
guanidino compounds. Kidney Int. Suppl. 84, Renal Physiol. 310, F1351–F1355 (2016). Pharmacol. 372, 465–475 (2006).
S25–S28 (2003). 175. Wang, K. & Kestenbaum, B. Proximal tubular 184. Eraly, S. A. et al. Multiple organic anion transporters
166. De Deyn, P. P., D’Hooge, R., Van Bogaert, P. P. secretory clearance: a neglected partner of kidney contribute to net renal excretion of uric acid.
& Marescau, B. Endogenous guanidino compounds function. Clin. J. Am. Soc. Nephrol. 13, 1291–1296 Physiol. Genomics 33, 180–192 (2008).
as uremic neurotoxins. Kidney Int. Suppl. 78, (2018). 185. Vallon, V. et al. A role for the organic anion transporter
S77–S83 (2001). 176. Leong, S. C. et al. Residual function effectively controls OAT3 in renal creatinine secretion in mice. Am. J.
167. Chen, J. Y. et al. Nitric oxide bioavailability dysfunction plasma concentrations of secreted solutes in patients Physiol. Renal Physiol. 302, F1293–F1299 (2012).
involves in atherosclerosis. Biomed. Pharmacother. on twice weekly hemodialysis. J. Am. Soc. Nephrol.
97, 423–428 (2018). 29, 1992–1999 (2018). Acknowledgements
168. Velenosi, T. J. et al. Untargeted plasma and tissue 177. Bhatnagar, V. et al. Analyses of 5′ regulatory region The authors’ work referred to in this Review was partly sup-
metabolomics in rats with chronic kidney disease polymorphisms in human SLC22A6 (OAT1) and ported by US National Institutes of Health grants DK109392
given AST-120. Sci. Rep. 6, 22526 (2016). SLC22A8 (OAT3). J. Hum. Genet. 51, 575–580 and HD090259 (U54) to S.K.N.
169. Hsiao, E. Y. et al. Microbiota modulate behavioral (2006).
and physiological abnormalities associated with 178. Xu, G. et al. Analyses of coding region polymorphisms Author contributions
neurodevelopmental disorders. Cell 155, 1451–1463 in apical and basolateral human organic anion Both authors researched data for the article, contributed sub-
(2013). transporter (OAT) genes [OAT1 (NKT), OAT2, OAT3, stantially to discussions of the article content, wrote the man-
170. Lafaye, A. et al. Profiling of sulfoconjugates in urine by OAT4, URAT (RST)]. Kidney Int. 68, 1491–1499 uscript and participated in the review or editing of the
using precursor ion and neutral loss scans in tandem (2005). manuscript before submission.
mass spectrometry. Application to the investigation of 179. Stanley, L. A. in Pharmacognosy (ed. Delgoda, R.)
heavy metal toxicity in rats. J. Mass Spectrom. 39, 527–545 (Academic, 2017). Competing interests
655–664 (2004). 180. Almazroo, O. A., Miah, M. K. & Venkataramanan, R. The authors declare no competing interests.
171. John, G. K. et al. Dietary alteration of the gut microbiome Drug metabolism in the liver. Clin. Liver Dis. 21, 1–20
and its impact on weight and fat mass: a systematic (2017). Publisher’s note
review and meta-analysis. Genes 9, E167 (2018). 181. Ishikawa, T. The ATP-dependent glutathione Springer Nature remains neutral with regard to jurisdictional
172. Yamaguchi, J., Tanaka, T. & Inagi, R. Effect of AST-120 S-conjugate export pump. Trends Biochem. Sci. 17, claims in published maps and institutional affiliations.
in chronic kidney disease treatment: still a 463–468 (1992).
controversy? Nephron 135, 201–206 (2017). 182. Döring, B. & Petzinger, E. Phase 0 and phase III Reviewer information
173. Masereeuw, R. et al. The kidney and uremic toxin transport in various organs: combined concept Nature Reviews Nephrology thanks T. D. Nolin and the other
removal: glomerulus or tubule? Semin. Nephrol. 34, of phases in xenobiotic transport and metabolism. anonymous reviewer(s) for their contribution to the peer
191–208 (2014). Drug Metab. Rev. 46, 261–282 (2014). review of this work.

316 | MAY 2019 | volume 15 www.nature.com/nrneph