Pegues MA, McCrory MA, Zarjou A, Szalai AJ. C-reactive protein exacerbates renal ischemia-reperfusion injury. Am J Physiol Renal Physiol 304: F1358 -F1365, 2013. First published March 27, 2013 doi:10.1152/ajprenal.00476.2012.-Renal ischemia-reperfusion injury (IRI) is a common cause of acute kidney injury (AKI), occurring with hypotension and cardiovascular surgery and inevitably during kidney transplantation. Mortality from AKI is high due to incomplete knowledge of the pathogenesis of IRI and the lack of an effective therapy. Inflammation accompanies IRI and increases the blood level of C-reactive protein (CRP), a biomarker of worsened outcomes in AKI. To test if CRP is causal in AKI we subjected wild-type mice (WT) and human CRP transgenic mice (CRPtg) to bilateral renal IRI (both pedicles clamped for 30 min at 37°C then reperfused for 24 h). Serum human CRP level was increased approximately sixfold after IRI in CRPtg (10.62 Ϯ 1.31 g/ml at baseline vs. 72.01 Ϯ 9.41 g/ml at 24 h) but was not elevated by sham surgery wherein kidneys were manipulated but not clamped. Compared with WT, serum creatinine, urine albumin, and histological evidence of kidney damage were increased after IRI in CRPtg mice. RT-PCR analysis of mRNA isolated from whole kidneys of CRPtg and WT subjected to IRI revealed that in CRPtg kidneys 1) upregulation of markers of macrophage classical activation (M1 markers) was blunted, 2) downregulation of markers of macrophage alternative activation (M2 markers) was more robust, and 3) expression of the activating receptor Fc␥RI was increased. Our finding that CRP exacerbates IRI-induced AKI, perhaps by shifting the balance of macrophage activation and Fc␥R expression towards a detrimental portfolio, might make CRP a promising therapeutic target for the treatment of AKI.alternatively activated macrophages; acute phase proteins; AKI ACUTE KIDNEY INJURY (AKI) can occur in any setting where renal ischemia reperfusion injury (IRI) is manifest, including during cardiovascular surgery (37) and kidney transplantation (50). In fact, AKI is a serious complication in ϳ1% of all hospitalizations and has a mortality rate as high as 80% (22,37). Despite this risk to patients and its burden on the health care system, there is still no effective therapy for AKI. The pathogenesis of renal IRI is not completely understood, but it is recognized that it is always accompanied by a systemic inflammatory response (35). Damage to the kidney is thought to evoke the release of inflammatory cytokines like TNF-␣ and IL-6 that in turn foster renal infiltration of leukocytes, neutrophils, dendritic cells, and macrophages (1,20). Exactly how this inflammatory cascade culminates in kidney damage and how this process is regulated are unknown.