Abstract-Dyslipidemia often accompanies and accelerates renal disease, partly by promoting fibrosis. However, the mechanisms mediating this effect are unclear. We hypothesized that hypercholesterolemia modulates several interlinked pathways that promote deposition and blunt degradation of extracellular matrix, and that these could be manipulated by reversal of hypercholesterolemia. Fourteen pigs were fed a 16-week 2% high-cholesterol diet (HC-HC; nϭ7) or normal diet (nϭ7), whereas in 7 others, a 10-week HC was followed by a 6-week normal diet (HC-N). Renal endothelial function was assessed in vivo with electron-beam computed tomography, and renal tissue was then studied ex vivo using Western blot, real-time quantitative polymerase chain reaction, gelatin zymography, and immunostaining. HC-HC kidneys showed endothelial dysfunction, accompanied by increased intrarenal oxidative stress, inflammation, activation of the endothelin and transforming-growth factor- systems, and decreased matrix metalloproteinase expression and activity. Accordingly, HC-HC kidneys showed increased collagen IV expression and fibrosis. A lipid-lowering dietary intervention reversed most of these changes. In conclusion, this study indicates that renal fibrosis in early atherosclerosis is a result of a simultaneous increase in extracellular matrix deposition and blunted matrix metalloproteinase-mediated degradation, overall promoting perivascular and tubulointerstitial fibrosis. Notably, many of these pathways may be reversible in hypercholesterolemia, and crucial targets could potentially be identified for early interventions to preserve the kidney. Key Words: kidney Ⅲ hypercholesterolemia Ⅲ fibrosis Ⅲ remodeling Ⅲ oxidative stress H ypercholesterolemia is a common cardiovascular risk factor. Approximately 50% of the middle-aged adult population has total cholesterol above desirable levels, 1 a strong, independent predictor of progression of atherosclerosis. 2 Dyslipidemia also often accompanies and aggravates early and advanced renal disease. 3,4 We have previously shown in a pig model that a 10-to 12-week diet-induced hypercholesterolemia, a risk factor for early atherosclerosis, elicited renal dysfunction, inflammation, and fibrosis, partly mediated by increased oxidative stress. [5][6][7][8] Increased oxidative stress may contribute to renal damage in hypercholesterolemia and atherosclerosis by virtue of augmented generation of reactive oxygen species (ROS) and oxidation of LDLs, 8 -12 which may induce endothelial dysfunction and activate redox-sensitive growth factors and cytokines. In addition, lipid accumulation or cellular damage can promote renal dysfunction, glomerular injury, and interstitial fibrosis. 13,14 A dynamic and complex process in which tissue growth is counterbalanced by degradation and removal preserves the normal structure of the kidney and may be partly modulated by endothelium-derived factors. Kidney disease and normal renal development are characterized by a high rate of extracellular matrix (ECM) turnover. Sev...