Hepatic warm ischemia and reperfusion (IR) injury occurs in many clinical situations and has an important link to subsequent hepatic failure. The pathogenesis of this injury involves numerous pathways, including mitochondrial-associated apoptosis. We studied the effect of mitochondrial calcium uptake inhibition on hepatic IR injury using the specific mitochondrial calcium uptake inhibitor, ruthenium red (RR). Rats were subjected to 1 hour of 70% warm hepatic ischemia following RR pretreatment or vehicle injection. Sham-operated animals served as controls. Analysis was performed at 15 minutes, 1 hour, 3 hours, or 6 hours after reperfusion. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) concentrations were determined. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) staining was performed to assess apoptosis, and hepatocellular necrosis was semiquantitated from hematoxylin and eosin -stained tissue sections. RR pretreatment significantly decreased both AST and ALT serum levels after 6 hours of reperfusion (AST: 1,556 ؎ 181 U/L vs. 597 ؎ 121 U/L, P ؍ 0.005; ALT: 1,118 ؎ 187 U/L vs. 294 ؎ 39 U/L, P ؍ 0.005). Apoptosis was observed within 15 minutes of reperfusion in vehicle-pretreated animals and peaked after 3 hours of reperfusion (98 ؎ 21 cells/high-power field [hpf]). Apoptosis was inhibited at all time points by RR pretreatment. Histologic evidence of necrosis was not observed prior to 3 hours of reperfusion (23% ؎ 4%), and maximal necrosis was observed after 6 hours of reperfusion (26% ؎ 1% percent area). RR pretreatment significantly decreased the necrotic percent area at both the 3-hour and the 6-hour time points (4.2% ؎ 2%; 3.7% ؎ 1%, respectively). Hepatic IR injury resulted in both apoptotic and necrotic cell death, which were attenuated by RR pretreatment. In conclusion, these observations implicate mitochondrial calcium uptake in the pathogenesis of hepatic IR injury. H epatic warm ischemia and reperfusion (IR) injury occur in many clinical situations including transplantation, resection, trauma, shock, hemorrhage, and thermal injury. Evidence exists linking the periods of ischemia associated with these events to subsequent liver failure. 1 In addition, there is evidence that the duration of the ischemic periods during hepatic resection directly correlates with postoperative liver dysfunction. [2][3][4][5] The pathogenesis of ischemic hepatocellular injury is complex and involves numerous mediators. [6][7][8][9] Although many authors have demonstrated apoptosis following hepatic ischemia, the role of mitochondrialassociated apoptotic mechanisms in hepatic IR injury remains unclear. A better understanding of the cellular pathophysiology of IR and identification of methods to attenuate this injury has important clinical implications.Within the last decade, a series of findings have shown that mitochondria play a central role in intracellular calcium dynamics. 10,11 Mitochondria can take up calcium rapidly via the ruthenium red...