Nephrotoxicity and the proximal tubule. Insights from cadmium

Nephron Physiol. 2003;93(4):p87-93. doi: 10.1159/000070241.


Cadmium (Cd(2+)) is a non-essential heavy metal, which is taken up from the environment into the body through pulmonary and enteral pathways. The S1 segment of the kidney proximal tubule (PT) is a major target of chronic Cd(2+) toxicity. Renal dysfunction develops in up to 7% of the general population and in its most severe form displays major features of Fanconi syndrome, such as a defective protein, amino acid, glucose, bicarbonate and phosphate reabsorption. The major pathway for Cd(2+) uptake by PT cells (PTCs) in vivo is apical endocytosis of Cd(2+) complexed to the high-affinity metal-binding protein metallothionein (MT), which may be receptor-mediated. MT is subsequently degraded in endo-lysosomes, and Cd(2+) is liberated for translocation into the cytosolic compartment, possibly using transporters for Fe(2+), Zn(2+) or Cu(2+), such as the divalent metal transporter DMT1. Free Cd(2+) ions in the extracellular space are translocated across apical and/or basolateral PTC membranes into the cytosol via transporters, whose identity remains unknown. Cytosolic Cd(2+) generates reactive oxygen species (ROS), which deplete endogenous radical scavengers. ROS also damage a variety of transport proteins, including the Na(+)/K(+)-ATPase, which are subsequently degraded by the proteasome and endo-lysosomal proteases. Cd(2+) causes mitochondrial swelling and release of cytochrome C. If these ROS-mediated stress events are not balanced by repair processes, affected cells undergo apoptosis. But Cd(2+) also induces the upregulation of cytoprotective stress and metal-scavenging proteins, such as MT. In addition, Cd(2+) upregulates the detoxifying pump multidrug resistance P-glycoprotein, which appears to protect PTCs against Cd(2+)-induced apoptosis. Thus, Cd(2+) interferes with various cellular events ranging from mechanisms of induction of programmed cell death to activation of cell survival genes. A better understanding of the cellular mechanisms involved in Cd(2+) nephrotoxicity should provide insights into other heavy metal (e.g. Pb(2+), Hg(2+)) nephropathies and various forms of acquired Fanconi syndrome.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Animals
  • Apoptosis / physiology
  • Cadmium / pharmacokinetics
  • Cadmium / toxicity*
  • Cell Survival / drug effects
  • Endopeptidases / metabolism
  • Humans
  • Kidney Diseases / chemically induced*
  • Kidney Diseases / physiopathology*
  • Kidney Tubules, Proximal / drug effects*
  • Kidney Tubules, Proximal / physiopathology*
  • Macromolecular Substances
  • Mitochondria / drug effects
  • Mitochondria / metabolism
  • Proteins / metabolism
  • Reactive Oxygen Species / metabolism
  • Sodium / metabolism
  • Ubiquitin / metabolism


  • Macromolecular Substances
  • Proteins
  • Reactive Oxygen Species
  • Ubiquitin
  • Cadmium
  • Sodium
  • Endopeptidases