Indoxyl sulfate, a representative uremic toxin, suppresses erythropoietin production in a HIF-dependent manner

Lab Invest. 2011 Nov;91(11):1564-71. doi: 10.1038/labinvest.2011.114. Epub 2011 Aug 22.


Advanced chronic kidney disease (CKD) patients encounter anemia through insufficient erythropoietin (EPO) production by peritubular fibroblasts. Recent studies showed an increase in EPO production by pharmacological activation of hypoxia-inducible transcription factors (HIFs) in dialysis patients, suggesting that desensitization of the oxygen-sensing mechanism is responsible for the development of renal anemia. Our recent work demonstrated that indoxyl sulfate (IS), a uremic toxin, dysregulates oxygen metabolism in tubular cells. Here we provide evidence of an additional property that IS impairs oxygen sensing in EPO-producing cells. HepG2 cells were stimulated with cobalt chloride (CoCl(2)) or hypoxia under varying concentrations of IS. EPO mRNA was evaluated by quantitative PCR. Nuclear accumulation of HIF-α was evaluated by western blotting. Transcriptional activity of HIF was checked by hypoxia-responsive element (HRE)-luciferase reporter assay. The impact of IS was further evaluated in vivo by administering rats with indole, a metabolic precursor of IS, and subjecting them to CoCl(2) stimulation, in which renal EPO mRNA as well as plasma EPO levels were measured by quantitative PCR and enzyme-linked immunosorbent assay, respectively. Although IS induced cellular toxicity at relatively high concentrations (2.5 mM), EPO mRNA expression was significantly suppressed by IS at concentrations below cytotoxic ranges. In HepG2 cells, IS treatment decreased nuclear accumulation of HIF-α proteins and suppressed HRE-luciferase activity following hypoxia. Furthermore, administration of rats with indole suppressed renal EPO mRNA expression and plasma EPO levels, corroborating in vitro findings. Results of the present study provide a possible connection between a uremic toxin and the desensitization of the oxygen-sensing mechanism in EPO-producing cells, which may partly explain inadequate EPO production in hypoxic kidneys of CKD patients.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Animals
  • Blotting, Western
  • Cobalt
  • Enzyme-Linked Immunosorbent Assay
  • Erythropoietin / biosynthesis*
  • Erythropoietin / blood
  • Erythropoietin / genetics
  • Erythropoietin / metabolism
  • Gene Expression Regulation / drug effects*
  • Hep G2 Cells
  • Humans
  • Hypoxia-Inducible Factor 1 / metabolism*
  • Indican / toxicity*
  • Indoles / administration & dosage
  • Indoles / pharmacology
  • Kidney Failure, Chronic / physiopathology*
  • Luciferases
  • Oxygen / metabolism*
  • Rats
  • Uremia / blood*


  • Hypoxia-Inducible Factor 1
  • Indoles
  • Erythropoietin
  • Cobalt
  • indole
  • Luciferases
  • cobaltous chloride
  • Indican
  • Oxygen