We recently found that insufficient activation of Akt-mediated signaling underlies aggravation of reperfusion injury, leading to enlarged infarct size. 6 In addition to modified signal transduction, alteration in metabolism is possibly involved in CKD-induced increase in myocardial sensitivity to ischemia/ reperfusion (I/R) injury. Insulin resistance is a metabolic hallmark of uremia, 7,8 and Tamaki et al 9 showed that CKD induces substantial changes in metabolites and the number of mitochondria in skeletal muscle. However, to our knowledge, the effect of CKD on cardiac metabolomes has not been reported, and its relationship to modification of the cytoprotective signal pathway also remains unclear.Erythropoietin is produced in the adult kidney and plays a major role in promotion of erythropoiesis. However, erythropoietin protein is also expressed in nonrenal tissues, including the liver and central nervous system. 10 Erythropoietin receptors are also expressed not only in hematopoietic cells but also in other types of cells, such as endothelial cells, neurons, and cardiomyocytes. [11][12][13] A series of studies using a mutant mouse that expresses the erythropoietin receptor exclusively in hematopoietic cells (EpoR −/− rescued) showed that deletion of the erythropoietin receptor aggravates I/R injury and Abstract-Chronic kidney disease (CKD) is known to increase myocardial infarct size after ischemia/reperfusion. However, a strategy to prevent the CKD-induced myocardial susceptibility to ischemia/reperfusion injury has not been developed. Here, we examined whether epoetin β pegol, a continuous erythropoietin receptor activator (CERA), normalizes myocardial susceptibility to ischemia/reperfusion injury by its effects on protective signaling and metabolomes in CKD. CKD was induced by 5/6 nephrectomy in rats (subtotal nephrectomy, SNx), whereas sham-operated rats served controls (Sham). Infarct size as percentage of area at risk after 20-minutes coronary occlusion/2-hour reperfusion was larger in SNx than in Sham: 60.0±4.0% versus 43.9±2.2%. Administration of CERA (0.6 μg/kg SC every 7 days) for 4 weeks reduced infarct size in SNx (infarct size as percentage of area at risk=36.9±3.9%), although a protective effect was not detected for the acute injection of CERA. Immunoblot analyses revealed that myocardial phospho-Akt-Ser473 levels under baseline conditions and on reperfusion were lower in SNx than in Sham, and CERA restored the Akt phosphorylation on reperfusion. Metabolomic analyses showed that glucose 6-phosphate and glucose 1-phosphate were reduced and malate:aspartate ratio was 1.6-fold higher in SNx than in Sham, suggesting disturbed flux of malate-aspartate shuttle by CKD. The CERA improved the malate:aspartate ratio in SNx to the control level. In H9c2 cells, mitochondrial Akt phosphorylation by insulin-like growth factor-1 was attenuated by malate-aspartate shuttle inhibition. In conclusion, the results suggest that a CERA prevents CKD-induced susceptibility of the myocardium to ischemia/reperfusion in...