We develop a unifying theory of hypoxia tolerance based on information from two cell level models (brain cortical cells and isolated hepatocytes) from the highly anoxia tolerant aquatic turtle and from other more hypoxia sensitive systems. We propose that the response of hypoxia tolerant systems to oxygen lack occurs in two phases (defense and rescue). The first lines of defense against hypoxia include a balanced suppression of ATP-demand and ATP-supply pathways; this regulation stabilizes (adenylates) at new steady-state levels even while ATP turnover rates greatly decline. The ATP demands of ion pumping are down-regulated by generalized "channel" arrest in hepatocytes and by "spike" arrest in neurons. Hypoxic ATP demands of protein synthesis are down-regulated probably by translational arrest. In hypoxia sensitive cells this translational arrest seems irreversible, but hypoxia-tolerant systems activate "rescue" mechanisms if the period of oxygen lack is extended by preferentially regulating the expression of several proteins. In these cells, a cascade ofprocesses underpinning hypoxia rescue and defense begins with an oxygen sensor (a heme protein) and a signaltransduction pathway, which leads to significant gene-based metabolic reprogramming-the rescue process-with maintained down-regulation of energy-demand and energy-supply pathways in metabolism throughout the hypoxic period. This recent work begins to clarify how normoxic maintenance ATP turnover rates can be drastically (10-fold) down-regulated to a new hypometabolic steady state, which is prerequisite for surviving prolonged hypoxia or anoxia. The implications of these developments are extensive in biology and medicine. energy turnover supplies the greatest protection against, and hence, advantage in, hypoxia. The immense advantage of this defense strategy is widely appreciated by many biologists (4, 5, 11-13). In one of his last personal communications to one of the authors (P.W.H.), the great comparative physiologist Kjell Johansen referred to this strategy as "turning down to the pilot light" and he, like many earlier workers, was acutely aware of its relative importance. Although recognized as a kind of hallmark of reversible entry into and return from states of severe 02 deprivation, a number of unexplained problems have remained. In particular, it has not been clear (i) how cells/ tissues "know" when to turn on their hypoxia defense mechanisms, (ii) which pathways of ATP demand and ATP supply are down-regulated or by how much, (iii) how membrane electrochemical gradients are stabilized, and (iv) what geneexpression and protein-expression level adjustments are involved in hypoxic reorganization of cell structure and function. Recent studies of a well-known vertebrate "facultative anaerobe," the aquatic turtle, used brain cortical slices to probe electrophysiological properties of neurons under anoxia (16)(17)(18)(19) and isolated liver hepatocytes to probe cell level biochemical responses to anoxia (20)(21)(22)(23)(24). When integrated with ...