Administration of activated protein C (APC) protects from renal dysfunction, but the underlying mechanism is unknown. APC exerts both antithrombotic and cytoprotective properties, the latter via modulation of protease-activated receptor-1 (PAR-1) signaling. We generated APC variants to study the relative importance of the two functions of APC in a model of LPS-induced renal microvascular dysfunction. Compared with wild-type APC, the K193E variant exhibited impaired anticoagulant activity but retained the ability to mediate PAR-1-dependent signaling. In contrast, the L8W variant retained anticoagulant activity but lost its ability to modulate PAR-1. By administering wild-type APC or these mutants in a rat model of LPS-induced injury, we found that the PAR-1 agonism, but not the anticoagulant function of APC, reversed LPS-induced systemic hypotension. In contrast, both functions of APC played a role in reversing LPS-induced decreases in renal blood flow and volume, although the effects on PAR-1-dependent signaling were more potent. Regarding potential mechanisms for these findings, APC-mediated PAR-1 agonism suppressed LPS-induced increases in the vasoactive peptide adrenomedullin and infiltration of iNOS-positive leukocytes into renal tissue. However, the anticoagulant function of APC was responsible for suppressing LPS-induced stimulation of the proinflammatory mediators ACE-1, IL-6, and IL-18, perhaps accounting for its ability to modulate renal hemodynamics. Both variants reduced active caspase-3 and abrogated LPS-induced renal dysfunction and pathology. We conclude that although PAR-1 agonism is solely responsible for APC-mediated improvement in systemic hemodynamics, both functions of APC play distinct roles in attenuating the response to injury in the kidney. 20: 267-277, 200920: 267-277, . doi: 10.1681 Acute kidney injury (AKI) leading to renal failure is a devastating disorder, 1 with a prevalence varying from 30 to 50% in the intensive care unit. 2 AKI during sepsis results in significant morbidity, and is an independent risk factor for mortality. 3,4 In patients with severe sepsis or shock, the reported incidence ranges from 23 to 51% 5-7 with mortality as high as 70% versus 45% among patients with AKI alone. 1,8 The pathogenesis of AKI during sepsis involves hemodynamic alterations along with microvascular impairment. 4 Although many factors change during sepsis, suppression of the plasma serine protease, protein C (PC), has been shown to be predictive of early death in sepsis models, 9 and clinically has been associated with early death resulting from refractory shock and multiple organ failure in severe sepsis. 10 Moreover, low levels of PC have been
J Am Soc Nephrol