AKI is characterised by upregulation of competing pro-survival and pro- inflammatory/ apoptotic signaling pathways whereby processes associated with renal recovery; tubular epithelial phenotypic change and proliferation occur simultaneously with those associated with diminished GFR, vascular inflammation, tubular dysfunction and epithelial apoptosis. Protection from AKI can be achieved by altering the balance of these pathways; for example upregulation of the pivotal phosphatidylinositol 3-kinase - serine-threonine protein kinase B (PI3K-Akt) pro-survival pathway following the administration of erythropoietin or insulin like growth factor inhibits experimental AKI following renal ischaemia and reperfusion in rodents and swine. In our own work we have shown that post cardiopulmonary bypass (CPB) AKI in swine can be prevented by the administration of either a phosphodiesterase type 5 (PDE-5) inhibitor which promotes cell survival and endothelial homeostasis via augmentation of endogenous nitric oxide (NO) signalling, or by the inhibition of endothelin-1 (ET-1), an important pro-inflammatory mediator and promoter of oxidative stress in renal injury How these competing pathways are regulated in patients at risk of AKI is poorly understood however, and it is our belief that the identification of these processes will facilitate the development of new and effective prevention and treatment strategies for AKI and improved outcomes for patients