In this review we summarize the findings from the literature and our own laboratory on the decreased PON1 activity in renal failure, the mechanisms proposed and the effect of interventions. In addition to profound alterations in lipoproteins, reduced serum PON1 activity has been clearly established in the past decade and could contribute to accelerated development of atherosclerosis in ESRD and in HD. PON1 lactonase activity is lower in ESRD patients. Hemodialysis partially restores PON1 lactonase and the other activities. PON1 activity recovery after dialysis suggests that uremic toxins may play a mechanistic role in PON1 inactivation. Lower PON1 activity in CRF patients is associated with low thiol concentration, high CRP, and is beneficially enhanced with vitamin C and flavonoids. Changes in HDL subclasses, namely lower HDL3 in these patients may also play a role in PON1 lower activity. Future research should focus on: (1) mechanistic studies on causes for low PON1 activity and mass; (2) prospective studies focusing on whether there is an added predictive value in measuring PON1 activity (and PON1 activity in HDL3) in this patient population; (3) intervention studies attempting to increase PON1 activity. 1. Introduction The major cause of mortality in patients with end-stage renal disease (ESRD) receiving renal replacement therapy is cardiovascular disease. More than one million of these patients throughout the world are surviving with the assistance of renal replacement therapy [1–8]. More than 800,000 patients receive hemodialysis (HD), the most frequent modality. Survival on HD has improved, although vascular accidents, such as ischemic heart disease and hemorrhagic stroke, remain major problems [2, 7, 8]. All patients with chronic renal failure (CRF) have increased risk for death from cardiovascular disease, especially those undergoing HD [1, 2, 9]. They have numerous metabolic disorders that may hasten the development of plaques, such as insulin resistance, hypertension, and dyslipoproteinemia, along with other ESRD-related risk factors such as the classical calcium and phosphate metabolism disorders and secondary hyperparathyroidism [1–9]. CRF patients frequently have lipoprotein abnormalities such as low high-density lipoprotein (HDL)-cholesterol concentrations, increased remnant particles and hypertriglyceridemia. HDL-cholesterol concentrations are inversely correlated with atherogenic risk [3, 4, 6, 7]. HDL is not only a key player in reverse cholesterol transport but has the ability to protect low-density lipoprotein (LDL) against
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