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The mechanism is disputed, but several theories have been proposed: (a) that hemoglobin or hemoglobin products are directly toxic to proximal tubule cells, (b) that precipitation of hemoglobin results in tubular obstruction and renal failure, and (c) that direct renal injury by hemoglobin does not occur but instead products of intravascular hemolysis result in hypotension and other systemic and local vascular events, and these lead to renal failure ( 135 , 136 , 137 , 138 )

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