Aminoglycoside antibiotics, such as gentamicin and amikacin, are a class of clinically important antibiotics used worldwide in the treatment of infections caused by Gram-positive and Gram-negative bacteria. However, nephrotoxicity and ototoxicity are serious problems in the use of aminoglycosides and are the major dose-limiting side effects. Most of the intravenously administered dose is excreted into the urine, whereas some of the aminoglycoside injected (about 10% of the dose) is selectively accumulated in the renal cortex, leading to renal injury. Aminoglycosides are taken up into the epithelial cells of the renal proximal tubules by an endocytic pathway. Acidic phospholipids, broadly distributed in the plasma membranes in various tissues, were considered to be the binding site of aminoglycosides. Recently, megalin, a giant endocytic receptor abundantly expressed in renal proximal tubules, has been reported to bind aminoglycosides. Therefore we first examined whether megalin plays an important role in the renal accumulation of aminoglycosides under in vivo and in vitro conditions. We then attempted to develop new strategies for preventing the nephrotoxicity of aminoglycosides based on the molecular mechanisms of aminoglycoside accumulation in the kidney. This review summarizes our recent findings ol the role of megalin in the renal accumulation of aminoglycosides and our approach to develop nonnephrotoxic aminoglycoside therapy.