Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine

Interventions for protecting renal function in the perioperative period

BACKGROUND

Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, N-acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO).

OBJECTIVES

This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period.We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others?

SEARCH METHODS

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards.

SELECTION CRITERIA

We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period.

DATA COLLECTION AND ANALYSIS

We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre-existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality.

MAIN RESULTS

The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit.Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta-analysis on the combined data.Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre-existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97.

AUTHORS' CONCLUSIONS

No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end-stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period.

Alpha-lipoic acid for the prevention of contrast-induced nephropathy in patients undergoing coronary angiography: the ALIVE study - a prospective randomized trial

OBJECTIVES

α-Lipoic acid (ALA) is widely used for diabetic neuropathy due to its antioxidant properties. We evaluated its potential for preventing contrast-induced nephropathy (CIN).

METHODS

We conducted a prospective randomized controlled trial to evaluate the efficacy of ALA in CIN prevention. Two hundred and two patients with basal renal insufficiency who received elective coronary angiography were randomized to the ALA group [ALA treatment for 2 days (600 mg orally three times a day before and after coronary catheterization, n = 100)] or the control group (n = 102). The primary end point was the maximum increase in serum creatinine (sCr) and the secondary end point was the incidence of CIN defined as an increase in sCr of either ≥ 25% or ≥ 44.2 µmol/l.

RESULTS

Mean maximum increase in sCr was not different between the ALA and the control group (-1.32 ± 30.5 vs. -1.19 ± 30.1 µmol/l, respectively; p = 0.977). sCr did not significantly change from baseline (120.8 ± 69.8 vs. 122 ± 88.1 µmol/l) in the ALA group and the simple saline hydration group (108.2 ± 37.5 vs. 110 ± 49 µmol/l). There was a lower rate of CIN in the ALA group than in the control group, but the difference was not statistically significant (3.0 vs. 6.9%, respectively; p = 0.332).

CONCLUSION

ALA showed no benefit in CIN prevention.

The effect of L-carnitine on oxidative stress responses of experimental contrast-induced nephropathy in rats

This study was conducted to investigate the prophylactic effects of carnitine against contrast-induced nephropathy (CIN) and its relation to oxidant/antioxidant status in kidney, liver, heart, spleen and lung tissues in a CIN rat model. Twenty-eight adult male Wistar rats were divided into 4 groups, the control, contrast media (CM), carnitine and contrast media+carnitine (CM+carnitine) groups. Animals were placed in individual metabolism cages, and on the 2nd day, rats were deprived of water for 24 hr. On the 3rd day, contrast media were administered to groups CM and CM+carnitine. L-carnitine was administered on days 2, 3 and 4. Histopathological changes were evaluated in the right kidney after euthanization. Superoxide dismutase (SOD) and catalase (CAT) activities and glutathione (GSH) and malondialdehyde (MDA) levels were measured in renal, liver, heart, spleen and lung tissues. The SOD activities in the renal (P<0.05), liver (P<0.001) and spleen (P<0.05) tissues were increased in the carnitine group. The CAT activities in the spleen tissue were decreased (P<0.01) only in the CM group. Renal (P<0.05), liver (P<0.001), spleen (P<0.001) and lung tissue (P<0.01) GSH levels were found to be higher in the carnitine group. In renal, liver and lung tissues, the MDA levels increased in the CM group (P<0.001). The histopathological findings showed that L-carnitine may have a preventative effect in alleviating the negative effects of CIN. Similar to this, L-carnitine may play a major role in the stability of the antioxidant status in the kidney, liver, spleen and lung of the CIN rat model.

The effects of VARC-defined acute kidney injury after transcatheter aortic valve implantation (TAVI) using the Edwards bioprosthesis

AIMS

The aim of this study was to identify the incidence and risk factors for acute kidney injury (AKI) after TAVI, a potentially serious complication of transcatheter aortic valve implantation (TAVI) that has been redefined by the Valve Academic Research Consortium (VARC).

METHODS AND RESULTS

We performed a retrospective analysis of 248 patients undergoing TAVI. AKI was defined as a VARC-modified Risk, Injury, Failure, Loss, and End-stage (RIFLE) kidney disease score ≥ 2. Eighty-nine patients suffered AKI (35.9%) and demonstrated increased mortality at 30 days (13.5% vs. 3.8%) and one year (31.5% vs. 15.0%) (p<0.001). Multivariate regression analysis identified diabetes mellitus (p<0.001), peripheral vascular disease (p=0.007), chronic kidney disease stage (p=0.010) as independently associated risk factors for AKI.

CONCLUSIONS

More than one third of patients sustain AKI after TAVI using the Edwards bioprosthesis, as defined by the VARC-modified RIFLE score. AKI increased the mortality at both 30 days and at one year. A history of diabetes mellitus, peripheral vascular disease and higher chronic kidney disease stage had the strongest independent associations with post-TAVI AKI.

N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography

STUDY OBJECTIVE

We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy.

METHODS

The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.

RESULTS

The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval -4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids.

CONCLUSION

We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy.

The protective effect of ebselen on radiocontrast-induced nephrotoxicity

AIM

Radiocontrast-induced nephropathy has become one of the most important causes of renal acute failure. The most effective management of reducing the incidence of contrast nephropathy is to understand and prevent its causes. We aimed to investigate the protective role of ebselen against radiocontrast-induced nephrotoxicity in terms of tissue oxidant/antioxidant parameters and light microscopy in rats.

METHODS

Albino Wistar rats were randomly separated into four groups. The Group 1 rats were treated with sodium chloride as the control group, Group 2 with radiocontrast, Group 3 with radiocontrast plus ebselen, and Group 4 with ebselen alone. After 24 h, the animals over the experimental period were euthanized and blood samples were analyzed for blood urea nitrogen (BUN) and serum creatinine (Cr) levels. Kidney sections were analyzed for malondialdehyde (MDA) levels and superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px) activities, as well as histopathological changes.

RESULTS

In the radiocontrast group, BUN, MDA, and GSH-Px levels increased while SOD activity decreased compared with the control group. These decays were improved by ebselen administration in the radiocontrast group. Significant histological deteriorations were observed in the radiocontrast group. We noted improvement in the histologic findings with ebselen administration.

CONCLUSION

These results indicate that ebselen might produce a protective mechanism against radiocontrast-induced nephrotoxicity.

N-acetylcysteine does not prevent contrast nephropathy in patients with renal impairment undergoing emergency CT: a randomized study

BACKGROUND

Patients admitted to the emergency room with renal impairment and undergoing a contrast computed tomography (CT) are at high risk of developing contrast nephropathy as emergency precludes sufficient hydration prior to contrast use. The value of an ultra-high dose of intravenous N-acetylcysteine in this setting is unknown.

METHODS

From 2008 to 2010, we randomized 120 consecutive patients admitted to the emergency room with an estimated clearance lower than 60 ml/min/1.73 m2 by MDRD (mean GFR 42 ml/min/1.73 m2) to either placebo or 6000 mg N-acetylcysteine iv one hour before contrast CT in addition to iv saline. Serum cystatin C and creatinine were measured one hour prior to and at day 2, 4 and 10 after contrast injection. Nephrotoxicity was defined either as 25% or 44 μmol/l increase in serum creatinine or cystatin C levels compared to baseline values.

RESULTS

Contrast nephrotoxicity occurred in 22% of patients who received placebo (13/58) and 27% of patients who received N-acetylcysteine (14/52, p = 0.66). Ultra-high dose intravenous N-acetylcysteine did not alter creatinine or cystatin C levels. No secondary effects were noted within the 2 groups during follow-up.

CONCLUSIONS

An ultra-high dose of intravenous N-acetylcysteine is ineffective at preventing nephrotoxicity in patients with renal impairment undergoing emergency contrast CT.

TRIAL REGISTRATION

The study was registered as Clinical trial (NCT01467154).

Acute kidney injury in children: an update on diagnosis and treatment

The concept and definition of acute kidney injury (AKI) in adults and children has undergone significant change in recent years. Biomarker assessment is aiding in description, defining and understanding timing of AKI. AKI demonstrates unique characteristics in association with sepsis and septic shock, organ dysfunction, and fluid overload. Treatment remains problematic, but growing experience with pediatric continuous renal replacement therapies has improved the delivery of care in children. Increasingly, continuous renal replacement therapy is provided in combination with other extracorporeal technologies, and approaches are advancing to improve combined therapy use.

Clinical use of biomarkers for toxicant-induced acute kidney injury

Toxicant-induced acute kidney injury (ToxAKI) causes substantial morbidity and retards drug development. ToxAKI is relatively underexplored compared with ischemia–reperfusion injury in clinical biomarker studies. We highlight the rationale for novel AKI biomarkers in management of ToxAKI, and review the contemporary evidence supporting their clinical use. Directly-acting nephrotoxins, such as cisplatin, aminoglycosides, vancomycin and radiocontrast, remain widely used and highlight how novel biomarkers can either improve the detection of changes in glomerular filtration rate or directly signal cellular injury and structural damage. Serum cystatin C has already improved clinical risk prediction and drug dosing although its clinical use for early diagnosis awaits validation. The use of novel functional and structural biomarkers to stage ToxAKI and aid prognosis requires robust validation and better understanding of the relationship between biomarkers, morbidity and mortality. Biomarkers that illustrate the probable mechanisms and phase of ToxAKI may guide mechanism-specific diagnosis and therapy.

Prevention of contrast-induced AKI: a review of published trials and the design of the prevention of serious adverse events following angiography (PRESERVE) trial

Contrast-induced AKI (CI-AKI) is a common condition associated with serious, adverse outcomes. CI-AKI may be preventable because its risk factors are well characterized and the timing of renal insult is commonly known in advance. Intravenous (IV) fluids and N-acetylcysteine (NAC) are two of the most widely studied preventive measures for CI-AKI. Despite a multitude of clinical trials and meta-analyses, the most effective type of IV fluid (sodium bicarbonate versus sodium chloride) and the benefit of NAC remain unclear. Careful review of published trials of these interventions reveals design limitations that contributed to their inconclusive findings. Such design limitations include the enrollment of small numbers of patients, increasing the risk for type I and type II statistical errors; the use of surrogate primary endpoints defined by small increments in serum creatinine, which are associated with, but not necessarily causally related to serious, adverse, patient-centered outcomes; and the inclusion of low-risk patients with intact baseline kidney function, yielding low event rates and reduced generalizability to a higher-risk population. The Prevention of Serious Adverse Events following Angiography (PRESERVE) trial is a randomized, double-blind, multicenter trial that will enroll 8680 high-risk patients undergoing coronary or noncoronary angiography to compare the effectiveness of IV isotonic sodium bicarbonate versus IV isotonic sodium chloride and oral NAC versus oral placebo for the prevention of serious, adverse outcomes associated with CI-AKI. This article discusses key methodological issues of past trials investigating IV fluids and NAC and how they informed the design of the PRESERVE trial.

Protective effect of N-acetylcysteine against ischemia/reperfusion injury in rat urinary bladders

Ischemia/reperfusion (I/R) injury represents an important cause of bladder contractile dysfunction. One of the major causes leading to this dysfunction is thought to be reactive oxygen species formation. In this study, we investigated the potential benefit of N-acetylcysteine (NAC), a potent antioxidant that neutralizes free radicals, in a rat model of urinary bladder injury. NAC treatment rescues the reduction of contractile response to I/R injury in a dose-dependent manner. In addition, all levels of reactive oxygen species, lipid peroxidation, and NADPH-stimulated superoxide production in the I/R operation+NAC (I/R+NAC) group also decreased compared with a marked increase in the I/R operation+saline (I/R+S) group. Moreover, an in situ fluorohistological approach also showed that NAC reduces the generation of intracellular superoxides enlarged by I/R injury. Together, our findings suggest that NAC has a protective effect against the I/R-induced bladder contractile dysfunction via radical scavenging property.

Acetylcysteine for the prevention of renal outcomes in patients with diabetes mellitus undergoing coronary and peripheral vascular angiography: a substudy of the acetylcysteine for contrast-induced nephropathy trial

BACKGROUND

Diabetes mellitus represents an independent risk factor for contrast-induced acute kidney injury. We report the results of a prespecified substudy of patients with diabetes mellitus included in the Acetylcysteine for Contrast-Induced Nephropathy Trial (ACT), the largest randomized study evaluating the effects of acetylcysteine for the prevention of contrast-induced acute kidney injury conducted to date.

METHODS AND RESULTS

From the 2308 patients included in the ACT, 1395 had diabetes mellitus and were considered for the present analysis. The study drugs (acetylcysteine 1200 mg or matching placebo) were administered orally twice daily for 2 doses before and 2 doses after the procedure. The allocation was concealed (central Web-based randomization). Participants, healthcare staff, data collectors, and outcome assessors were blinded. All analysis followed the intention-to-treat principle. The incidence of contrast-induced acute kidney injury (primary end point) was 13.8% in the acetylcysteine group and 14.7% in the control group (relative risk 0.93; 95% confidence interval, 0.69-1.26; P=0.64). A combined end point of death or need for dialysis at 30 days was also similar in both the groups (2.2% and 2.1%, respectively; hazard ratio, 1.07; 95% confidence interval, 0.52-2.19; P=0.86).

CONCLUSIONS

In this subanalysis, acetylcysteine did not reduce the risk of contrast-induced acute kidney injury or other clinically relevant outcomes in patients with diabetes mellitus undergoing coronary and peripheral vascular angiography.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00736866.

Evaluation of Short-Term Use of N-Acetylcysteine as a Strategy for Prevention of Anthracycline-Induced Cardiomyopathy: EPOCH Trial - A Prospective Randomized Study

Background and Objectives

We investigate to determine whether N-acetylcysteine (NAC) can prevent anthracycline-induced cardiotoxicity.

Subjects and Methods

A total of 103 patients were enrolled in this prospective randomized open label controlled trial. They are patients first diagnosed with breast cancer or lymphoma, who require chemotherapy, including anthracycline like adriamycine or epirubicine. Patients were randomized to the NAC group {n=50; 1200 mg orally every 8 hours starting before and ending after the intravenous infusion of anthracycline in all chemotherapy cycles (3-6)} or the control group (n=53). Primary outcome was the decrease in left ventricular ejection fraction (LVEF) absolutely ≥10% from the baseline and concomitantly <50% at 6-month. Composite of all-cause death, heart failure and readmission were compared.

Results

The primary outcome was not significantly different in the NAC and control groups {3/47 (6.4%) vs. 1/52 (1.9%), p=0.343}. The mean LVEF significantly decreased in both the NAC (from 64.5 to 60.8%, p=0.001) and control groups (from 64.1 to 61.3%, p<0.001) after the completion of whole chemotherapy. The mean LVEF change did not differ between the two groups (-3.64% in NAC vs. -2.78% in control group, p=0.502). Left ventricular (LV) end systolic dimension increased with higher trend in NAC by 3.08±4.56 mm as compared with 1.47±1.83 mm in the control group (p=0.064). LV end diastolic dimension did not change in each group and change does not differ in both. Peak E, A and E/A ratio change and cardiac enzymes were comparable in two groups. Cumulative 12-month event rate was 6% and 3.8% in the NAC group and the control group, respectively, with no difference (p=0.672).

Conclusion

We cannot prove that NAC prevents anthracycline-induced cardiomyopathy.

The effects of N-acetylcysteine on hepatic function during isoflurane anaesthesia for laparoscopic surgery patients

Introduction:

Although most general anaesthesia procedures are performed without any complications, volatile agents may have adverse effects on various living systems. This study aims to compare the antioxidant effects of isoflurane and N-acetylcysteine (NAC) on liver function.

Methods:

Forty-one patients in the ASA I-II risk groups, who were scheduled to undergo gynaecologic laparoscopy, were randomly divided into two groups: The placebo (group P, n=21) and the NAC group (group N, n=20). In both groups, anaesthesia was maintained with 1–2% isoflurane in 50% Oxygen–50% N₂O at 6 l/min, also administered by inhalation. Venous blood samples were obtained before anaesthesia induction, and then in the postoperative 1^st hour and at the 24^th hour. The samples were centrifuged and serum levels of glutathione S-transferase (GST), malondialdehyde (MDA), aspartate amino transferase (AST), alanine amino transferase (ALT), lactate dehydrogenase (LDH), gamma glutamyltranspeptidase (GGT), prothrombin time (PT), activated partial thromboplastin time (aPTT) and international normalised ratio were determined.

Results:

GST levels were significantly higher in group N than in group P in the postoperative 1^st hour. Postoperative values of GST in the two groups were higher when compared to preoperative values (P<0.05). When postoperative levels were compared with preoperative levels, the postoperative MDA levels of group N were significantly higher (P<0.05). Levels of AST, ALT, GGT and LDH in both groups revealed significant decreases at the postoperative 1^st hour and postoperative 24^th hour compared to preoperative values (P<0.05, P<0.001). PT values were significantly higher in both groups in the postoperative 1^st hour and 24^th hour (P<0.05, P<0.001), although there were no differences in aPTT levels.

Conclusion:

Our results showed that liver functions were well preserved with administration of NAC during anaesthesia with isoflurane. Isoflurane with NAC has lesser effect on liver function tests compared to isoflurane alone.

Dopamine-1 Receptor Agonist: Renal Effects and Its Potential Role in the Management of Radiocontrast-Induced Nephropathy

Radiocontrast-induced nephropathy remains the third leading cause of hospital-acquired acute renal failure. Once established, this syndrome is associated with increased morbidity and mortality as well as increased health care costs. Recently, studies have been initiated to evaluate the potential of a selective dopamine-1 receptor agonist (fenoldopam) in ameliorating radiocontrast-induced renal failure. Selective dopamine-1 receptor agonists exhibit many desirable renal effects that support their use for the prophylaxis of radiocontrast-induced nephropathy, including decreases in renal vascular resistance and increases in renal blood flow, glomerular filtration, and sodium and water excretion. Several reports have documented a beneficial effect of fenoldopam administration in attenuating radiocontrast-induced nephropathy. In contrast, a recent multicenter, randomized study did not demonstrate a renoprotective effect of fenoldopam against radiocontrast-induced nephropathy. The presence of multiple confounders, however, precludes a definitive conclusion regarding the ability of fenoldopam to protect against radiocontrast-induced nephropathy. Additional studies are needed to properly evaluate the role of fenoldopam in radiocontrast-induced nephropathy prophylaxis.

Update on clinical trials for the prevention of acute kidney injury in patients undergoing cardiac surgery

BACKGROUND

Effective therapeutic agents for the prevention and treatment of acute kidney injury (AKI) after cardiac surgery remain elusive despite the tremendous advances in surgical techniques, technology, and understanding of disease processes. Recent developments and their effect on the incidence of AKI after cardiac surgery are discussed.

DATA SOURCES

Published clinical trials in PubMed, strength of evidence assessed by the guidelines of the American Family Physicians.

CONCLUSIONS

The definition of AKI has changed, and the focus of interventions has shifted from treatment to prevention to recovery from AKI. Antioxidants and biological agents have been added to classic armaments of hydration and diuretics in addition to tighter metabolic control to prevent AKI. Although the treatment options remain unsatisfactory, a lot of progress nevertheless continues to be made in the prevention and treatment of AKI.

Role of diuretics and lipid formulations in the prevention of amphotericin B-induced nephrotoxicity

PURPOSE

To collect available clinical data to define the role of diuretics and lipid formulations in the prevention of amphotericin B (AmB)-induced nephrotoxicity (AIN) in human populations.

METHOD

A literature search was performed in the following databases: Scopus, Medline, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews.

RESULTS AND CONCLUSION

Co-administration of mannitol failed to show any clinically significant benefit in preventing AIN. Potassium-sparing diuretics, such as amiloride and spironolactone, have been shown to have beneficial effects as an alternative or adjunct to oral/parenteral potassium supplements in preventing hypokalemia due to AmB. Lipid-based formulations of AmB are clinically effective and safe in preventing AIN. However, due to their high cost and limited accessibility, these formulations are generally used as second-line antifungal therapy in cases of conventional AmB refractoriness and/or intolerance or pre-existing renal dysfunction. The potential effects of other nephroprotective agents, such as N-acetylcysteine, AIN merit further considerations and investigations.

Intravenous N-acetylcysteine for prevention of contrast-induced nephropathy: a meta-analysis of randomized, controlled trials

Background

Contrast-induced nephropathy (CIN) is one of the common causes of acute renal insufficiency after contrast procedures. Whether intravenous N-acetylcysteine (NAC) is beneficial for the prevention of contrast-induced nephropathy is uncertain. In this meta-analysis of randomized controlled trials, we aimed to assess the efficacy of intravenous NAC for preventing CIN after administration of intravenous contrast media.

Study Design

Relevant studies published up to September 2012 that investigated the efficacy of intravenous N-acetylcysteine for preventing CIN were collected from MEDLINE, OVID, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, and the conference proceedings from major cardiology and nephrology meetings. The primary outcome was CIN. Secondary outcomes included renal failure requiring dialysis, mortality, and length of hospitalization. Data were combined using random-effects models with the performance of standard tests to assess for heterogeneity and publication bias. Meta-regression analyses were also performed.

Results

Ten trials involving 1916 patients met our inclusion criteria. Trials varied in patient demographic characteristics, inclusion criteria, dosing regimens, and trial quality. The summary risk ratio for contrast-induced nephropathy was 0.68 (95% CI, 0.46 to 1.02), a nonsignificant trend towards benefit in patients treated with intravenous NAC. There was evidence of significant heterogeneity in NAC effect across studies (Q = 17.42, P = 0.04; I² = 48%). Meta-regression revealed no significant relation between the relative risk of CIN and identified differences in participant or study characteristics.

Conclusion

This meta-analysis showed that research on intravenous N-acetylcysteine and the incidence of CIN is too inconsistent at present to warrant a conclusion on efficacy. A large, well designed trial that incorporates the evaluation of clinically relevant outcomes in participants with different underlying risks of CIN is required to more adequately assess the role for intravenous NAC in CIN prevention.

Risk of contrast induced nephropathy in the critically ill: a prospective, case matched study

Introduction

Computerized tomography is frequently employed in the critically ill, often using intravenous radiocontrast material. Many of these patients have clinical features that are considered risk factors for contrast induced nephropathy, but are simultaneously at risk for renal injury from other factors related to their acute illnesses. The attributable risk for renal dysfunction from radiocontrast exposure has not been well quantified in this population.

Methods

A prospective matched cohort study was conducted of patients scanned with or without radiocontrast enhancement while receiving intensive care in a Veterans Affairs Medical Center. Patients were matched for pre-scan measured creatinine clearance, diabetes, mechanical ventilation, and vasopressor use. Measured clearance was followed for three days after scanning. Evolution of nephropathy, as determined by change in measured clearance, was compared within matched pairs.

Results

Fifty-three pairs of patients satisfied matching criteria. Unmatched characteristics were similar among the pairs, including serum creatinine variability during the week preceding scanning (67 ± 85% among contrast recipients, 63 ± 62% among others) and clinical risk factors for renal failure. In 29 pairs, pre-scan measured clearances were less than 60 mL/minute/1.73 m². Following scanning, measured clearance declined by at least 33% in 14 contrast and 19 non-contrast patients (95% confidence interval for contrast associated difference in nephropathy rates -27% to 9%), while a 50% reduction in clearance persisted three days after scanning in three contrast and nine non-contrast patients (95% confidence interval for difference in rates -25% to 2%).

Conclusions

Among established intensive care unit patients declines in glomerular filtration following contrast-enhanced scanning are common, but these changes are far more likely to be attributable to factors other than the contrast exposure itself. The upper bound for the incidence of contrast induced renal injury lasting even three days was 2% in the population studied.

Antioxidant treatment prevents cognitive impairment and oxidative damage in pneumococcal meningitis survivor rats

Pneumococcal meningitis is associated with the highest fatality case ratios in the world. Most of patients that survive present neurologic sequelae at later times as well as biochemicals alterations such as oxidative stress in both earlier and later times after central nervous system infection. In this context, we evaluated the effect of antioxidant treatment on memory and oxidative parameters in the hippocampus of meningitis survivor rats 10 days after infection. To this aim, the animals underwent a magna cistern tap receiving either 10 μL sterile saline as a placebo or an equivalent volume of a Streptococcus pneumoniae suspension at the concentration 5x10(9) cfu/mL. The animals submitted to meningitis were divided into the following groups: 1) treated with antibiotic, 2) treated with basic support plus N-acetylcysteine, 3) treated with basic support plus deferoxamine, 4) treated with basic support plus N-acetylcysteine and deferoxamine, or 5) treated with N-acetylcysteine plus deferoxamine. Ten days after meningitis, the animals underwent inhibitory avoidance and habituation to an open field tasks and, immediately after, were assessed for oxidative damage in the hippocampus and cortex. The meningitis group showed significantly decreased performance in latency retention compared with the sham group in the inhibitory avoidance task. In the open-field task, the meningitis group presented memory impairment after meningitis. All these memory impairments were prevented by N-acetylcysteine plus deferoxamine with or without basic support and its isolate use. In addition, there was an increase of lipid phosphorylation in cortex and hippocampus and all the combined antioxidants attenuated lipid phosphorylation in both structures. On the other hand, there was an increase of protein phosphorylation in cortex and N-acetylcysteine plus deferoxamine with or without basic support prevented it. Thus, we hypothesize that oxidative stress may be related to cognitive impairment in pneumococcal meningitis.

The Role of N--Acetylcysteine in the Prevention of Contrast-Induced Nephropathy in Patients Undergoing Peripheral Angiography

Contrast-induced nephropathy (CIN) is a leading cause of hospital-acquired acute kidney injury (AKI). N-acetylcysteine (NAC) was proposed as an effective preventative measure. As data in relation to the use of NAC for the prevention of CIN in peripheral angiography are lacking, a systematic review and meta-analysis were undertaken. A comprehensive search for the published and unpublished data was performed. Data were extracted from the eligible studies. Pooled odds ratios (ORs) were used to calculate the effect of NAC on CIN incidence. Pooled effect size estimates were used to calculate the effect of NAC on serum creatinine (SCr) postcontrast. Our results showed that NAC did not reduce CIN incidence (pooled OR 1.05; 95% confidence interval [CI] 0.38-2.88; P = .92) or the mean SCr levels (pooled weighted mean difference, 4.38; 95% CI 10.4-1.65; P = .15). In conclusion, insufficient evidence exists to recommend NAC for the prevention of CIN in patients undergoing peripheral angiography.

Is cardiac CT a reproducible alternative for cardiac MR in adult patients with a systemic right ventricle?

OBJECTIVE

20 % of patients with a systemic RV are pacemaker dependent, and unsuitable to undergo cardiac magnetic resonance (CMR). Multidetector row computed tomography (MDCT) could provide a reproducible alternative to CMR in these patients. The aim of this study was to compare variability of MDCT with CMR.

METHODS

Thirty-five patients with systemic RV underwent either MDCT (n = 15) or CMR (n = 20). Systemic RV volumes and ejection fraction were obtained, and intra- and interobserver variability for both modalities were assessed and compared.

RESULTS

We found the intra- and interobserver variability of volumes and function measurements of the systemic RV obtained with MDCT to be higher compared with those obtained with CMR. However, these differences in variability were not significant, the only exception being the interobserver variability of systemic RV stroke volume.

CONCLUSIONS

MDCT provides a reproducible alternative to CMR for volumes and function assessment in patients with a systemic RV.

Role of contrast media on oxidative stress, Ca(2+) signaling and apoptosis in kidney

Contrast media (CM)-induced nephropathy is a common cause of iatrogenic acute renal failure. The aim of the present review was to discuss the mechanisms and risk factors of CM, to summarize the controlled studies evaluating measures for prevention and to conclude with evidence-based strategies for prevention. A review of the relevant literature and results from recent clinical studies as well as critical analyses of published systematic reviews used MEDLINE and the Science Citation Index. The cytotoxicity induced by CM leads to apoptosis and death of endothelial and tubular cells and may be initiated by cell membrane damage together with reactive oxygen species (ROS) and inflammation. Cell damage may be aggravated by factors such as tissue hypoxia, properties of individual CM such as ionic strength, high osmolarity and/or viscosity. Clinical studies indeed support this possibility, suggesting a protective effect of ROS scavenging with the administration of N-acetylcysteine, ascorbic acid erdosteine, glutathione and bicarbonate infusion. The interaction between extracellular Ca(2+), which plays a central role in intercellular contacts and production of ROS, and the in vitro toxicity of CM was also reviewed. The current review addresses the role of oxidative stress in the pathogenesis of CM in the kidney as well as current and potential novel treatment modalities for the prevention of neutrophil activation and CM-induced kidney degeneration in patients. ROS production through CM-induced renal hypoxia may exert direct tubular and vascular endothelial injury. Preventive strategies via antioxidant supplementation include inhibition of ROS generation or scavenging.

Involvement of caspase-12-dependent apoptotic pathway in ionic radiocontrast urografin-induced renal tubular cell injury

Contrast medium (CM) induces a direct toxic effect on renal tubular cells. This toxic effect subjects in the disorder of CM-induced nephropathy. Our previous work has demonstrated that CM shows to activate the endoplasmic reticulum (ER)-related adaptive unfolding protein response (UPR) activators. Glucose-regulated protein 78 (GRP78)/eukaryotic initiation factor 2α (eIF2α)-related pathways play a protective role during the urografin (an ionic CM)-induced renal tubular injury. However, the involvement of ER stress-related apoptotic signals in the urografin-induced renal tubular cell injury remains unclear. Here, we examined by the in vivo and in vitro experiments to explore whether ER stress-regulated pro-apoptotic activators participate in urografin-induced renal injury. Urografin induced renal tubular dilation, tubular cells detachment, and necrosis in the kidneys of rats. The tubular apoptosis, ER stress-related pro-apoptotic transcriptional factors, and kidney injury marker-1 (kim-1) were also conspicuously up-regulated in urografin-treated rats. Furthermore, treatment of normal rat kidney (NRK)-52E tubular cells with urografin augmented the expressions of activating transcription factor-6 (ATF-6), C/EBP homologous protein (CHOP), Bax, caspase-12, JNK, and inositol-requiring enzyme (IRE) 1 signals. Urografin-induced renal tubular cell apoptosis was not reversed by the inhibitors of ATF-6, JNK signals or CHOP siRNA transfection, but it could be partially reversed by the inhibitor of caspase-12. Taken together, the present results and our previous findings suggest that exposure of CM/urografin activates the ER stress-regulated survival- and apoptosis-related signaling pathways in renal tubular cells. Caspase-12-dependent apoptotic pathway may be partially involved in the urografin-induced nephropathy.

Contrast-induced nephropathy: nursing implications

Contrast-induced nephropathy is a major adverse event that occurs during studies that require contrast medium. Almost 10% of all hospital-acquired instances of renal insufficiency are directly attributed to contrast material, with significantly higher mortality and morbidity than cases that do not involve contrast material. Contrast material causes an acceleration of the renal vasoconstrictive response, which results in a cascade of events that affect the vasoregulatory system. Multiple prophylactic measures must be instituted when considering a patient for a contrast study. Critical care nurses are pivotal in identifying patients' risk factors and potential nephrotoxic agents in order to avoid contrast-induced nephropathy. This article outlines the pathophysiology and definitions of normal kidney function, nephropathy, and chronic kidney disease.

Prevention and management of contrast-induced acute kidney injury

OPINION STATEMENT

Contrast-induced acute kidney injury (AKI) is an important complication associated with coronary angiography, percutaneous coronary intervention, and computed tomography studies. The increasing utilization of contrast agents for imaging makes the importance of this complication even greater. Patients can be risk stratified for the risk of contrast-induced AKI by several clinical factors including hypotension, renal function, age, advanced heart failure, anemia, and diabetes mellitus. Contrast volume is also an important and modifiable risk factor for AKI. For the prevention of contrast-induced AKI, multiple approaches have been tried. The most effective prevention strategy is hydration. Normal saline has been the standard, but other options such as sodium bicarbonate may be a reasonable alternative. Further studies will be required to clarify the best preventive strategies.

Renal management in the critically ill patient

Acute kidney injury is common in the hospital setting and morbidity and mortality outcomes depend on early recognition and early intervention. Identifying patients at risk of acute kidney injury is critical in prevention, early identification, and appropriate treatment.

Protective effect of N-acetylcysteine on kidney as a remote organ after skeletal muscle ischemia-reperfusion

PURPOSE: To investigate whether N-acetylcysteine has a protective effect against renal injury as a remote organ after skeletal muscle ischemia-reperfusion in rats. METHODS: Twenty Wistar male rats were divided randomly into two experimental groups: group ischemia-reperfusion (group I) and group ischemia-reperfusion + N-acetylcysteine (group II). After ketamine and xylazine anesthesia, femoral artery was exposed. All animals were undergone 2h of ischemia by occlusion femoral artery and 24h of reperfusion. Rats that were treated with N-acetylcysteine given IV at a dose of 150 mg/kg-¹, immediately before reperfusion. After 24h of reperfusion, the blood samples were collected and submitted for evaluation of plasmatic urea, creatinine values and then rats were euthanized and left kidney harvested for histopathological analysis under light microscopy. RESULTS: The urea (35±7.84 mg.dL-1), creatinine (1.46±0.47 mg.dL-1) values were significantly lower in group II (P=0.000). Renal histopathologic study in group I showed extensive distal and proximal tubular cells necrosis and sloughing of epithelial cells into the tubular lumen, cast formation in tubule and glomerul, glomerul fibrosis and hemorrhage. Histopathologically, there was a significant difference (p=0.037) between two groups. CONCLUSION: The N-acetylcysteine was able to decrease renal injury induced by skeletal muscle ischemia reperfusion in rats.

Prevention of contrast-induced nephropathy: A randomized controlled trial of sodium bicarbonate and N-acetylcysteine

BACKGROUND

Contrast-induced nephropathy (CIN) continues to be a common cause of acute renal failure in high-risk patients undergoing radiocontrast studies. However, there is still a lack of consensus regarding the most effective measures to prevent CIN.

METHODS

ONE HUNDRED EIGHTEEN PATIENTS WITH DIABETES MELLITUS AND/OR RENAL INSUFFICIENCY, SCHEDULED FOR CORONARY ANGIOGRAPHY OR INTERVENTION, WERE RANDOMLY ASSIGNED TO ONE OF FOUR TREATMENT GROUPS: intravenous (IV) 0.9% NaCl alone, IV 0.9% NaCl plus N-acetylcysteine (NAC), IV 0.9% sodium bicarbonate (NaHCO(3)) alone or IV 0.9% NaHCO(3) plus NAC. All patients received IV hydration as a preprocedure bolus and as maintenance. Iso-osmolar contrast was used in all patients. CIN was defined as an increase of greater than 25% in the serum creatinine concentration from baseline to 72 h.

RESULTS

The overall incidence of CIN was 6%. There was no statistically significant difference in the incidence of CIN among the groups. There was a CIN incidence of 7% in the NaCl only group, 5% in the NaCl/NAC group, 11% in the NaHCO(3) only group and 4% in the NaHCO(3)/NAC group (P=0.86). The maximum increase in serum creatinine was 14.14±12.38 μmol/L in the NaHCO(3) group, 10.60±29.14 μmol/L in the NaCl only group, 9.72±13.26 μmol/L in the NaCl/NAC group and 0.177±15.91 μmol/L for the NaHCO(3)/NAC group (P=0.0792).

CONCLUSION

CIN in high-risk patients may be effectively minimized solely through the use of an aggressive hydration protocol and an iso-osmolar contrast agent. The addition of NaHCO(3) and/or NAC did not have an effect on the incidence of CIN.

Prevention of Contrast-Induced Nephropathy (CIN) in Interventional Radiology Practice

Contrast-induced nephropathy (CIN) is a widely recognized and clinically significant problem in patients undergoing an increasing number of minimally invasive procedures that require contrast administration. Contrast-induced nephropathy is the third most common cause of hospital-acquired renal failure and has significant prognostic implications on patient outcomes. Interventional practitioners are faced with challenging decisions regarding prophylaxis and patient management. The major risk factor for developing CIN is preexisting renal dysfunction, particularly in association with diabetes. Patients are considered to be at risk when estimated glomerular filtration rate (eGFR) or estimated creatinine clearance (eC(Cr)) is less than 60. The cornerstone of prevention of CIN is appropriate risk stratification, intravenous hydration with normal saline or sodium bicarbonate, appropriate withholding of nephrotoxic medications, use of low or iso-osmolar contrast media, and various intraprocedural methods for iodinated contrast dose reduction. Although N-acetylcysteine administration is popular, it remains unproven. Practitioners must be familiar with prevention strategies and diagnosis of CIN to minimize its clinical impact.

Acute kidney injury and the critically ill patient

Acute kidney injury (AKI) is a serious complication for the critically ill patient. The term has been increasingly adopted over recent years as efforts have been made to capture and better define mild to severe renal dysfunction. Persistent AKI can lead to the subsequent development of renal failure recognized as an important determinant of morbidity and mortality in the critically ill patient. This article explores the clinical implications of AKI for the critically ill patient and how this can have a profound influence on the principal presenting disease and expected outcome.

N-acetylcysteine protects rats with chronic renal failure from gadolinium-chelate nephrotoxicity

The aim of this study was to evaluate the effect of Gd-chelate on renal function, iron parameters and oxidative stress in rats with CRF and a possible protective effect of the antioxidant N-Acetylcysteine (NAC). Male Wistar rats were submitted to 5/6 nephrectomy (Nx) to induced CRF. An ionic-cyclic Gd (Gadoterate Meglumine) was administrated (1.5 mM/KgBW, intravenously) 21 days after Nx. Clearance studies were performed in 4 groups of anesthetized animals 48 hours following Gd- chelate administration: 1--Nx (n = 7); 2--Nx+NAC (n = 6); 3--Nx+Gd (n = 7); 4--Nx+NAC+Gd (4.8 g/L in drinking water), initiated 2 days before Gd-chelate administration and maintained during 4 days (n = 6). This group was compared with a control. We measured glomerular filtration rate, GFR (inulin clearance, ml/min/kg BW), proteinuria (mg/24 hs), serum iron (µg/dL); serum ferritin (ng/mL); transferrin saturation (%), TIBC (µg/dL) and TBARS (nmles/ml). Normal rats treated with the same dose of Gd-chelate presented similar GFR and proteinuria when compared with normal controls, indicating that at this dose Gd-chelate is not nephrotoxic to normal rats. Gd-chelate administration to Nx-rats results in a decrease of GFR and increased proteinuria associated with a decrease in TIBC, elevation of ferritin serum levels, transferrin oversaturation and plasmatic TBARS compared with Nx-rats. The prophylactic treatment with NAC reversed the decrease in GFR and the increase in proteinuria and all alterations in iron parameters and TBARS induced by Gd-chelate. NAC administration to Nx rat did not modify the inulin clearance and iron kinetics, indicating that the ameliorating effect of NAC was specific to Gd-chelate. These results suggest that NAC can prevent Gd-chelate nephrotoxicity in patients with chronic renal failure.

Effect of N-acetyl cysteine in prevention of contrast nephropathy on patients under intravenous pyelography and contrast CT

Background:

Contrast nephropathy is a common and often reversible cause of acute renal failure (ARF). About 10% of ARF in admitted patients might be due to it and may also lead to dialysis. Some methods could prevent it such as fluid therapy with half or normal saline, Na bicarbonate, N-acetyl cysteine (NAC), and so on. The aim of this study was to evaluate the efficacy of NAC to prevent contrast nephropathy.

Materials and Methods:

In a cross-sectional study, 110 patients who were candidate for intravenous pyelography (IVP) or CT scan enrolled in two groups: Case and control. In patients of case group, meglumine compound and in control group, placebo was prescribed before procedure. Before study and after 48 h, blood urea nitrogen (BUN) and creatinine (Cr) was checked, and glomerular filtration rate (GFR) was measured with Cockcroft-Gault formula.

Results:

There were no difference between age and gender of two groups. There was also no significant difference between mean Cr before and after study; however, GFR of patients in case group was significantly higher than the control group after 48 h of procedure.

Conclusion:

Because GFR was higher in case group and there were no drug side-effects in patients, we recommend the use of NAC before administration of intravenous contrast especially in high-risk population such as diabetic patients.

Systolic blood pressure reduction and risk of acute renal injury in patients with intracerebral hemorrhage

BACKGROUND

Aggressive systolic blood pressure reduction may precipitate acute renal injury because of underlying hypertensive nephropathy in patients with intracerebral hemorrhage. The study's objective was to determine the rate and determinants of acute renal injury during acute hospitalization among subjects with intracerebral hemorrhage using a post hoc analysis of a multicenter prospective study.

METHODS

Subjects with intracerebral hemorrhage and elevated systolic blood pressure of 170 mm Hg or greater who presented within 6 hours of symptom onset and underwent treatment of acute hypertensive response and fluid management as per study and local protocols, respectively. Acute renal injury was defined post hoc using the criteria used in Acute Kidney Injury Network classifications within 72 hours of admission. Descriptive statistics and standard statistical tests were used to characterize and evaluate the effect of systolic blood pressure reduction parameters (relative to initial systolic blood pressure) and average maximum hourly dose of nicardipine on the occurrence of acute renal injury.

RESULTS

A total of 60 subjects were recruited (57% were men; mean age of 62.0 ± 15.1 years). Five subjects (9%) had stage I acute renal injury according to the Acute Kidney Injury Network criteria. None of the subjects had stage II or III acute renal injury. The serum creatinine course for the first 3 days suggested that the peak elevation of creatinine was seen at 18, 30, 57, 58, and 71 hours after baseline measurements in these 5 subjects, all of which except for the first one were beyond the protocol-specified treatment period. The incidences of neurologic deterioration and symptomatic hematoma expansion were significantly greater in the subjects with stage I renal impairment. The systolic blood pressure reduction parameters (in particular, the area under the curve depicting the 24-hour systolic blood pressure summary statistic) and the higher average maximum hourly nicardipine dose were strongly associated with stage I renal impairment.

CONCLUSIONS

Although acute renal injury is infrequent and mild among subjects with intracerebral hemorrhage undergoing systolic blood pressure reduction, a trend in association between systolic blood pressure reduction and renal impairment was observed in this small study. Therefore, it is important to carefully monitor the renal function when administering treatment to reduce systolic blood pressure in patients with intracerebral hemorrhage.

How to reduce nephropathy following contrast-enhanced CT: a lesson in policy implementation

In excess of 50 contrast-enhanced computed tomography (CT) examinations are typically undertaken in our tertiary hospital NHS Trust each weekday, approximately 13,000 each year. In the Department of Radiology alone, we inject more than 1300 l of iodinated contrast medium per annum. There is a real need to devise a policy to anticipate contrast medium-induced nephropathy (CIN) and minimize its effects, without disrupting the high-intensity CT service. Having written a comprehensive yet pragmatic policy to reduce the incidence of this iatrogenic condition, it seemed sensible to share it with the wider radiology community and share the experience and lessons learnt in engaging all the stakeholders, ushering in the change with as little fuss as possible. The ramifications on primary and secondary care had to be anticipated, resource implications managed, and staff trained. This review is therefore presented in four sections: framing the problem, assessing its size and nature; a succeeding section on the available guidelines and their uptake; the policy itself to reduce CIN in CT is presented in the third section; and crucially, a description of the policy introduction process in the last section.

N-acetylcysteine use for amelioration of aminoglycoside-induced ototoxicity in dialysis patients

Use of aminoglycoside antibiotics is associated with significant ototoxicity, especially on patients with decreased renal function. The risk of aminoglycoside ototoxicity may approach 60%. Oxidative stress has been suggested as a general mechanism of aminoglycoside ototoxicity and is prevalent in dialysis population. N-acetylcysteine (NAC) is an effective antioxidant and has been safely used in dialysis patients. New experimental and clinical data, explored in this review, provide a good case to recommend NAC administration to all dialysis patients, receiving aminoglycosides.