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Koh A, Wong T, Adiamah A, Sanyal S. Systematic review and meta-analysis of the effect of N-acetylcysteine on outcomes after liver resection. ANZ J Surg 2024. [PMID: 39101362 DOI: 10.1111/ans.19183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/13/2024] [Accepted: 07/17/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND N-Acetylcysteine (NAC) is a recognized antioxidative agent that facilitates the conjugation of toxic metabolites. In recent years, NAC has been routinely used to limit ischaemia-reperfusion injury in liver transplantation. There remains, however, contradictory evidence on its effectiveness in liver resection. This meta-analysis examines the effectiveness of NAC in improving outcomes following hepatectomy. METHODS A comprehensive search of the MEDLINE, EMBASE, and Cochrane databases was performed to identify relevant randomized controlled trials (RCTs) published since database inception until November 2023. The outcomes of Day 1 biochemical markers (lactate, ALT, bilirubin, and INR), length of stay, transfusion rates, and morbidity were extracted. Quantitative pooling of data was based on a random-effects model. The study protocol was registered on PROSPERO (Registration no: CRD42023442429). RESULTS Five RCTs reporting on 388 patients undergoing hepatectomy were included in the analysis. There were no significant differences in patient demographics between groups. Post-operative lactate was lower in patients receiving NAC (WMD -0.61, 95% CI -1.19 to -0.04, I2 = 67%). There were, however, no differences in the post-operative INR (WMD -0.04, 95% CI -0.19 to 0.12, I2 = 96%) and ALT (WMD -94.94, 95% CI -228.46 to 40.38; I2 = 67%). More importantly, there were no statistically significant differences in length of stay, transfusion rates, and morbidity between the two groups. CONCLUSION The administration of NAC in liver resection did not alter important biochemical parameters suggesting any real effectiveness in reducing hepatic dysfunction. There were no improvements in the clinical outcomes of length of stay, transfusion rates, and overall morbidity.
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Affiliation(s)
- Amanda Koh
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Tiffany Wong
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Sudip Sanyal
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Dong H, Li H, Fang L, Zhang A, Liu X, Xue F, Chen Y, Liu W, Chi Y, Wang W, Sun T, Ju M, Dai X, Yang R, Fu R, Zhang L. Increased reactive oxygen species lead to overactivation of platelets in essential thrombocythemia. Thromb Res 2023; 226:18-29. [PMID: 37087805 DOI: 10.1016/j.thromres.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Platelet function, rather than platelet count, plays a crucial role in thrombosis in essential thrombocythemia (ET). However, little is known about the abnormal function of platelets in ET. Here, we investigated the functional characteristics of platelets in ET hemostasis to explore the causes of ET platelet dysfunction and new therapeutic strategies for ET. MATERIALS AND METHODS We analyzed platelet aggregation, activation, apoptosis, and reactive oxygen species (ROS) in ET patients and JAK2V617F-positive ET-like mice. The effects of ROS on platelet function and the underlying mechanism were investigated by inhibiting ROS using N-acetylcysteine (NAC). RESULTS Platelet aggregation, activation, apoptosis, ROS, and clot retraction were elevated in ET. No significant differences were observed between ET patients with JAK2V617F or CALR mutations. Increased ROS activated the JAK-STAT pathway, which may further influence platelet function. Inhibition of platelet ROS by NAC reduced platelet aggregation, activation, and apoptosis, and prolonged bleeding time. Furthermore, NAC treatment reduced platelet count in ET-like mice by inhibiting platelet production from megakaryocytes. CONCLUSIONS Elevated ROS in ET platelets resulted in enhanced platelet activation, function and increased risk of thrombosis. NAC offers a potential therapeutic strategy for reducing platelet count.
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Affiliation(s)
- Huan Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Huiyuan Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Lijun Fang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Anqi Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Ying Chi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Wentian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China.
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China; Tianjin Institutes of Health Science, Tianjin 301600, China.
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Khan SA, Campbell AM, Lu Y, An L, Alpert JS, Chen QM. N-Acetylcysteine for Cardiac Protection During Coronary Artery Reperfusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Cardiovasc Med 2021; 8:752939. [PMID: 34869660 PMCID: PMC8640098 DOI: 10.3389/fcvm.2021.752939] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022] Open
Abstract
Coronary artery reperfusion is essential for the management of symptoms in the patients with myocardial ischemia. However, the benefit of reperfusion often comes at an expense of paradoxical injury, which contributes to the adverse events, and sometimes heart failure. Reperfusion is known to increase the production of reactive oxygen species (ROS). We address whether N-acetylcysteine (NAC) reduces the ROS and alleviates reperfusion injury by improving the clinical outcomes. A literature search for the randomized controlled trials (RCTs) was carried out in the five biomedical databases for testing the effects of NAC in patients undergoing coronary artery reperfusion by percutaneous coronary intervention, thrombolysis, or coronary artery bypass graft. Of 787 publications reviewed, 28 RCTs were identified, with a summary of 2,174 patients. A meta-analysis using the random effects model indicated that NAC administration during or prior to the reperfusion procedures resulted in a trend toward a reduction in the level of serum cardiac troponin (cTn) [95% CI, standardized mean difference (SMD) −0.80 (−1.75; 0.15), p = 0.088, n = 262 for control, 277 for NAC group], and in the incidence of postoperative atrial fibrillation [95% CI, relative risk (RR) 0.57 (0.30; 1.06), p = 0.071, n = 484 for control, 490 for NAC group]. The left ventricular ejection fraction or the measures of length of stay in intensive care unit (ICU) or in hospital displayed a positive trend that was not statistically significant. Among the nine trials that measured ROS, seven showed a correlation between the reduction of lipid peroxidation and improved clinical outcomes. These lines of evidence support the potential benefit of NAC as an adjuvant therapy for cardiac protection against reperfusion injury.
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Affiliation(s)
- Sher Ali Khan
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Ashley M Campbell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Yingying Lu
- Graduate Interdisciplinary Program in Statistics and Data Science, University of Arizona, Tucson, AZ, United States
| | - Lingling An
- Department of Biosystems Engineering, College of Agriculture and Life Sciences, University of Arizona, Tucson, AZ, United States.,Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | - Joseph S Alpert
- Department of Medicine and the Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Qin M Chen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, United States
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Gomez-Aparicio LS, Bernáldez-Sarabia J, Camacho-Villegas TA, Lugo-Fabres PH, Díaz-Martínez NE, Padilla-Camberos E, Licea-Navarro A, Castro-Ceseña AB. Improvement of the wound healing properties of hydrogels with N-acetylcysteine through their modification with methacrylate-containing polymers. Biomater Sci 2021; 9:726-744. [PMID: 33179647 DOI: 10.1039/d0bm01479f] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hydrogels with antioxidant activity have shown to significantly improve the standard of care, because they promote efficient wound healing, i.e. regeneration. N-Acetylcysteine (NAC) is an antioxidant amino acid derivative that promotes complete tissue restoration. However, NAC has anticoagulant properties that may also hinder blood coagulation, which is crucial for hydrogels for wound healing applications. To take advantage of the regenerative activity of NAC while avoiding hampering the hemostasis stage during wound healing, we modified gelatin-NAC with the methacrylate-containing polymers 2-hydroxyethyl methacrylate (H) and poly(ethylene glycol) methyl ether methacrylate (P) to produce Gel-HP-NAC. These hydrogels clotted more blood and faster than Gel and Gel-NAC hydrogels, while maintaining fluid absorption properties adequate to promote wound healing. Similarly, there were more viable human skin fibroblasts after 10 days cultured in Gel-HP-NAC compared with Gel and Gel-NAC. A mouse full-thickness skin wound model demonstrated that Gel-HP-NAC hydrogels improved the wound healing process as compared to the untreated group as proved by the increased wound closure rates and re-epithelialization. Histology of the biopsied tissues indicated more organized collagen deposits on the wounds treated with either Gel-HP-NAC or Gel-NAC than untreated wounds. Our results show that modification of NAC-containing hydrogels through methacrylate-containing polymers improved their wound healing properties, including blood-clotting, and demonstrate the potential of Gel-HP-NAC hydrogels for wound treatment and tissue regeneration.
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Affiliation(s)
- Lesly S Gomez-Aparicio
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico.
| | - Johanna Bernáldez-Sarabia
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico.
| | - Tanya A Camacho-Villegas
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico and CONACYT-Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Pavel H Lugo-Fabres
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico and CONACYT-Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Néstor Emmanuel Díaz-Martínez
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Eduardo Padilla-Camberos
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Alexei Licea-Navarro
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico.
| | - Ana B Castro-Ceseña
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico. and CONACYT- Departamento de Innovación Biomédica, Centro de Investigación Científica de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico
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Pereira JEG, El Dib R, Braz LG, Escudero J, Hayes J, Johnston BC. N-acetylcysteine use among patients undergoing cardiac surgery: A systematic review and meta-analysis of randomized trials. PLoS One 2019; 14:e0213862. [PMID: 31071081 PMCID: PMC6508704 DOI: 10.1371/journal.pone.0213862] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/01/2019] [Indexed: 12/13/2022] Open
Abstract
Background Cardiac surgeries are complex procedures aiming to re-establish coronary flow and correct valvular defects. Oxidative stress, caused by inflammation and ischemia-reperfusion injury, is associated with these procedures, increasing the risk of adverse outcomes. N-acetylcysteine (NAC) acts as an antioxidant by replenishing the glutathione stores, and emerging evidence suggests that NAC may reduce the risk of adverse perioperative outcomes. We conducted a systematic review and meta-analysis to investigate the addition of NAC to a standard of care among adult patients undergoing cardiac surgery. Methods We searched four databases (PubMed, EMBASE, CENTRAL, LILACS) from inception to October 2018 and the grey literaure for randomized controlled trials (RCTs) investigating the effect of NAC on pre-defined outcomes including mortality, acute renal insufficiency (ARI), acute cardiac insufficiency (ACI), hospital length of stay (HLoS), intensive care unit length of stay (ICULoS), arrhythmia and acute myocardial infarction (AMI). Reviewers independently screened potentially eligible articles, extracted data and assessed the risk of bias among eligible articles. We used the GRADE approach to rate the overall certainty of evidence for each outcome. Results Twenty-nine RCTs including 2,486 participants proved eligible. Low to moderate certainty evidence demonstrated that the addition of NAC resulted in a non-statistically significant reduction in mortality (Risk Ratio (RR) 0.71; 95% Confidence Interval (CI) 0.40 to 1.25), ARI (RR 0.92; 95% CI 0.79 to 1.09), ACI (RR 0.77; 95% CI 0.44 to 1.38), HLoS (Mean Difference (MD) 0.21; 95% CI -0.64 to 0.23), ICULoS (MD -0.04; 95% CI -0.29 to 0.20), arrhythmia (RR 0.79; 95% CI 0.52 to 1.20), and AMI (RR 0.84; 95% CI 0.48 to 1.48). Limitations Among eligible trials, we observed heterogeneity in the population and interventions including patients with and without kidney dysfunction and interventions that differed in route of administration, dosage, and duration of treatment. This observed heterogeneity was not explained by our subgroup analyses. Conclusions The addition of NAC during cardiac surgery did not result in a statistically significant reduction in clinical outcomes. A large randomized placebo-controlled multi-centre trial is needed to determine whether NAC reduces mortality. Registration PROSPERO CRD42018091191.
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Affiliation(s)
- José Eduardo G. Pereira
- Department of Anesthesiology, Botucatu Medical School, Universidade Estadual Paulista, Botucatu, São Paulo, São Paulo, Brazil
- Department of Anesthesiology, EsSEx, Hospital Central do Exército, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Anesthesiology, Santa Casa de Misericórdia de Barra Mansa, Barra Mansa, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Regina El Dib
- Department of Community Health and Epidemiology, Dalhousie University, Faculty of Medicine, Halifax, Canada
- Institute of Science and Technology, Univ Estadual Paulista, São Paulo, São José dos Campos, Brazil
- McMaster Institute of Urology, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - Leandro G. Braz
- Department of Anesthesiology, Botucatu Medical School, Universidade Estadual Paulista, Botucatu, São Paulo, São Paulo, Brazil
| | - Janaina Escudero
- Institute of Science and Technology, Univ Estadual Paulista, São Paulo, São José dos Campos, Brazil
| | - Jason Hayes
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bradley C. Johnston
- Department of Community Health and Epidemiology, Dalhousie University, Faculty of Medicine, Halifax, Canada
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Hobson C, Lysak N, Huber M, Scali S, Bihorac A. Epidemiology, outcomes, and management of acute kidney injury in the vascular surgery patient. J Vasc Surg 2018; 68:916-928. [PMID: 30146038 PMCID: PMC6236681 DOI: 10.1016/j.jvs.2018.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 05/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Conventional clinical wisdom has often been nihilistic regarding the prevention and management of acute kidney injury (AKI), despite its being a frequent and morbid complication associated with both increased mortality and cost. Recent developments have shown that AKI is not inevitable and that changes in management of patients can reduce both the incidence and morbidity of perioperative AKI. The purpose of this narrative review was to review the epidemiology and outcomes of AKI in patients undergoing vascular surgery using current consensus definitions, to discuss some of the novel emerging risk stratification and prevention techniques relevant to the vascular surgery patient, and to describe a standardized perioperative pathway for the prevention of AKI after vascular surgery. METHODS We performed a critical review of the literature on AKI in the vascular surgery patient using the PubMed and MEDLINE databases and Google Scholar through September 2017 using web-based search engines. We also searched the guidelines and publications available online from the organizations Kidney Disease: Improving Global Outcomes and the Acute Dialysis Quality Initiative. The search terms used included acute kidney injury, AKI, epidemiology, outcomes, prevention, therapy, and treatment. RESULTS The reported epidemiology and outcomes associated with AKI have been evolving since the publication of consensus criteria that allow accurate identification of mild and moderate AKI. The incidence of AKI after major vascular surgery using current criteria is as high as 49%, although there are significant differences, depending on the type of procedure performed. Many tools have become available to assess and to stratify the risk for AKI and to use that information to prevent AKI in the surgical patient. We describe a standardized clinical assessment and management pathway for vascular surgery patients, incorporating current risk assessment and preventive strategies to prevent AKI and to decrease its complications. Patients without any risk factors can be managed in a perioperative fast-track pathway. Those patients with positive risk factors are tested for kidney stress using the urinary biomarker TIMP-2•IGFBP7, and care is then stratified according to the result. Management follows current Kidney Disease: Improving Global Outcomes guidelines. CONCLUSIONS AKI is a common postoperative complication among vascular surgery patients and has a significant impact on morbidity, mortality, and cost. Preoperative risk assessment and optimal perioperative management guided by that risk assessment can minimize the consequences associated with postoperative AKI. Adherence to a standardized perioperative pathway designed to reduce risk of AKI after major vascular surgery offers a promising clinical approach to mitigate the incidence and severity of this challenging clinical problem.
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Affiliation(s)
- Charles Hobson
- Department of Surgery, Malcom Randall VAMC, Gainesville, Fla; Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Fla
| | - Nicholas Lysak
- Department of Surgery, College of Medicine, University of Florida, Gainesville, Fla
| | - Matthew Huber
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Fla
| | - Salvatore Scali
- Department of Surgery, Malcom Randall VAMC, Gainesville, Fla; Department of Surgery, College of Medicine, University of Florida, Gainesville, Fla
| | - Azra Bihorac
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Fla; Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Fla.
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8
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Wijeysundera DN, Parikh CR. Sodium bicarbonate for kidney protection in cardiac surgery: demise of yet another magic bullet? Anesthesiology 2014; 122:233-5. [PMID: 25501900 DOI: 10.1097/aln.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Duminda N Wijeysundera
- From the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.N.W.); Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada (D.N.W.); Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (D.N.W.); Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut (C.R.P.); Veterans Affairs Connecticut Healthcare System, New Haven, Connecticut (C.R.P.); and Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut (C.R.P.)
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9
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George JN, López JA, Konkle BA. N-Acetylcysteine: an old drug, a new insight, a potentially effective treatment for thrombotic thrombocytopenic purpura. Transfusion 2014; 54:1205-7. [PMID: 24819072 DOI: 10.1111/trf.12561] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- James N George
- Department of Biostatistics and Epidemiology, College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK; Department of Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Li GW, Rambally S, Kamboj J, Reilly S, Moake JL, Udden MM, Mims MP. Treatment of refractory thrombotic thrombocytopenic purpura with N-acetylcysteine: a case report. Transfusion 2013; 54:1221-4. [PMID: 24117464 DOI: 10.1111/trf.12440] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/27/2013] [Accepted: 07/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease resulting in systemic microvascular thrombosis. The disease is caused by excessive platelet (PLT) adhesion to ultra-large (UL) von Willebrand factor (VWF) multimers inadequately cleaved by the processing enzyme ADAMTS-13. While many cases respond to plasma exchange performed with or without concurrent corticosteroids, treatment of the 10% to 20% of patients with refractory disease is difficult. Experimental studies demonstrating that N-acetylcysteine (NAC) inhibits PLT binding to endothelial cell-secreted and anchored UL VWF multimers suggest that NAC may be useful in the treatment of TTP. CASE REPORT A 44-year-old woman presented with malaise, confusion, chest and abdominal pain, and transient visual loss. Laboratory results and peripheral blood smear were consistent with TTP. The patient was begun on plasma exchange and corticosteroid treatment, but after 10 days the PLT count was still less than 10.0 × 10(9) /L and she developed a fever. Rituximab was initiated, but the patient's condition worsened and she became comatose. Antibiotics were initiated, but cultures remained sterile. After 3 days of coma and further clinical deterioration, treatment with NAC was begun. The patient received a loading dose of 150 mg/kg NAC intravenously (IV) over 1 hour. Within 18 hours the patient awakened abruptly and began communicating with medical personnel. Plasma exchange, corticosteroids, rituximab, and NAC infusion (150 mg/kg IV over 17 hr daily × 10 days) were continued and by Day 17 the PLT count was more than 50 × 10(9) /L. The patient fully recovered and was discharged on Day 31. CONCLUSION This is the first complete report of a TTP patient treated with NAC. NAC was a safe and effective supplementary treatment for refractory TTP in this patient.
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Affiliation(s)
- Gloria W Li
- Department of Medicine, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas; The Hematology Service, Ben Taub General Hospital, Houston, Texas
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Landoni G, Bove T, Székely A, Comis M, Rodseth RN, Pasero D, Ponschab M, Mucchetti M, Bove T, Azzolini ML, Caramelli F, Paternoster G, Pala G, Cabrini L, Amitrano D, Borghi G, Capasso A, Cariello C, Carpanese A, Feltracco P, Gottin L, Lobreglio R, Mattioli L, Monaco F, Morgese F, Musu M, Pasin L, Pisano A, Roasio A, Russo G, Slaviero G, Villari N, Vittorio A, Zucchetti M, Guarracino F, Morelli A, De Santis V, Del Sarto PA, Corcione A, Ranieri M, Finco G, Zangrillo A, Bellomo R. Reducing mortality in acute kidney injury patients: systematic review and international web-based survey. J Cardiothorac Vasc Anesth 2013; 27:1384-98. [PMID: 24103711 DOI: 10.1053/j.jvca.2013.06.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this setting. DESIGN AND SETTING Systematic literature review and international web-based survey. PARTICIPANTS More than 300 physicians from 62 countries. INTERVENTIONS Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality. MEASUREMENTS AND MAIN RESULTS Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions. CONCLUSION The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics.
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Affiliation(s)
- Giovanni Landoni
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy.
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Chousterman BG, Bouadma L, Moutereau S, Loric S, Alvarez-Gonzalez A, Mekontso-Dessap A, Laissy JP, Rahmouni A, Katsahian S, Brochard L, Schortgen F. Prevention of contrast-induced nephropathy by N-acetylcysteine in critically ill patients: Different definitions, different results. J Crit Care 2013; 28:701-9. [DOI: 10.1016/j.jcrc.2013.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/11/2013] [Accepted: 03/13/2013] [Indexed: 11/24/2022]
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Szakmany T, Hauser B, Radermacher P. N-acetylcysteine for sepsis and systemic inflammatory response in adults. Cochrane Database Syst Rev 2012; 2012:CD006616. [PMID: 22972094 PMCID: PMC6517277 DOI: 10.1002/14651858.cd006616.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Death is common in systemic inflammatory response syndrome (SIRS) or sepsis-induced multisystem organ failure and it has been thought that antioxidants such as N-acetylcysteine could be beneficial. OBJECTIVES We assessed the clinical effectiveness of intravenous N-acetylcysteine for the treatment of patients with SIRS or sepsis. SEARCH METHODS We searched the following databases: Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (January 1950 to January 2012); EMBASE (January 1980 to January 2012); CINAHL (1982 to January 2012); the NHS Trusts Clinical Trials Register and Current Controlled Trials (www.controlled-trials.com); LILACS; KoreaMED; MEDCARIB; INDMED; PANTELEIMON; Ingenta; ISI Web of Knowledge and the National Trials Register to identify all relevant randomized controlled trials available for review. SELECTION CRITERIA We included only randomized controlled trials (RCTs) in the meta-analysis. DATA COLLECTION AND ANALYSIS We independently performed study selection, quality assessment and data extraction. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. MAIN RESULTS We included 41 fully published studies (2768 patients). Mortality was similar in the N-acetylcysteine group and the placebo group (RR 1.06, 95% CI 0.79 to 1.42; I(2) = 0%). Neither did N-acetylcysteine show any significant effect on length of stay, duration of mechanical ventilation or incidence of new organ failure. Early application of N-acetylcysteine to prevent the development of an oxidato-inflammatory response did not affect the outcome, nor did late application that is after 24 hours of developing symptoms. Late application was associated with cardiovascular instability. AUTHORS' CONCLUSIONS Overall, this meta-analysis puts doubt on the safety and utility of intravenous N-acetylcysteine as an adjuvant therapy in SIRS and sepsis. At best, N-acetylcysteine is ineffective in reducing mortality and complications in this patient population. At worst, it can be harmful, especially when administered later than 24 hours after the onset of symptoms, by causing cardiovascular depression. Unless future RCTs provide evidence of treatment effect, clinicians should not routinely use intravenous N-acetylcysteine in SIRS or sepsis and academics should not promote its use.
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Affiliation(s)
- Tamas Szakmany
- Department of Anaesthesia, Cwm Taf NHS Trust, Royal Glamorgan Hospital, Llantrisant, UK.
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Renal dysfunction and CABG. Curr Opin Pharmacol 2012; 12:181-8. [DOI: 10.1016/j.coph.2012.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 01/30/2012] [Accepted: 02/23/2012] [Indexed: 12/27/2022]
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Effect of preoperative N-acetylcysteine on postoperative blood loss parameters in cardiac surgery patients. Int J Vasc Med 2011; 2011:859020. [PMID: 21761005 PMCID: PMC3134103 DOI: 10.1155/2011/859020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 04/25/2011] [Indexed: 11/17/2022] Open
Abstract
Purpose. To determine if recent preoperative exposure to n-acetylcysteine (NAC), Mucomyst, increases postoperative blood loss in cardiac surgery patients. Methods. Retrospective review of cardiac surgery patients who underwent a cardiac catheterization within four days of surgery and whose serum creatinine was ≥1.0 mg/dL. The study groups were those who received NAC in the pericatheterization period versus those who did not. The primary endpoint was postoperative chest tube output at 24, 48, and 72 hours. Secondary endpoints included number of transfusions and other bleeding parameters. Results. Mean blood loss in the first 24 hours was 962 ± 595 mL in the treatment group (n = 79) and 1,178 ± 788 mL in the control group (n = 106), P = .040. Blood loss between groups at 48 (366 ± 318 mL versus 412 ± 363 mL, P = .382) and 72 (194 ± 300 mL versus 176 ± 224 mL, P = .643) hours was not significantly different. There were no significant differences in postoperative transfusions or other bleeding parameters. Conclusions. Preoperative exposure to NAC did not increase postoperative blood loss or negatively affect other bleeding parameters.
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Noris P, Balduini CL. Investigational drugs in thrombotic thrombocytopenic purpura. Expert Opin Investig Drugs 2011; 20:1087-98. [DOI: 10.1517/13543784.2011.588599] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Talasaz AH, Khalili H, Fahimi F, Mojtaba S. Potential role ofN-acetylcysteine in cardiovascular disorders. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/thy.11.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Wang G, Bainbridge D, Martin J, Cheng D. N-acetylcysteine in Cardiac Surgery: Do the Benefits Outweigh the Risks? A Meta-Analytic Reappraisal. J Cardiothorac Vasc Anesth 2011; 25:268-75. [DOI: 10.1053/j.jvca.2010.04.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Indexed: 02/05/2023]
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Chen J, Reheman A, Gushiken FC, Nolasco L, Fu X, Moake JL, Ni H, López JA. N-acetylcysteine reduces the size and activity of von Willebrand factor in human plasma and mice. J Clin Invest 2011; 121:593-603. [PMID: 21266777 DOI: 10.1172/jci41062] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 11/17/2010] [Indexed: 12/18/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease characterized by systemic microvascular thrombosis caused by adhesion of platelets to ultra-large vWF (ULVWF) multimers. These multimers accumulate because of a deficiency of the processing enzyme ADAMTS13. vWF protein forms long multimers from homodimers that first form through C-terminal disulfide bonds and then join through their N termini by further disulfide bonding. N-acetylcysteine (NAC) is an FDA-approved drug that has long been used to treat chronic obstructive lung disease and acetaminophen toxicity and is known to function in the former disorder by reducing mucin multimers. Here, we examined whether NAC could reduce vWF multimers, which polymerize in a manner similar to mucins. In vitro, NAC reduced soluble plasma-type vWF multimers in a concentration-dependent manner and rapidly degraded ULVWF multimer strings extruded from activated ECs. The effect was preceded by reduction of the intrachain disulfide bond encompassing the platelet-binding A1 domain. NAC also inhibited vWF-dependent platelet aggregation and collagen binding. Injection of NAC into ADAMTS13-deficient mice led to the rapid resolution of thrombi produced by ionophore treatment of the mesenteric venules and reduced plasma vWF multimers. These results suggest that NAC may be a rapid and effective treatment for patients with TTP.
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Affiliation(s)
- Junmei Chen
- Puget Sound Blood Center, 921 Terry Ave., Seattle, Washington 98104, USA
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Sisillo E, Marenzi G. N-acetylcysteine for the prevention of acute kidney injury after cardiac surgery. J Clin Pharmacol 2011; 51:1603-10. [PMID: 21233303 DOI: 10.1177/0091270010384117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Erminio Sisillo
- Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
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Ramakrishna H, Fassl J, Sinha A, Patel P, Riha H, Andritsos M, Chung I, Augoustides JG. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2009. J Cardiothorac Vasc Anesth 2010; 24:7-17. [DOI: 10.1053/j.jvca.2009.10.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Indexed: 11/11/2022]
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Pathophysiologie, Prophylaxe und Therapie von Herzchirurgie-assoziierten Nierenfunktionsstörungen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0743-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Berra L, Alston TA. Worse bleeding but better survival associated with N-acetylcysteine in cardiac surgery. Crit Care Med 2009; 37:2113-4. [PMID: 19448461 DOI: 10.1097/ccm.0b013e3181a5e949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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