Original article
Adult cardiac
High Dose of N-Acetylcystein Prevents Acute Kidney Injury in Chronic Kidney Disease Patients Undergoing Myocardial Revascularization

https://doi.org/10.1016/j.athoracsur.2014.01.056Get rights and content

Background

The renoprotective effect of N-acetylcystein in patients undergoing coronary artery bypass graft surgery is controversial.

Methods

We assessed the renoprotective effect of the highest dose of N-acetylcystein sanctioned for clinical use in a prospective, double-blind, placebo-controlled study including 70 chronic kidney disease patients, stage 3 or 4, who underwent coronary artery bypass graft surgery, on cardiopulmonary bypass (CPB) and off CPB, and were randomly allocated to receive either N-acetylcystein 150 mg/kg followed by 50 mg/kg for 6 hours in 0.9% saline or only 0.9% saline. Acute kidney injury was defined by the Acute Kidney Injury Network classification.

Results

The incidence of kidney injury was reduced in the N-acetylcystein group (57.1% versus 28.6%, p = 0.016). Nonuse of N-acetylcystein (relative risk 3.58, 95% confidence interval: 1.04 to 12.33, p = 0.04) and cardiopulmonary bypass (relative risk 4.55, 95% confidence interval: 1.28 to 16.15, p = 0.02) were independent predictors of kidney injury. In patients treated with CPB, N-acetylcystein reduced the incidence of kidney injury from 63% to 46%. Oxidative stress was increased in control subjects (p = 0.01) and abolished in patients receiving N-acetylcystein.

Conclusions

Maximum intravenous doses of N-acetylcystein reduce the incidence of acute kidney injury in patients with kidney disease undergoing coronary artery bypass graft surgery, abolish oxidative stress, and mitigate the negative effect of CPB on renal function.

Section snippets

Study Protocol

This study is registered for clinical trials (clinicaltrials.gov NCT01359722). The Institutional Ethics Board approved the study; participants signed a written informed consent.

Patients with estimated glomerular filtration rate of 15 or greater and less than 60 mL · min−1 · 1.73 m−2 [19], scheduled to undergo elective CABG from January 2, 2009, to November 15, 2012, were considered for inclusion. There were eligible 231 patients; 161 were excluded for the following reasons: dialysis (n = 22);

Preoperative Characteristics

Table 1 shows the preoperative characteristics. The proportion of males was greater in the control group (86% versus 57%, p = 0.02) whereas the left ventricular ejection fraction tended to be higher in the NAC group (p = 0.052). In all other aspects, the groups were well balanced. Creatinine, glomerular filtration rate (control, 44.7 ± 12; NAC, 45.9 ± 9.2; p = 0.64) as well as lipids, urea, and glucose were similar in both groups.

Perioperative Characteristics

We found no differences between groups in intraoperative

Comment

In this study, we showed that maximum doses of NAC sanctioned for human use reduced the incidence of AKI among patients with moderate chronic kidney disease undergoing elective CABG. The nonuse of NAC was an independent predictor of AKI (RR 3.58, p = 0.04) together with CPB (RR 4.55, p = 0.02). The data suggest that the nonuse of NAC and CPB interact to increase the probability of AKI and that NAC attenuates the negative effects of CPB on renal function. To our knowledge, this is the first

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