Original Investigation
Pathogenesis and Treatment of Kidney Disease
Meta-analysis of N-Acetylcysteine to Prevent Acute Renal Failure After Major Surgery

https://doi.org/10.1053/j.ajkd.2008.05.019Get rights and content

Background

Acute renal failure after major surgery is associated with significant mortality and morbidity that theoretically may be attenuated by N-acetylcysteine.

Design

Meta-analysis of relevant studies sourced from the Cochrane Controlled Trial Register (2007 issue 4), EMBASE, and MEDLINE databases (1966 to February 1, 2008) without language restriction.

Setting & Population

Adult patients undergoing major surgery without the use of radiocontrast.

Selection Criteria for Studies

Randomized controlled studies comparing N-acetylcysteine with a placebo perioperatively.

Data Analysis

Categorical variables are reported as odds ratio (OR) with 95% confidence interval (CI), and continuous variables are reported as weighted-mean-difference (WMD) with 95% CI.

Outcome Measures

Effects of N-acetylcysteine on mortality and acute renal failure requiring dialysis were the main outcomes of interest. Additional outcome measures included an incremental increase in serum creatinine concentration greater than 25% above baseline, surgical reexploration for bleeding, amount of allogeneic blood transfusion, and length of intensive care unit stay.

Results

10 studies involving a total of 1,193 adult patients undergoing major surgery were considered. N-Acetylcysteine use was not associated with a decrease in mortality (OR, 1.05; 95% CI, 0.58 to 1.92), acute renal failure requiring dialysis (OR, 1.04; 95% CI, 0.45 to 2.37), incremental increase in serum creatinine concentration greater than 25% above baseline (OR, 0.84; 95% CI, 0.64 to 1.11), or length of intensive care unit stay (WMD in days, 0.46; 95% CI, −0.43 to 1.36). N-Acetylcysteine did not appear to increase the risk of surgical reexploration for bleeding (OR, 1.16; 95% CI, 0.57 to 2.38) or amount of allogeneic blood transfusion required (WMD in units, 0.31; 95% CI, −0.21 to 0.84).

Limitations

Most studied patients had cardiac surgery and normal renal function preoperatively.

Conclusions

There is no current evidence that N-acetylcysteine used perioperatively can alter mortality or renal outcomes when radiocontrast is not used.

Section snippets

Search Strategy

The literature search was performed on the Cochrane Controlled Trials Register (2007 issue 4), EMBASE (January 1990 to February 1, 2008), and MEDLINE databases (1966 to February 1, 2008). During the electronic database search, the following exploded MeSH terms were used: “N-acetylcysteine” or “N-acetyl-l-cysteine” with “renal failure, renal dysfunction, dialysis,” or “renal replacement therapy” with “surgery, perioperative, operation,” or “surgical patients.” The initial search results were

Study Description

Ten randomized controlled studies with a total of 1,193 adult patients undergoing high-risk surgery were considered (Fig 1).4, 11, 15, 16, 17, 18, 19, 20, 21, 22 Seven studies (1,003 patients) evaluated the effects of NAC in patients undergoing cardiac surgery,4, 11, 15, 16, 17, 18, 19 and 3 of these (508 patients) exclusively studied patients with preexisting renal impairment.11, 15, 16 Two studies (111 patients) evaluated the effects of NAC on patients undergoing abdominal aneurysm repair

Discussion

This meta-analysis shows that perioperative NAC use is not effective in reducing mortality and acute renal failure after major surgery when radiocontrast is not used.

NAC is inexpensive and potentially would be very cost-effective if it could prevent acute renal failure after major surgery. Although there is evidence to support the use of NAC to prevent radiocontrast nephropathy,9, 10 our results suggest that the beneficial effect of NAC on risk of acute renal failure does not extend to other

Acknowledgements

Support: None.

Financial Disclosure: None.

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    Originally published online as doi:10.1053/j.ajkd.2008.05.019 on July 25, 2008.

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