N-acetylcysteine in Kidney Disease: Molecular Mechanisms, Pharmacokinetics, and Clinical Effectiveness

Abstract

N-acetylcysteine (NAC) has shown beneficial effects in both acute kidney disease and chronic kidney disease (CKD) in preclinical and clinical studies. Different dosage and administration forms of NAC have specific pharmacokinetic properties that determine the temporal pattern of plasma concentrations of NAC and its active metabolites. Especially in acute situations with short-term NAC administration, appropriate NAC and glutathione (GSH) plasma concentrations should be timely ensured. For oral dosage forms, bioavailability needs to be established for the respective NAC formulation. Kidney function influences NAC pharmacokinetics, including a reduction of NAC clearance in advanced CKD. In addition, mechanisms of action underlying beneficial NAC effects depend on kidney function as well as comorbidities, both involving GSH deficiency, alterations in nuclear factor erythroid 2-related factor 2 (Nrf2)-dependent signaling, oxidative stress, mitochondrial dysfunction, and disturbed mitochondrial bioenergetics. This also applies to nonrenal NAC mechanisms. The timing of preventive NAC administration in relation to potential injury is important. NAC administration seems most effective either preceding, or preceding and paralleling conditions that induce tissue damage. Furthermore, studies suggest that very high concentrations of NAC should be avoided because they could exert reductive stress. Delayed administration of NAC might interfere with endogenous repair mechanisms. In conclusion, studies on NAC treatment regimens need to account for both NAC pharmacokinetics and NAC molecular effects. Kidney function of the patient population and pathomechanisms of the kidney disease should guide rational NAC trial design. A targeted trial approach and biomarker-guided protocols could pave the way for the use of NAC in precision medicine.

Keywords: N-acetylcysteine; acute kidney injury; chronic kidney disease; glutathione; mitochondrial function; pharmacokinetics.

Figure 1

Protective effects of N-acetylcysteine (NAC) on renal damage. The figure illustrates reported effects of NAC. NAC enhances glutathione (GSH) levels by restoring S-glutathionylation in mitochondria, thereby preventing the production of mitochondrial reactive oxygen species (mtROS) and lipid peroxidation. Decreased mtROS levels reduce inflammation, fibrosis, and ultimately apoptosis. Restoration of the electron transport chain (ETC) function also improves mitochondrial dynamics. NAC additionally activates sirtuins 1 and 3 (Sirt1 and 3) and AMP-activated protein kinase (AMPK), promoting mitochondrial biogenesis and further restoring mitochondrial dynamics. Δѱmt, mitochondrial membrane potential; 4-HNE, 4-hydroxynonenal; ARE, antioxidant response element; GSSG, glutathione disulfide; MDA, malondialdehyde; NF-κB, nuclear factor kappa B; NLRP3, NLR family pyrin domain containing 3; Nrf2, nuclear factor erythroid 2-related factor 2; PGC-1α, peroxisome proliferator-activated receptor-gamma coactivator; TFAM, mitochondrial transcription factor A. Image created with Biorender.com.