1. Introduction
cute renal failure is a sudden decrease in renal function due to renal toxicity [2, 3]. Deferasirox or oxide can generate acute renal failure due to the oxidative stress and dysfunction of the renal tubules by increasing cell apoptosis.
Deferasirox is a selective iron chelator. It is used to treat chronic iron overload conditions caused by repeated blood transfusions in patients with beta-thalassemia major [5, 6].
Vitamin C, as an essential coenzyme and antioxidant, prevents cell membrane damage caused by oxidative radicals [7]. Therefore, using antioxidants, like vitamin C can be effective for the treatment or prevention of deferasirox-induced kidney damage. This study investigated the effect of the concomitant use of vitamin C on the renal toxicity of deferasirox.
2. Materials and Methods
 This experimental study was performed on 30 rats of Wistar breed in 3 groups of control, deferasirox, and deferasirox plus vitamin C. Deferasirox (75 mg/kg/day) was intraperitoneally injected for 8 days to induce renal toxicity. In the concomitant treatment group, in addition to deferasirox (75 mg/kg/day), vitamin C 200 mg/kg /day was intraperitoneally injected for 8 days. On the eighth day, the explored animals were placed in a metabolic cage for 6 hours; after collecting urine samples, they were anesthetized. Then, the required blood sample was obtained from the aorta using a heparin syringe.
 After plasma extraction from the rat blood samples, the concentrations of Cr, + Na, + K, + Mg, osmolality, and BUN in plasma and urine samples were determined. Accordingly, renal creatinine clearance (Cr), as well as the absolute and relative excretion of sodium and potassium were calculated.  Kidney tissue was stained by Hematoxylin and Eosin (H&E) staining for histological study; antioxidant capacity was measured by FRAP and lipid peroxidation by MDA for biochemical study [12, 13].
The percentage of damage caused by the pathologist was determined and graded as follows: The lack of damage equivalent to zero degrees; damage between 1% to 25% equivalent to grade 1; damage between 25% to 50% equivalent to grade 2; damage between 50% to 75% equivalent to grade 3, and damage between 75% to 100% equivalent to grade 4 [15].
3. Results
The present research results revealed that creatinine clearance in the group treated with vitamin C (1.63±0.1 mL/min/kg) was significantly different, compared to that in the deferasirox group (0.59±0.1 mL/min /kg, P<0.001) (Figure 1).  The relative excretion of sodium and potassium was significantly different, compared with the deferasirox group (P<0.001). The absolute excretion of sodium was significantly different in the concomitant treatment group with vitamin C (2.46 ± 0.087 mmol/min/kg), compared with the deferasirox group (001.15±0.04 mmol/min/kg, P<0.7). The absolute excretion of potassium was significantly higher in the deferasirox group (13.41±0.098 mmol/min/kg,) compared with the vitamin C group (2.986±0.163 mmol/mi /kg) (P<0.001).
The obtained data revealed that urinary creatinine concentration in the deferasirox group (32.7±1.55 mg/dL) was significantly lower than that of the concomitant treatment group with vitamin C (69.8±6.7 mg/dL) (P<0.001). Urinary urea concentration in the concomitant treatment group with vitamin C (137±3.82 mg/dL) was significantly increased, compared to the deferasirox group (72±0.14 mg/dL) (P<0.001). Urinary sodium concentration signified that the concomitant treatment group with vitamin C (127.4±3.1 μmol/mL) had lower values ​​than the deferasirox group (220.4±4.55 μmol/mL) (P<0.001). Urine osmolality in the concomitant treatment group with vitamin C (1681±60.9 mOsm/kgH2O) was significantly reduced, compared to the deferasirox group (612.5±18 mOsm/kgH2O) (P<0.001).
The level of tissue MDA in the concomitant treatment group with vitamin C (1.94±0.355 μmol/gkw) was significantly reduced, compared to the deferasirox group (4.31±0.5 μmol/gkw, P<0.001) (Figure 2). Renal tissue FRAP level was significantly increased in the concomitant treatment with vitamin C (1.07±0.25 μmol/gkw,) compared with the deferasirox group (001.75±0.61 μmol/gkw, P<0.0) (Figure 3). In the concomitant treatment group with vitamin C, the amount of tubular cell necrosis, the formation of protein molds in the lumen of the tubule, the vacuolation of tubular cells, and the increase in the space of the Bowman capsule were significantly different, compared to the deferasirox group (P<0.001).
4. Discussion
The current study results indicated that vitamin C decreased renal toxicity due to deferasirox by reducing plasma urea and creatinine, the relative and absolute excretion of sodium and potassium and MDA, as well as increasing creatinine clearance and FRAP.  The concomitant use of vitamin C plus deferasirox protects kidneys by reducing oxidative stress. Previous studies reported that vitamin C reduces oxidative stress during gentamicin nephrotoxicity [2].
An effective factor in causing deferasirox-induced kidney damage is oxidative stress, which increased MDA and decreased FRAP.
 As in previous studies, mice treated with vitamin C had lower levels of MDA than the deferasirox group. Furthermore, the extent of FRAP in the tissue of all explored rats treated with vitamin C was much higher than that in the deferasirox group [9].
 In the vitamin C concomitant treatment group, compared with the deferasirox group, a lower rate of relative excretion of sodium and potassium ions was observed; thus, such data indicated the prevention of kidney damage. The effect of vitamin C on the renal toxicity of deferasirox with decreasing creatinine and blood urea, and tissue MDA with decreasing oxidative stress is similar to the effect of vitamin C on the renal toxicity of gentamicin [9]. Vitamin C reduces the renal toxicity induced by deferasirox administration by decreasing oxygen species. In this study, in line with the previous studies, administrating vitamin C significantly maintained creatinine clearance and significantly increased plasma creatinine concentration, compared to the deferasirox group [9, 17, 25].
 Oxidative stress is a major factor in the development of the renal toxicity of deferasirox with the destruction of epithelial cells; increased necrosis and fibrosis of renal tissue; as well as tubular and glomerular atrophy on renal function [4, 22]. The kidney toxicity of deferasirox is believed to be due to the production of oxygen free radicals; the increased production of cytokines; as well as the induction of apoptosis and necrosis [23]. Apoptosis plays a crucial role in cell death and may be involved in the removal of damaged cells [16]. 
5. Conclusion
The concomitant administration of vitamin C in treatment with deferasirox presented a significant efficacy in maintaining renal function. The protective effect of vitamin C is due to its antioxidant properties and the trapping of free radicals. It prevented hemodynamic changes in the kidneys, impaired salt excretion, and tissue changes caused by deferasirox.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Arak University of Medical Sciences (code: IR.ARAKMU.REC.1396.309).  All ethical codes approved by the Ministry of Health and Medical Education and Arak University of Medical Sciences were observed regarding maintenance and testing in this investigation.

Funding
This article was extracted from the PhD.  dissertation of first author at the Department of Physiology, School of Medicine, Arak University of Medical Sciences, Arak. 

Authors' contributions
Methodology, validation, data analysis, and writing: Dr. Saeed Haji Hashemi; Conducting research experiments, resources, and drafts: Dr. Taha Fereydoni and Dr. Ali Rahbari;  Conceptualization: Dr. Parsa Yousefi Chaijan.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to thank the Vice-Chancellor for Research and Technology of Arak University of Medical Sciences for their support.


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