Available online at www.annclinlabsci.

org

312

Annals of Clinical & Laboratory Science, vol. 36, no.3, 2006

L-Carnitine Reduces Cochlear Damage Induced by Gamma Irradiation in Guinea Pigs

Enver Altas,1 Mustafa Vecdi Ertekin,2 Cemal Gundogdu,3 and Elif Demirci3 Departments of 1 Otolaryngology, 2 Radiation Oncology, and 3 Pathology, School of Medicine, Ataturk University, Erzurum, Turkey Abstract. L-carnitine (LC) protects cells from peroxidative damage. In this study, we tested whether Lcarnitine (LC) prevents radiation-induced cochlear damage after total cranial irradiation (radiotherapy; RT). Male albino guinea pigs were randomly distributed in 3 groups. The Control group (n = 11) received neither LC nor irradiation, but saline solution ip and sham irradiation for 5 days. The RT group (n = 32) received saline solution ip as placebo therapy and exposure to total cranial irradiation of 33 Gy in 5 fractions of 6.6 Gy/day on 5 successive days, with a calculated (/ = 3.5) biological effective dose of fractionated irradiation equal to 60 Gy conventional fractionation. The LC + RT group (n = 36) received total cranial irradiation, plus LC (100 mg/kg/day, ip) for 5 days. The guinea pigs were killed at 4, 24, or 96 hr after the last dose of RT and the cochleas were enucleated for histopathologic examination. There was no cochlear degeneration in the control group. In the RT group, total cranial irradiation caused degeneration in stria vascularis (SV), spiral ganglion (SG), outer hair cells (OHC), and inner hair cells (IHC) of cochleas at 4, 24, and 96 hr. In the LC + RT group, LC administration reduced radiation-induced cochlear degeneration in SV and SG at 4, 24, and 96 hr, and in OHC and IHC at 24 and 96 hr (p <0.05). Thus, this study shows that L-carnitine can ameliorate radiation-induced cochlear damage in guinea pigs. Keywords: gamma irradiation, cochlear damage, L-carnitine, antioxidant, radioprotection Introduction Radiotherapy (RT) is used widely for both primary and adjuvant treatment of cancer. Despite its curative efficacy, RT causes side effects such as ototoxicity. Hearing loss due to ototoxicity may be severe enough to impair the quality of life in patients [1-4]. Numerous trials have been conducted to reduce or prevent the ototoxic side effects of RT. These studies have tested pantothenic acid, coenzyme A, D-methionine, histidine, brainderived neurotrophic factor with D-methionine, L-methionine, diethyldithiocarbamate, 4-methylthiobenzoic acid, ebselen, -lipoic acid, -tocoAddress correspondence to Dr. Enver Altas, Ataturk Universitesi, Tip Fakultesi, K.B.B. Anabilim Dali, Erzurum 25240, Turkey; tel 90 442 236 1212; fax 90 442 236-1301; e-mail enveraltas@hotmail.com.

pherol, vitamins A, B, C, E, and K, zinc-coppersuperoxide dismutase, nicotinamide, various amino acids, choline, ATP, glucuronic acid, chondroitin sulfate, corticoids, sulfhydryl compounds (eg, panthotenic acid, glutathione, sodium thiosulfate), piracetam, aminoguanidine, and L-carnitine [516]. The focus of the present study is L-carnitine (LC), which is crucial for mitochondrial energy production via -oxidation of fatty acids [17]. LC has been reported to have antiperoxidative effects in several tissues [18-22]. In addition to protecting cells from peroxidative stress that damages cell membrane, LC has a scavenger effect on reactive oxygen species (ROS) [18,23]. The present study tests the protective effects of ip administration of LC on cochlear damage induced in guinea pigs by exposure to total cranial irradiation.

0091-7370/06/0300-0312. $1,75. 2006 by the Association of Clinical Scientists, Inc.

L-carnitine reduces irradiation-induced ototoxicity in guinea pigs

313

Materials and Methods

Animals, drugs, and irradiation. All experimental procedures conformed to the Principles for Use of Animals in Research. The guinea pigs were quarantined for at least 1 day before irradiation and were housed in cages in a windowless room with regulated temperature (22 1C), controlled illumination (12 hr light/12 hr dark cycle), and ad libitum access to laboratory chow and water. L-carnitine was obtained from Santa Pharma Co., Istanbul, Turkey Male albino guinea pigs (475-620 g body wt, n = 79) were randomly divided into 3 groups. The Control group (n = 11) received neither LC nor irradiation, but saline solution (0.5 ml/kg, ip) and sham irradiation for 5 successive days. The RT group (n = 32) received saline solution ip for 5 successive days and exposure to total cranial irradiation of 33 Gy in 5 fractions of 6.6 Gy/day for 5 successive days, with a calculated (/ = 3.5) biological effective dose of fractionated irradiation equal to 60 Gy conventional fractionation. The LC + RT group (n = 36) received total cranial irradiation plus LC (100 mg/kg/day, ip) for 5 successive days. Prior to total cranial radiotherapy, the guinea pigs were anesthetized with ketamine HCl (50 mg/kg, ip, Pfizer, Istanbul, Turkey) and placed on a plexiglas tray in a prone position. While the guinea pigs in the control group received sham-irradiation, the guinea pigs in the RT and LC+RT groups were irradiated using a cobalt-60 teletherapy unit (C9, Picker Corp., USA) with a source-to-surface distance of 80 cm, by 7.5 x 7.5 cm anterior fields with 33 Gy to the total cranium in 5 fractions of 6.6 Gy/day for 5 successive days. The calculated (/=3.5) biological effective dose of fractionated irradiation was equal to 60 Gy conventional fractionation. The dose was calculated for the central axis at a depth of 1.5 cm and the dose rate was 0.65 Gy/min. After the last dose of irradiation and/or LC, the guinea pigs were anesthetized with ketamine HCl (100 mg/kg, ip, Pfizer) and diazepam (3 mg/kg, ip, Deva, Istanbul, Turkey). The animals were killed with overdoses of pentobarbital (100 mg/kg, ip, Abbott, Istanbul, Turkey) as follows: all 11 animals in the Control group, 12 animals from the RT group, and 12 from the LC + RT group at 4 hr; 10 from the RT group and 13 from the LC + RT group at 24 hr; 10 from the RT group and 11 from the LC + RT group at 96 hr, respectively. In all animals, the right and left temporal bones were removed within 5 min after death and the tympanic bulla was reached after removing the lateral wall of the mastoid-like process of temporal bone. The left cochleas were enucleated for histopathologic examination. The right temporal bones were used for another study. Histopathology. The left tympanic bullas were fixed in 10% neutral buffered formaldehyde solution at 4C for 24 hr. For decalcification, specimens were stored in 10% (w/v) EDTA solution at 4C for 20 days. All specimens were dehydrated, embedded in paraffin, serially sectioned at 5 m, and stained with H&E. Light microscopic examinations of the sections were performed independently by 2 pathologists. The organ of Corti was examined for degenerative changes (hydropic and vacuolar degeneration and loss of outer hair cells (OHC)

and inner hair cells (IHC)). The spiral ganglion (SG) was evaluated for cytoplasmic and nuclear condensation, nucleus and neuron loss; and the stria vascularis (SV) for edema, vacuolization, and loss of cells. Changes in the SV were scored as absent (0), mild (1), moderate (2) or severe (3); the percentages of degenerated cells in the SG, and the numbers of guinea pigs with degenerated hair cells (IHC and OHC) in the organ of Corti were estimated [24]. Statistics. Statistical analyses were made by the SPSS program (Statistical Package for Social Science; Windows version 11.0). The results are expressed as mean SD. Differences between groups were tested by the Mann-Whitney U test. Comparisons among more than 2 groups were performed by Friedman ANOVA; p <0.05 was considered significant.

Results No cochlear degeneration was observed in the Control group (Table 1, Fig. 1a,b,c). In the RT group, total cranial irradiation promoted degeneration in the SV (severe hydropic and vacuolar degeneration, Fig. 2a), in the OHC and IHC (hydropic and vacuolar degeneration, and loss of cells, Fig. 2b), and in the SG (cytoplasmic and nuclear condensation, nuclear and neuronal loss, Fig. 2c) at 4, 24, and 96 hr after last treatment (p <0.05) (Table 1). In the LC + RT group, LC administration decreased the RT-induced degeneration in the SV (mild hydropic and vacuolar degeneration, Fig. 3a) at 4, 24, and 96 hr, in the OHC and IHC (hydropic degeneration, Fig. 3b) at 24 and 96 hr, and in the SG (cytoplasmic and nuclear condensation, and occasional nuclear and neuronal loss, Fig. 3c) at 4, 24, and 96 hr after last treatment. These findings show that LC administration ameliorated the radiation-induced cochlear damage. (Table 1). Discussion The goal of radiation treatment of cancer patients is to deliver accurately measured doses of ionizing radiation to a defined tumor volume with minimal injurious effects on surrounding healthy tissue; by eliminating tumor cells, radiation treatment can enhance the quality of life and prolong the survival of cancer patients at reasonable cost [25]. Unfortunately, cochlear damage may occur during the irradiation therapy of patients with head and neck cancer [1].

314

Annals of Clinical & Laboratory Science, vol. 36, no.3, 2006

Table 1: Statistical analysis and scoring of histopathological changes in the organ of Corti, spiral ganglion, and stria vascularis of guinea pig cochleas in the Control group (sham irradiation and placebo), RT group (cranial irradiation and placebo), and LC-RT group (cranial irradiation and L-carnitine), at 4, 24, or 96 hr after the last treatment (see text for experimental details). Control Group Group: Treatment: (sham irradiation & placebo) Time after last treatment (hr): 4 Number of guinea pigs: 11 Degeneration in the stria vascularis Severity score = 0 11 Severity score = 1 0 Severity score = 2 0 Severity score = 3 0 mean 0 SD 0.0 p values b,c,d,e,f,g Degenerated cells (%) in the spiral ganglion mean 0 SD 0.0 p values b,c,d,e,f,g Number of guinea pigs with degenerated outer hair cells (OHC) in the organ of Corti Severity score = 0 11 Severity score = 1 0 Severity score = 2 0 Severity score = 3 0 mean 0 SD 0.0 p values b,c,d,e,f,g Number of guinea pigs with degenerated inner hair cells (IHC) in the organ of Corti Severity score = 0 11 Severity score = 1 0 mean 0 SD 0.0 p values b,c,d RT Group (irradiation & placebo) 4 24 96 12 10 10 0 0 7 5 3.42 0.51
a,e,f,g

LC+RT Group (irradiation & L-carnitine) 4 24 96 12 13 11 0 1 11 0 2.92 0.28 0 7 6 0 2.46 0.51 4 4 3 0 1.91 0.83

0 0 4 6 3.60 0.51
a,e,f,g

0 0 2 8 3.80 0.42
a,e,f,g

a,b,c,d,f,g a,b,c,d,e,g a,b,c,d,e,f

66.50 4.27

80.80 3.15

88.80 3.01

53.83 2.48

43.84 2.76

32.36 2.94

a,c,d,e,f,g a,b,d,e,f,g a,b,c,e,f,g

a,b,c,d,f,g a,b,c,d,e,g a,b,c,d,e,f

0 0 7 5 3.42 0.51
a,f,g

0 0 4 6 3.60 0.51
a,e,f,g

0 0 2 8 3.80 0.42
a,e,f,g

0 5 3 4 2.92 0.90
a,c,d,g

0 6 4 3 2.77 0.83

5 3 2 1 1.91 1.04

a,b,c,d,g a,b,c,d,e,g

7 5 1.42 0.51
a

4 6 1.60 0.51
a,f,g

3 7 1.70 0.48
a,e,f,g

9 3 1.25 0.45
d

11 2 1.15 0.37
c,d

10 1 1.09 0.30
c,d

Degeneration severity was scored as absent (0), mild (1), moderate (2). or severe (3). a p <0.05 vs Control group; b p <0.05 vs RT 4 hr group; c p <0.05 vs RT 24 hr group; d p <0.05 vs RT 96 hr group; e p <0.05 vs LC+RT 4 hr group; f p <0.05 vs LC+RT 24 hr group; g p <0.05 vs LC+RT 96 hr group.

Exposure of cells to ionizing radiation causes oxidative stresses that are associated with radiationinduced cytotoxicity [26]. Oxidative stress is important in the pathophysiology of ototoxicity [27]. Oxidative tolerance can occur as a defense against oxidative substances. Oxidative tolerance may explain why ototoxicity is limited in low dose RT [28]. Kim et al [29] evaluated histopathologically the cochlea of guinea pigs following single doses of irradiation (2, 6, 10, or 15 Gy). Outer hair cell damage appeared with irradiation 10 Gy, and

inner hair cell damage with irradiation 15 Gy. The morphologic changes in the stria vascularis were intercellular and perivascular fluid accumulation that appeared to be reversible. In a study by Yang et al [30], guinea pigs were treated with irrradiation doses of 1 Gy for 30 days, and the inner ear structures were evaluated by histopathology. There was degeneration in the support cells, OHC of the organ of Corti, stria vascularis, vessel endothelial cells, reduced number of capillaries, and tissue atrophy. In the present study, high dose RT of 60

L-carnitine reduces irradiation-induced ototoxicity in guinea pigs

315

Fig. 1. Histopathological images of the Control group: (a) normal histopathological appearance of the stria vascularis in the cochlea (arrow-head) (H&E x 400); (b) normal histopathological appearance of organ of Corti (outer hair cells and inner hair cells) in the cochlea (arrow-head) (H&E x 400); (c) normal histopathological appearance of the spiral ganglion in the cochlea (H&E x 200).

Fig. 2. Histopathological images of the radiotherapy (RT) group: (a) severe radiation damage of stria vascularis in the cochlea (arrow-head) (H&E x 400); (b) severe radiation damage of the organ of Corti in the cochlea (arrow-head) (H&E x 400); (c) severe radiation damage of the spiral ganglion in the cochlea (arrow) (H&E x 400).

Gy caused extensive damage to the inner ear, including the stria vascularis, outer hair cells, inner hair cells, and spiral ganglion cells.

In order to protect the cochlea from ototoxicity, numerous drugs have been used (eg, cisplatin, aminoglycosides, antioxidant agents such as Lmethionine, -lipoic acid, vitamin E, vitamin B, pantothenic acid, coenzyme A, piracetam, and

316

Annals of Clinical & Laboratory Science, vol. 36, no.3, 2006

Fig. 3. Histopathological images of the radiotherapy plus Lcarnitine (LC+RT) group: (a) mild radiation damage of stria vascularis in the cochlea (arrow) (H&E x 400); (b) mild radiation damage of the organ of Corti in the cochlea (arrow) (H&E x 400); (c) mild radiation damage of the spiral ganglion in the cochlea (head arrows) (H&E x 400). The radiation damage was less severe in the LC+RT group than in the RT group (see Fig. 2a,b,c)

aminoguanidine) [8-16]. L-carnitine (LC) is an antioxidant molecule with ubiquitous tissue distribution and cardioprotective, neuroprotective, and immunostimulant properties [31]. Studies have

shown that LC administration ameliorates postischemic reperfusion-induced oxidative damage of the kidney [32], retina [14], spinal-cord [33], and heart [34]. Studies in vivo and in vitro suggest that LC protects the myocardium against adriamycininduced cardiotoxicity [35,36] and the kidney and small intestine against cisplatin-induced injury [37] without interfering with its antitumor activity. Carnitine acts as an anti-apoptotic mediator [38,39]. Exposure of mouse spleen to low-frequency high-intensity magnetic field (MF) decreases splenocyte viability, leukocyte count, and mitogeninduced lymphocyte proliferation; LC ameliorates most of these adverse effects of MF, suggesting a possible immunoprotective role of LC [40]. Acetylcarnitine can increase the metabolic rate of mitochondria and improve mitochondrial oxygen utilization, which may counteract some toxic effects in ischemically injured tissue [41]. L-propionylcarnitine and LC act as superoxide scavengers, inhibit peroxidation of linoleic acid, and protect DNA from cleavage induced by H2O2 UV-photolysis [42,43]. LC may acts as a chelator to decrease the concentration of cytosolic iron, which may play an important role in free radical chemistry [44]. Acetyl-L-carnitine has a capacity to enhance the activities of non-enzymatic antioxidants, such as vitamin E and ascorbic acid [45], and to modulate the secretion of melatonin [46,47]. These are some of the reasons why we tested LC as a radioprotector in the present study. We are not aware of any previous investigation of LC protection against inner ear damage. The present study in guinea pigs shows that fractionated total cranial irradiation of 60 Gy (RT group) damaged the stria vascularis, spiral ganglion cells, OHC, and IHC of cochleas, and that LC administration (RT+LC group) decreased the radiation-induced cochlear damage. Thus, LC played a significant neuroprotective role after fractionated total cranial irradiation of 60 Gy. The authors speculate that LC protection against inner ear damage may be mediated by improving mitochondrial oxygen utilization and scavenging free-radicals. In summary, ip administration of L-carnitine resulted in beneficial reduction of radiation-induced ototoxicity in guinea pigs.

L-carnitine reduces irradiation-induced ototoxicity in guinea pigs

317

References
1. 2. Ondrey FG, Greig JR, Herscher L. Radiation dose to otologic structures during head and neck cancer radiation therapy. Laryngoscope 2000;110:217-221. Huang E, Teh BS, Strother DR, Davis QG, Chiu JK, Lu HH, Carpenter LS, Mai WY, Chintagumpala MM, South M. Intensitymodulated radiation therapy for pediatric medulloblastoma: early report on the reduction of ototoxicity. Int Radiat Oncol Biol Phys 2002;52:599605. Ho WK, Wei WI, Kwong DL, Sham JS, Tai PT, Yuen AP, Au DK. Long term sensorineural hearing deficit following radiotherapy in patients suffering from nasopharyngeal carcinoma: a prospective study. Head Neck Surgery 1999;21:547-553. Chang SD, Poen J, Hancock SL, Martin DP, Adler JR. Acute hearing loss following fractionated stereotactic radiosurgery for acoustic neuroma. Report of two cases. J Neurosurg 1998;89:321-325. Jereczek-Fossa BA, Zarowski A, Milani F, Orecchia R. Radiotherapy-induced ear toxicity. Cancer Treat Rev 2003;29:417-430. Mencher GT, Novotny G, Mencher L, Gulliver M. Ototoxicity and irradiation: additional etiologies of hearing loss in adults. J Am Acad Audiol 1995;6:351357. Schacht J. Biochemical basis of aminoglycoside ototoxicity. Otolaryngol Clin North Am 1993;26:845-856. Li G, Frenz DA, Brahmblatt S, Feghali JG, Ruben RJ, Bergren D, Arezzo J, Van de Water TR. Round window membrane delivery of L-methionine provides protection from cisplatin ototoxicity without compromising chemotherapeutic efficacy. Neurotoxicology 2001;22: 163-176. Conlon BJ, Aran JM, Erre JP, Smith FW. Attenuation of aminoglycoside-induced cochlear damage with the metabolic antioxidant alpha lipoic acid. Hearing Res 1999;128:40-44. Teranishi M, Nakashima T, Wakabayashi T. Effects of alpha-tocopherol on cisplatin-induced ototoxicity in guinea pigs. Hearing Res 2001;151:61-70. Guneri EA, Serbetcioglu B, Ikiz AO, Guneri A, Ceryan K. TEOAE monitoring of cisplatin induced ototoxicity in guinea pigs: the protective effect of vitamin B treatment. Auris Nasus Larynx 2001;28:9-14. Ciges M, Fernandez-Cervilla F, Crespo PV, Campos A. Pantothenic acid and coenzyme A in experimental cisplatin-induced ototoxia. Acta Otolaryngol 1996;116: 263-268. Moyersoons F, Giurgea CE. Protective effect of piracetam in experimental barbiturate intoxication: EEG and behavioral studies. Arch Int Pharmacodyn 1974;210:3848. Kocer I, Kulacoglu D, Altuntas I, Gundogdu C, Gullulu G. Protection of the retina from ischemia-reperfusion injury by L-carnitine in guinea pigs. Eur J Ophthalmol 2003;13:80-85.

3.

4.

5. 6.

7. 8.

9.

10. 11.

12.

13.

14.

15. Altas E, Ucuncu H, Aktan B, Selimoglu E. The effect of piracetam in preventing combined cisplatin and gentamicin-induced ototoxicity in a guinea pig model. Pain Clinic 2004;16:427-435. 16. Iraz M, Kalcioglu MT, Kizilay A, Karatas E. Aminoguanidine prevents ototoxicity induced by cisplatin in rats. Ann Clin Lab Sci 2005;35:329-335. 17. Swamy-Mruthinti S, Carter AL. Acetyl-L-carnitine decreases glycation of lens proteins: in vitro studies. Exp Eye Res 1999;69:109-115. 18. Bertelli A, Conte A, Ronca G. L-propionyl carnitine protects erythrocytes and low density lipoproteins against peroxidation. Drugs Exp Clin Res 1994;20:191197. 19. Di Giacomo C, Latteri F, Fichera C, Sorrenti V, Campisi A, Castorina C, Russo A, Pinturo R, Vanella A. Effect of acetyl-L-carnitine on lipid peroxidation and xanthine oxidase activity in rat skeletal muscle. Neurochem Res 1993;18:1157-1162. 20. Ferrari R, Ciampalini G, Agnoletti G, Cargnoni A, Ceconi C, Visioli O. Effect of L-carnitine derivatives on heart mitochondrial damage induced by lipid peroxidation. Pharmacol Res Commun 1988;20:125-132. 21. Koudelova J, Mourek J, Drahota Z, Rauchova H. Protective effect of carnitine on lipoperoxide formation in rat brain. Physiol Res 1994;43:387-389. 22. Izgut-Uysal VN, Agac A, Derin N. Effect of carnitine on stress-induced lipid peroxidation in rat gastric mucosa. J Gastroenterol 2001;36:231-236. 23. Fritz IB, Arrigoni-Martelli E. Sites of action of carnitine and its derivatives on the cardiovascular system: interactions with membranes. Trends Pharmacol Sci 1993;14: 355-360. 24. Kalkandelen S, Selimoglu E, Erdogan F, Ucuncu H, Altas E. Comparative cochlear toxicities of streptomycin, gentamycin, amikacin and netilmicin in guinea pigs. J Int Med Res 2002;30:406-412. 25. Ertekin MV, Uslu H, Karslioglu I, Ozbek E, Ozbek A. Effect of oral zinc sulphate supplementation on agents of oropharyngeal infection in patients receiving radiotherapy for head and neck cancer. J Int Med Res 2003; 31:251-266. 26. Ertekin MV, Koc M, Karslioglu I, Sezen O, Taysi S, Bakan N. The effects of oral zinc sulphate during radiotherapy on anti-oxidant enzyme activities in patients with head and neck cancer: a prospective, randomized, placebo-controlled study. Int J Clin Pract 2004;58:662668. 27. Sha SH, Zajic G, Epstein CJ, Schacht J. Overexpression of copper/zinc-superoxide dismutase protects from kanamycin-induced hearing loss. Audiol Neurootol 2001;6:117-123. 28. Repine JE, Bast A, Lankhorst I. Oxidative stress in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997;156:341-357. 29. Kim CS, Shin SO. Ultrastructural changes in the cochlea of the guinea pig after fast neutron irradiation. Otolaryngol Head Neck Surg 1994;110:419-427.

318

Annals of Clinical & Laboratory Science, vol. 36, no.3, 2006

Simone C. Effect of L-carnitine treatment in vivo on apoptosis and ceramide generation in peripheral blood lymphocytes from AIDS patients. Proc Assoc Am Phys 1997;109:146-153. Arafa HM, Abd-Allah AR, El-Mahdy MA, Ramadan LA, Hamada FM. Immunomodulatory effects of Lcarnitine and q10 in mouse spleen exposed to lowfrequency high-intensity magnetic field. Toxicology 2003;187:171-181. Rosenthal RE, Williams R, Bogaert YE, Getson PR, Fiskum G. Prevention of postischemic canine neurological injury through potentiation of brain energy metabolism by acetyl-L-carnitine. Stroke 1992;23:13121318. Vanella A, Russo A, Acquaviva R, Campisi A, Di Giacomo C, Sorrenti V, Barcellona ML. L-propionylcarnitine as superoxide scavenger, antioxidant, and DNA cleavage protector. Cell Biol Toxicol 2000;16:99-104. Rani PJ, Panneerselvam C. Effect of L-carnitine on brain lipid peroxidation and antioxidant enzymes in old rats. J Gerontol Biol Sci Med Sci 2002;57:134-137. Reznick AZ, Kagan VE, Ramsey R, Tsuchiya M, Khwaja S, Serbinova EA, Packer L. Antiradical effects in L-propionyl carnitine protection of the heart against ischemia-reperfusion injury: the possible role of iron chelation. Arch Biochem Biophys 1992;296:394-401. Arockia Rani PJ, Panneerselvam C. Carnitine as a free radical scavenger in ageing. Exp Gerentol 2001;36:17131726. Esposti D, Mariani M, Demartini G, Lucini V, Fraschini F, Mancia M. Modulation of melatonin secretion by acetyl-L-carnitine in adult and old rats. J Pineal Res 1994;17:132-136. Olatunji-Bello II, Reiter RJ. Effect of acute acetyl-lcarnitine treatment on daytime melatonin synthesis in the rat. Afr J Med Med Sci 1997;26:175-177.

30. Yang X, Lu Y, Chen Z. Delayed damage of ionizing radiation on the inner ear (abstract). Zhonghua Er Bi Yan Hou Ke Za Zhi 1997;32:222-225. 31. Abd-Allah AR, Al-Majed AA, Al-Yahya AA, Fouda SI, Al-Shabana OA. L-Carnitine halts apoptosis and myelosuppression induced by carboplatin in rat bone marrow cell cultures. Arch Toxicol 2005;79:406-413. 32. Ergun O, Ulman C, Kilicalp AS, Ulman I. Carnitine as a preventive agent in experimental renal ischemia-reperfusion injury. Urol Res 2001;29:186-189. 33. Tetik O, Yagdi T, Islamoglu F, Calkavur T, Posacioglu H, Atay Y, Ayik F, Canpolat L, Yuksel M. The effects of L-carnitine on spinal cord ischemia/reperfusion injury in rabbits. Thorac Cardiovasc Surg 2002;50:11-15. 34. Loster H, Bohm U. L-carnitine reduces malondialdehyde concentrations in isolated rat hearts in dependence on perfusion conditions. Mol Cell Biochem 2001;217:8390. 35. Luo X, Reichetzer B, Trines J, Benson LN, Lehotay DC. L-carnitine attenuates doxorubicin-induced lipid peroxidation in rats. Free Radic Biol Med 1999;26:1158-1165. 36. Kawasaki N, Lee JD, Shimizu H, Ueda T. Long-term 1-carnitine treatment prolongs the survival in rats with adriamycin-induced heart failure. J Card Fail 1996;2: 293-299. 37. Chang B, Nishikawa M, Sato E, Utsumi K, Inoue M. L-Carnitine inhibits cisplatin-induced injury of the kidney and small intestine. Arch Biochem Biophys 2002;405:55-64. 38. Moretti S, Famularo G, Marcellini S, Boschini A, Santini G, Trinchieri V, Lucci L, Alesse E, De Simone C. L-carnitine reduces lymphocyte apoptosis and oxidant stress in HIV-1-infected subjects treated with zidovudine and didanosine. Antioxid Redox Signal 2002;4:391-403. 39. Cifone MG, Alesse E, Di Marzio L, Ruggeri B, Zazzeroni F, Moretti S, Famularo G, Steinberg SM, Vullo E, De

40.

41.

42.

43. 44.

45. 46.

47.