Novel insights into the mechanism of cyclophosphamide-induced bladder toxicity: chloroacetaldehyde's contribution to urothelial dysfunction in vitro

Arch Toxicol. 2019 Nov;93(11):3291-3303. doi: 10.1007/s00204-019-02589-1. Epub 2019 Oct 9.


The clinical use of cyclophosphamide and ifosfamide is limited by a resultant bladder toxicity which has been attributed to the metabolite acrolein. Another metabolite chloroacetaldehyde (CAA) associated with nephrotoxicity, has not been investigated for toxicity in the bladder and this study investigates the effects of acrolein and CAA on human urothelial cells in vitro. Human urothelial cells (RT4 and T24) were treated with acrolein or CAA and changes in cell viability, reactive oxygen species, caspase-3 activity and release of urothelial mediators ATP, acetylcholine, PGE2 were measured. The protective effects of N-acetyl cysteine (NAC) were also assessed. Both metabolites were toxic to human urothelial cells, however, CAA significantly decreased cell viability at a ten-fold lower concentration (10 µM) than acrolein (100 µM). This was associated with increased ROS production and caspase-3 activity. NAC protected cells from these changes. In RT4 cells 100 µM acrolein caused a significant increase in basal and stretch-induced ATP, Ach and PGE2 release. In T24 cells chloroacetaldehyde (10 µM) increased basal and stimulated ATP and PGE2 levels. Again, NAC protected against changes in urothelial mediator release following acrolein or CAA. This study is the first to report that CAA in addition to acrolein contributes to the urotoxicity of cyclophosphamide and ifosfamide. Both metabolites altered urothelial mediator levels which could contribute to the sensory and functional bladder changes experienced by patients after treatment with cyclophosphamide or ifosfamide. Alterations in urothelial cell viability and mediator release may be causally linked to oxidative stress, with NAC providing protection against these changes.

Keywords: Acrolein; Chloroacetaldehyde; Cyclophosphamide; Ifosfamide; N-acetyl cysteine; Oxidative stress; Urothelium; Urotoxicity.

MeSH terms

  • Acetaldehyde / analogs & derivatives*
  • Acetaldehyde / metabolism
  • Acetaldehyde / toxicity
  • Acrolein / metabolism
  • Acrolein / toxicity*
  • Antineoplastic Agents, Alkylating / metabolism
  • Antineoplastic Agents, Alkylating / toxicity*
  • Cell Culture Techniques
  • Cell Line
  • Cell Survival / drug effects
  • Cyclophosphamide / metabolism
  • Cyclophosphamide / toxicity*
  • Epithelial Cells / drug effects*
  • Epithelial Cells / metabolism
  • Epithelial Cells / pathology
  • Humans
  • Oxidative Stress / drug effects
  • Reactive Oxygen Species / metabolism
  • Urinary Bladder / drug effects*
  • Urinary Bladder / metabolism
  • Urinary Bladder / pathology
  • Urothelium / drug effects*
  • Urothelium / metabolism
  • Urothelium / pathology


  • Antineoplastic Agents, Alkylating
  • Reactive Oxygen Species
  • Acrolein
  • Cyclophosphamide
  • chloroacetaldehyde
  • Acetaldehyde