Angiotensin axis blockade, acute kidney injury, and perioperative morbidity in patients undergoing colorectal surgery

Abstract

Patients undergoing surgery and taking angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) are susceptible to complications related to intraoperative hypotension. Perioperative continuation of such medications in patients undergoing colorectal surgery may be associated with more harm than benefit, as these patients are often exposed to other risk factors which may contribute to intraoperative hypotension. Our objectives were to assess the incidence and severity of postinduction hypotension as well as the rates of acute kidney injury (AKI), 30-day all-cause mortality, 30-day readmission, and hospital length of stay in adult patients undergoing colorectal surgery who take ACEi/ARB.We performed a retrospective chart review of patients undergoing colorectal surgery of ≥4 hour duration at a tertiary care academic medical center between January 2011 and November 2016. The preoperative and intraoperative characteristics as well as postoperative outcomes were compared between patients taking ACEi/ARB and patients not taking these medications.Of the 1020 patients meeting inclusion criteria, 174 (17%) were taking either ACEi or ARB before surgery. Patients taking these medications were more likely to receive both postinduction and intraoperative phenylephrine and ephedrine. The incidences of postoperative AKI (P = .35), 30-day all-cause mortality (P = .36), 30-day hospital readmission (P = .45), and hospital length of stay (P = .25), were not significantly different between the 2 groups.Our results support the current recommendation that ACEi/ARB use is probably safe within the colorectal surgery population during the perioperative period. Intraoperative hypotension should be expected and treated with vasopressors.

Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

“…Many, but not all, of the available studies suggest that PO-AKI defined by oliguria alone is more common than PO-AKI defined by changes in serum creatinine levels 26 , 37 – 39 . In a study of PO-AKI after non-cardiac surgery, the incidence of AKI increased from 8% to 64% if urine output was included in the definition 37 .…”

Postoperative Acute Kidney Injury

“…Therefore, it seems logical that withholding these agents in the perioperative period may be effective at reducing postoperative AKI incidence. However, this is not borne out by recent prospective and retrospective studies (34,35), indeed the STARsurg collaborative concluded that withholding ACEis or ARBs did not demonstrate a protective effect against the development of postoperative AKI within the general surgical population (36). Given that many patients are placed on ACEis or ARBs for both their cardioprotective and kidneyprotective features, a risk-benefit analysis of continuing these medications in the perioperative period should be taken on an individualized basis, as should their reintroduction postoperatively.…”

Angiotensin II Receptor Blockers but Not Angiotensin-Converting Enzyme Inhibitors Are Associated With a Reduced Risk of Acute Kidney Injury After Major Surgery

“…Though a retrospective cohort study of 1,358 adults revealed that preoperative use of ACEIs/ARBs associated with an increased risk for AKI after cardiovascular surgery (Arora et al, 2008), a newer prospective cohort study of 1,594 adults revealed that preoperative ACEIs/ARBs usage was associated with functional but not structural AKI after cardiac surgery (Coca et al, 2013). However, some studies showed that ACEIs/ARBs were not associated with postoperative AKI (Tagawa et al, 2015;Bonavia et al, 2019), and a study suggested that preoperative ACEIs/ARBs are associated with reduced postoperative AKI requiring dialysis and even reduced mortality (Shah et al, 2014). The risk and benefit of perioperative use of ACEIs/ARBs remained uncertain.…”