Pre- and/or Intra-Operative Prescription of Diuretics, but Not Renin-Angiotensin-System Inhibitors, Is Significantly Associated with Acute Kidney Injury after Non-Cardiac Surgery: A Retrospective Cohort Study

Abstract

Background and ObjectivesPre- and/or intra-operative use of diuretics, angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) constitutes a potentially modifiable risk factor for postoperative acute kidney injury (AKI). It has been studied whether use of these drugs predicts AKI after cardiac surgery. The objective of this study was to examine whether administration of these agents was independently associated with AKI after non-cardiac surgery.Design, Setting, Participants, and MeasurementsThis was a retrospective observational study. Inclusion criteria were adult patients (age ≥ 18) who underwent non-cardiac surgery under general anesthesia from 2007 to 2009 at Kyoto Katsura Hospital. Exclusion criteria were urological surgery, missing creatinine values, and preoperative dialysis. The exposures of interest were pre- and/or intra-operative use of diuretics or ACE-I/ARB. Outcome variables were postoperative AKI as defined by the AKI Network (increase in creatinine ≥ 0.3 mg/dL or 150% within 48 hours, or urine output < 0.5 ml/kg/hour for > 6 hours). Multivariable logistic regression analyses were conducted and adjusted for potential confounders. Propensity scores (PS) for receiving diuretics or ACE-I/ARB therapy were estimated and PS adjustment, PS matching, and inverse probability weighting were performed.ResultsThere were 137 AKI cases (5.0%) among 2,725 subjects. After statistical adjustment for patient and surgical characteristics, odds (95% CI) of postoperative AKI were 2.07 (1.10-3.89) (p = 0.02) and 0.89 (0.56-1.42) (p = 0.63) in users of diuretics and ACE-I/ARB, respectively, compared with non-users. PS adjustment, PS matching, and inverse probability weighting yielded similar results. The effect size of diuretics was significantly greater in the patients with lower propensity for diuretic use (p for interaction < 0.1).ConclusionsPrescription of diuretics, but not ACE-I/ARB, was independently associated with postoperative AKI after non-cardiac surgery, especially in patients with low propensity for diuretic use. It might be reasonable to withhold preoperative diuretics in these patients.

Acute Kidney Injury in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

“…In addition, in recent years, the use of hydroxyethyl starch (HES) solutions, unnecessary blood transfusions, chloride-rich intravenous fluids, and aminoglycosides have been discouraged [29,52,73]. Furthermore, although the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) and perioperative AKI risk remains controversial [2,74,75], ACEIs/ARBs have been commonly discontinued before THA to prevent intraoperative hypotension [29]. Future studies are required to assess if discontinuation of ACEIs/ARBs before THA may affect the incidence of THA-associated AKI, and whether it should be included in AKI preventative strategies and care optimization among patients undergoing THA [37,40].…”

Contemporary practice patterns related to the risk of acute kidney injury in the catheterization laboratory: Results from a survey of Society of Cardiovascular Angiography and Intervention (SCAI) cardiologists

“…However, less clear is how to manage diuretics, ACE‐I/ARBs, and metformin. Initiation of diuretics without adequate volume support leading to a pre‐renal state is detrimental to renal function . Chronic diuretic use before contrast administration may also increase the risk of subsequent AKI .…”

Management of post-operative acute kidney injury

“…However, clinical studies do not support this theory with prophylactic use of furosemide found to increase rates of AKI following cardiac surgery (20). Similarly, in a recent study of non-cardiac surgery, perioperative use of diuretics was associated with increased post-operative AKI (21). No by guest on October 19, 2016 benefit was also shown in a Cochrane systematic review examining pharmacological interventions to prevent AKI (22).…”