Abstract
BackgroundSome studies but not others suggest angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use prior to major surgery associates with a higher risk of postoperative acute kidney injury (AKI) and death.MethodsWe conducted a large population-based retrospective cohort study of patients aged 66 years or older who received major elective surgery in 118 hospitals in Ontario, Canada from 1995 to 2010 (n = 237,208). We grouped the cohort into ACEi/ARB users (n = 101,494) and non-users (n = 135,714) according to whether the patient filled at least one prescription for an ACEi or ARB (or not) in the 120 days prior to surgery. Our study outcomes were acute kidney injury treated with dialysis (AKI-D) within 14 days of surgery and all-cause mortality within 90 days of surgery.ResultsAfter adjusting for potential confounders, preoperative ACEi/ARB use versus non-use was associated with 17% lower risk of post-operative AKI-D (adjusted relative risk (RR): 0.83; 95% confidence interval (CI): 0.71 to 0.98) and 9% lower risk of all-cause mortality (adjusted RR: 0.91; 95% CI: 0.87 to 0.95). Propensity score matched analyses provided similar results. The association between ACEi/ARB and AKI-D was significantly modified by the presence of preoperative chronic kidney disease (CKD) (P value for interaction < 0.001) with the observed association evident only in patients with CKD (CKD - adjusted RR: 0.62; 95% CI: 0.50 to 0.78 versus No CKD: adjusted RR: 1.00; 95% CI: 0.81 to 1.24).ConclusionsIn this cohort study, preoperative ACEi/ARB use versus non-use was associated with a lower risk of AKI-D, and the association was primarily evident in patients with CKD. Large, multi-centre randomized trials are needed to inform optimal ACEi/ARB use in the peri-operative setting.
Highlights
Some studies but not others suggest angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use prior to major surgery associates with a higher risk of postoperative acute kidney injury (AKI) and death
Previous observational studies on the association between preoperative ACEi/ARB use and AKI have had conflicting results, and have focused on milder forms of AKI rather than the most serious renal outcome of acute kidney injury treated with dialysis (AKI-D). We conducted this large retrospective cohort study to test the hypothesis that preoperative ACEi/ARB use compared to non-use associates with a different risk of AKI-D following major elective surgery
ACEi/ARB users, compared to non-users, were more likely to be on anti-diabetic medications, other anti-hypertensive medications (β-blockers, calcium channel blockers, and non-potassium sparing diuretics), and statins
Summary
Some studies but not others suggest angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use prior to major surgery associates with a higher risk of postoperative acute kidney injury (AKI) and death. Angiotensin converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) are frequently prescribed medications [11,12] Despite their demonstrated benefits in outpatient settings, their continued use in the perioperative period remains controversial as preoperative ACEi/ARB use may lead to the development of perioperative hypotension and subsequent AKI [8,13,14,15,16]. Previous observational studies on the association between preoperative ACEi/ARB use and AKI have had conflicting results, and have focused on milder forms of AKI rather than the most serious renal outcome of AKI-D. We conducted this large retrospective cohort study to test the hypothesis that preoperative ACEi/ARB use compared to non-use associates with a different risk of AKI-D following major elective surgery
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