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Open Access Highly Accessed Research article

Association between angiotensin converting enzyme inhibitor or angiotensin receptor blocker use prior to major elective surgery and the risk of acute dialysis

Mitesh Shah1, Arsh K Jain23, Steven M Brunelli4, Steven G Coca5, Philip J Devereaux67, Matthew T James8, Jin Luo3, Amber O Molnar9, Marko Mrkobrada10, Neesh Pannu11, Chirag R Parikh5, Michael Paterson123, Salimah Shariff4, Ron Wald13, Michael Walsh146, Richard Whitlock156, Duminda N Wijeysundera163 and Amit X Garg17236*

Author Affiliations

1 Divisions of Clinical Epidemiology and Internal Medicine, McGill University, Montreal, Canada

2 Division of Nephrology, Department of Medicine, Western University, London, Canada

3 Institute for Clinical Evaluative Sciences, Ontario, Canada

4 Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA

5 Section of Nephrology, Yale University School of Medicine, New Haven, USA

6 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada

7 Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada

8 Department of Medicine, University of Calgary, Hamilton, Canada

9 Division of Nephrology, University of Ottawa, Ottawa, Canada

10 Department of Medicine, Western University, London, Canada

11 Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada

12 Department of Family Medicine, McMaster University, Hamilton, Canada

13 Division of Nephrology, University of Toronto, Toronto, Canada

14 Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada

15 Department of Surgery, McMaster University, Hamilton, Canada

16 Department of Anesthesia, University of Toronto, Toronto, Canada

17 London Kidney Clinical Research Unit, Westminster, London Health Sciences Centre, Room ELL-101, 800 Commissioners Road East, London, Ontario N6A 4G5, Canada

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BMC Nephrology 2014, 15:53  doi:10.1186/1471-2369-15-53

Published: 2 April 2014

Abstract

Background

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.

Methods

We 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.

Results

After 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).

Conclusions

In 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.

Keywords:
Acute dialysis; Angiotensin converting enzyme inhibitor; Angiotensin receptor blocker; Major elective surgery