This document provides information about the Nephrology On-Demand iOS app, which allows users to access teaching resources on nephrology. It lists the contributors to the Nephrology On-Demand publication and publication details. The main article discusses a meta-analysis examining the risk of postoperative acute kidney injury in patients taking angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before surgery. The meta-analysis found no increased risk when adjusting for confounders, and some evidence that preoperative use may reduce AKI risk. Discontinuing these drugs before surgery may actually increase AKI risk.
This document provides information about the Nephrology On-Demand iOS app, which allows users to access teaching resources on nephrology. It lists the contributors to the Nephrology On-Demand publication and publication details. The main article discusses a meta-analysis examining the risk of postoperative acute kidney injury in patients taking angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before surgery. The meta-analysis found no increased risk when adjusting for confounders, and some evidence that preoperative use may reduce AKI risk. Discontinuing these drugs before surgery may actually increase AKI risk.
This document provides information about the Nephrology On-Demand iOS app, which allows users to access teaching resources on nephrology. It lists the contributors to the Nephrology On-Demand publication and publication details. The main article discusses a meta-analysis examining the risk of postoperative acute kidney injury in patients taking angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before surgery. The meta-analysis found no increased risk when adjusting for confounders, and some evidence that preoperative use may reduce AKI risk. Discontinuing these drugs before surgery may actually increase AKI risk.
This document provides information about the Nephrology On-Demand iOS app, which allows users to access teaching resources on nephrology. It lists the contributors to the Nephrology On-Demand publication and publication details. The main article discusses a meta-analysis examining the risk of postoperative acute kidney injury in patients taking angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before surgery. The meta-analysis found no increased risk when adjusting for confounders, and some evidence that preoperative use may reduce AKI risk. Discontinuing these drugs before surgery may actually increase AKI risk.
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Contributors: A Bansal (UPenn) | P Dedhia (U of
Cincinnati) | A Elebiary (Lahey Clinic) | X Vela (U of El Salvador) | D Thomson (ECU) | P Jawa (ECU) | S Sridharan (Lister Hospital, UK) | F Iannuzsella (IRCCS, Italy) | D Mitema (Johns Hopkins U) | Malvinder Parmar (Northern Ontario, Canada) | Wisit Cheungpasitporn (Mayo)
I ssue 2
Volume 2
Year 2015
URL http://goo.gl/QDSB5B
#Kidney KONNECTI ON Editor: Tejas Desai | Chief: Cynthia Christiano | Free subscription by emailing [email protected]
EVIDENCE-BASED MYTH BUSTING
PREOPERATIVE ACE INHIBITORS / ARBS
by Wisit Cheungpasitporn (@wisit661)
The long-term protective effects of renin?angiotensin system (RAS)
inhibitors, including angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs), in patients with congestive heart failure (CHF) and diabetic nephropathy are now well established. Animal models also suggest renoprotective effects of RAS inhibitors in ischemic acute kidney injury (AKI). But when patients develop AKI, clinicians usually discontinue RAS inhibitors b/c it's been assumed that they may worsen the severity of AKI; despite the fact that their effects on glomerular filtration rate (GFR) reduction are modest. Consider postoperative AKI; a very common encounter that is associated with hospital mortality. The use of a RAS inhibitor preoperatively has been a concern b/c they, theoretically, can blunt the compensatory activation of the RAS during surgery: resulting in intraoperative hypotension or ?vasoplegia?--> postoperative AKI. Unfortunately, there's been a lot of conflicting information about the effect of RAS inhibitors on developing post-op AKI. So when a recent meta-analysis suggested an increased postoperative AKI risk in patients who received preoperative RAS inhibitors, clinicians continued to stop RAS inhibitors before the day of surgery. It's just too bad that the incidences of postoperative AKI and AKI-associated mortality have not significantly reduced with this preventative measure. Looking closely @ this meta-analysis reveals a statistical faux-pas: no adjustment for the odds ratios of the included studies; Sounds boring, but this statistical omission could introduce confounding. Specifically patients who use RAS inhibitors usually have other co-morbidities (CHF, HTN, & DM) which can result in a higher risk of postoperative AKI. Rather than wait for a new meta-analysis to be done, I decided to help conduct a new one! In our meta-analysis we included more recent studies & a pre-specified sensitivity analysis based on propensity score-based studies to evaluate the risk of postoperative AKI in patients who received preoperative RAS inhibitors. In other words, we designed a meta-analysis that accounted for these confounders. Twenty-four studies with 102,675 patients were included. In most of these studies, patients received RAS inhibitors ?2 weeks before surgery and continued the medication until a day before or on the day of surgery.
When all studies, both adjusted and non-adjusted for potential confounders were included in the analysis, we found an insignificant association between postoperative AKI and preoperative use of RAS inhibitors! In fact, in the pre-specified analysis of RCTs and cohort studies with propensity score analyses, we found a significant association between preoperative RAS inhibitor use and a lower incidence of AKI (pooled RR of 0.92, 95% CI: 0.85?0.99, I2 = 78%). That led us to wonder: are we causing more AKI by discontinuing RAS inhibitors preoperatively? In major surgeries, the RAS system can be over-activated from 1) hemodynamic changes & 2) interruptions to blood flow (causing renal ischemia and a fall in GFR). Reducing the RAS response to renal ischemia during surgery has been demonstrated to lower systemic vascular resistance and improve renal plasma flow. In addition, the preoperative discontinuation of RAS inhibitors is associated with hypertension, higher emergency operations, and post-op intra-aortic balloon procedures. By reducing bias in this meta-analysis, we found remarkably different results. However, a causal relationship needs to be cautiously interpreted, and future RCTs are required to confirm an association between the preoperative use of RAS inhibitors and lower incidence of AKI. In the meanwhile, RAS inhibitors should not be routinely discontinued preoperatively to reduce the risk of developing AKI.
To learn more about preoperative RAS inhibition and the risk of developing postoperative AKI, contact the author @wisit661 or [email protected] or visit the following resources:
JACC 2007; 50:2148
CCM 2003; 31: 1421
Ann Int Med 2008;
148:30
Br J Anaest 2001; 86:169
AJKD 2013; 62:1077
AJKD 2015; 65:p82
NDT 2015; 22
HOW WELL DO YOU
KNOW...ANCA ASSOCIATED VASCULITIS?
SELFIES ECTOPIC CALCIFICATIONS
TAKE A STAB AT OUR LATEST CROSSWORD PUZZLE. MAIL IN
YOUR ANSWERS TO [email protected] OR TWEET THEM USING THE HASHTAG #KIDNEYKONNECTION Shown above is an abdomen-pelvis un-enhanced CT scan of a 62 year-old women who presented with the classic signs and symptoms of uremia. She was started on emergent renal replacement therapy after labs revealed a BUN > 100 mg/dl and creatinine ~ 13 mg/dl. During her workup the calcium-phosphate product was noted to be 80. She complained of abdominal pain which was evaluated through an abdominal XR. Interestingly, the XR (& subsequent CT) did not show vascular calcifications. Shown above is one section of that CT showing ectopic calcifications: the cause of her abdominal pain. Green arrows represent normal bone. Image courtesy of Dr. Francesco Iannuzzella (@caioqualunque )
Across 2 These antibodies are not necessarily positive in vasculitic disorders, nor are they necessarily negative in healthy patients 3 ANCAs cause tissue damage by activating monocytes and these cells
11 Acronym of the trial that compared azathioprine to
cyclophosphamide for maintenance therapy in granulomtosis with
4 The pathogenic molecule in anti-GBM disease
polyangiitis
5 A large percentage of Churg-Strauss patients suffer with this
6 Acronym of the trial that compared oral versus intravenous cyclophosphamide as induction therapy against granulomatosis with polyangiitis 7 Acronym of the scoring system used to assess the degree of remission or relapse of a small vessel vasculitis 8 The former name for Granulomatosis with Polyangitis 10 Acronym of the trial that showed potential benefit of using plasma exchange in patients with granulomatosis with polyangiitis who suffer from severe kidney damage (Cr 5.7 mg/dl) or alveolar hemorrhage
Down 1 PR3-ANCA is positive 75% of the time in this type of small vessel vasculitis 9 A common method of classifying systemic vasculitides relies upon this blood vessel characteristic
Early TIPS Versus Endoscopic Therapy For Secondary Prophylaxis After Management of Acute Esophageal Variceal Bleeding in Cirrhotic Patients: A Meta-Analysis of Randomized Controlled Trials
Enhancing Provider Education and Improving Healthcare Disparities in Chronic Myeloid Leukemia (CML) and Multiple Myeloma (MM) Through A Rural Regional North Carolina Hospital Network
