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peri-operative acute kidney injury

Last post 28 Oct 2018, 3:29 AM by Drake Thomas. 2 replies.
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  •  10 Oct 2018, 1:26 PM 2665

    peri-operative acute kidney injury

    I would like to thank the STARSurg Collaborative for their paper addressing the unresolved dilemma of whether to stop or continue angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-2 receptor blockers (ARBs) in the peri-operative period [1]. Could I invite the authors to comment on their definition of ‘peri-operative’, as it is not clear when patients were restarted on their ACEi and ARBs postoperatively?

    Secondly, the authors compared their study with a large cohort study that showed a significant reduction in all-cause mortality and cardiovascular events after stopping ACEi and ARBs before surgery [2] and noted that Roshanov et al. did not assess acute kidney injury. However, neither group assessed the benefits and harms of avoiding ACEi and ARBs in the immediate 48hrs after surgery, which appears to improve cardiovascular parameters and significantly reduce acute kidney injury as part of a peri-operative care bundle [3]. Could the authors comment on whether they agree ACEis and ARBs should be avoided in the early postoperative period (<48hours) after surgery?

     

    A.    Sell 

    Royal National Orthopaedic Hospital,

    London, UK.

    Email: alexander.sell@nhs.net

     

    No external funding and no conflicts of interest declared.

     

    References

    1. STARSurg Collaborative.  Association between peri-operative angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers and acute kidney injury in major elective non-cardiac surgery: a multicentre, prospective cohort study.  Anaesthesia 2018; 73: 1214-22.

    2.  Roshanov P, Rochwerg B, Patel A, et al.  Witholding versus continuing angiotenson-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery.  Anesthesiology 2017; 126: 16-27.

    3.  Meersch M, Schmidt C, Hoffmeier A, et al.  Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers:  the PrevAKI randomized controlled trial.  Intensive Care Medicine 2017; 43: 1551-61.

  •  22 Oct 2018, 8:23 AM 2674 in reply to 2665

    A reply

    We thank Dr. Sell for his reply to our recent paper on the use of Angiotensin Converting Enzyme Inhibitors (ACEi) and Angiotensin II Receptor Blockers (ARBs) in major gastrointestinal surgery [1]. We defined ‘peri-operative’ as administration of at least one dose of ACEi/ARB in the 24 hours before surgery, and ‘post-operative’ as administration of at least one dose of ACEi/ARB in the first seven days after surgery. These definitions were decided upon before undertaking data collection, and are described in the study protocol [2]. 

    There is a lack of evidence about whether withholding ACEi/ARBs directly contributes to post-operative acute kidney injury (AKI). The available evidence is based upon care bundles, which have the inherent drawback of making causality impossible to attribute to a single intervention [3]. Furthermore, the incidence of AKI has complex relationships with cardiovascular disease [4]. Patients with cardiovascular disease are highly likely to be taking ACEi/ARBs before surgery, and therefore the use of ACEi/ARBs serves as a marker for those who are more likely to develop AKI, regardless of their peri-operative withdrawal, at least in our observational data.

    A further unanswered question concerns relationship between ACEi/ARBs, intraoperative blood pressure and postoperative AKI. At present, there is conflicting evidence in this area, with lack of randomised evidence to underpin a clear recommendation on withholding ACEi/ARBs in major gastrointestinal surgery. Given this equipoise and lack of high-quality evidence, there is a clinical need for patients to be recruited into randomised controlled trials to identify the impact of withholding ACEi/ARBs in this patient group. We look forward to the results of the SPACE trial which should provide valuable answers to these questions [5]. 

     

    T. Drake 

    W. Ahmed

    R. A. Khaw

    I. Yasin

    D. Baker

    E. Mills

    S. K. Kamarajah

    A. Borakati

    On behalf of the STARSurg Collaborative

    Edinburgh, Scotland.

    Email: T.drake@ed.ac.uk

     

    No external funding and no conflicts of interest declared.

     

    References

    1.      STARSurg Collaborative. Association between peri-operative angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers and acute kidney injury in major elective non-cardiac surgery: a multicentre, prospective cohort study. Anaesthesia 2018; 73: 1214-22.

    2.      STARSurg Collaborative. Outcomes After Kidney injury in Surgery (OAKS): protocol for a multicentre, observational cohort study of acute kidney injury following major gastrointestinal and liver surgery. BMJ Open 2016; 6: e009812.

    3.      Joannidis M, Druml W, Forni LG, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017: Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Medicine 2017; 43: 730-49.

    4.      Hsiao PG, Hsieh CA, Yeh CF, Wu HH, Shiu TF, Chen YC, Chu PH. Early prediction of acute kidney injury in patients with acute myocardial injury. Journal of Critical Care 2012; 27: 525.e1-7.

    5.      Stopping perioperative angiotensin II converting enzyme inhibitors and/or angiotensin receptor blockers in major noncardiac surgery (SPACE) trial. https://www.isrctn.com/ISRCTN17251494 (accessed 22/10/2018).

     

  •  28 Oct 2018, 3:29 AM 2676 in reply to 2674

    Peri-operative acute kidney injury - a reply

     

    We thank Dr. Sell for his reply to our recent paper on the use of angiotensin converting enzyme inhibitors (ACEi) and angiotensin-2 receptor blockers (ARBs) in major gastrointestinal surgery [1]. We defined ‘peri-operative’ as administration of at least one dose of ACEi/ARB in the 24 hours before surgery, and ‘postoperative’ as administration of at least one dose of ACEi/ARB in the first seven days after surgery. These definitions were decided upon before undertaking data collection, and are described in the study protocol [2]. 

     

    There is a lack of evidence about whether withholding ACEi/ARBs directly contributes to postoperative acute kidney injury (AKI). The available evidence is based upon care bundles, which have the inherent drawback of making causality impossible to attribute to a single intervention [3]. Furthermore, the incidence of AKI has complex relationships with cardiovascular disease [4]. Patients with cardiovascular disease are highly likely to be taking ACEi/ARBs before surgery, and therefore the use of ACEi/ARBs serves as a marker for those who are more likely to develop AKI, regardless of their peri-operative withdrawal, at least in our observational data. 

     

    A further unanswered question concerns relationship between ACEi/ARBs, intra-operative blood pressure and postoperative AKI. At present, there is conflicting evidence in this area, with lack of randomised evidence to underpin a clear recommendation on withholding ACEi/ARBs in major gastrointestinal surgery. Given this equipoise and lack of high-quality evidence, there is a clinical need for patients to be recruited into randomised controlled trials to identify the impact of withholding ACEi/ARBs in this patient group. We look forward to the results of the SPACE trial which should provide valuable answers to these questions [5]. 

     

    T. M. Drake

    W. Ahmed

    R. A. Khaw

    I. Yasin

    D. Baker

    E. Mills

    S. K. Kamarajah

    A. Borakati

    On behalf of the STARSurg Collaborative

    Edinburgh, Scotland.

    Email: T.drake@ed.ac.uk

     

    No external funding and no conflicts of interest declared.

     

     

    References

    1.      STARSurg Collaborative. Association between peri-operative angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers and acute kidney injury in major elective non-cardiac surgery: a multicentre, prospective cohort study. Anaesthesia 2018; 73: 1214-22. 

    2.      STARSurg Collaborative. Outcomes After Kidney injury in Surgery (OAKS): protocol for a multicentre, observational cohort study of acute kidney injury following major gastrointestinal and liver surgery. BMJ Open 2016; 6: e009812. 

    3.      Joannidis M, Druml W, Forni LG, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017: Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Medicine 2017; 43: 730-49. 

    4.      Hsiao PG, Hsieh CA, Yeh CF, Wu HH, Shiu TF, Chen YC, Chu PH. Early prediction of acute kidney injury in patients with acute myocardial injury. Journal of Critical Care 2012; 27: 525.e1-7. 

    5.      Stopping perioperative angiotensin II converting enzyme inhibitors and/or angiotensin receptor blockers in major noncardiac surgery (SPACE) trial. https://www.isrctn.com/ISRCTN17251494 (accessed 22/10/2018).

     

     

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