Renin–angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Colorectal cancer surgery (n=9932). Intervention: Preoperative ACE inhibitor or angiotensin receptor blocker use (current and former users) vs. Non-users of ACE inhibitors or angiotensin receptor blockers within 365 days before surgery. Primary outcome: 7-day postoperative acute kidney injury (AKI) defined according to KDIGO creatinine criteria (aRR 1.20, 95% CI 1.09-1.32).

Q: What does this research mean for the field?

Preoperative use of ACE inhibitors or angiotensin receptor blockers is associated with an increased risk of postoperative acute kidney injury following colorectal cancer surgery. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Charlotte Slagelse; Henrik Gammelager; Lene Hjerrild Iversen; Kathleen D. Liu; Henrik Toft Sørensen; Christian Fynbo Christiansen

doi:10.1136/bmjopen-2019-032964

November 1, 2019BMJ OpenOpen Access

Renin–angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

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Why the study?

It was unknown whether preoperative use of ACE inhibitors or angiotensin receptor blockers affects the risk of acute kidney injury after colorectal cancer surgery.

Does preoperative use of ACE inhibitors or angiotensin receptor blockers increase the 7-day risk of acute kidney injury in patients undergoing colorectal cancer surgery?

Key Points

To determine whether preoperative use of ACE inhibitors or angiotensin receptor blockers affects the risk of developing acute kidney injury following colorectal cancer surgery.
Population-based observational cohort study of 9932 patients undergoing incident colorectal cancer surgery between 2005 and 2014 in northern Denmark using the Danish Colorectal Cancer Group Database.
Acute kidney injury within 7 days post-surgery was evaluated using KDIGO consensus criteria, and adjusted risk ratios (aRRs) were estimated via log-binomial regression accounting for death as a competing risk.
The 7-day postoperative acute kidney injury risk was 26.4% (95% CI 24.6% to 28.3%) for current users, 25.2% (95% CI 21.9% to 28.6%) for former users, and 17.8% (95% CI 17.0% to 18.7%) for non-users.
Compared with non-users, the adjusted risk ratio of acute kidney injury was 1.20 (95% CI 1.09 to 1.32) for current users and 1.16 (95% CI 1.01 to 1.34) for former users.
The increased relative risk among current users remained consistent across most clinical subgroups, but was notably higher in patients without a diagnosis of hypertension (aRR 1.39, 95% CI 1.23 to 1.59) than in those with hypertension (aRR 1.03, 95% CI 0.90 to 1.17).

Study Design

Type

Cohort (n=9,932)

Multicenter

Yes

Structured PICO

Does preoperative use of ACE inhibitors or angiotensin receptor blockers increase the 7-day risk of acute kidney injury in patients undergoing colorectal cancer surgery?

P

Population

9,932 adults undergoing incident colorectal cancer surgery in northern Denmark (mean age 69.5 years, 46.7% female), excluding those on prior chronic renal replacement therapy or undergoing explorative-only procedures, followed for 7 days postoperatively.

E

Exposure

Preoperative renin-angiotensin system blocker (ACE inhibitor or angiotensin receptor blocker) use, categorized as current users (21.3%, n=2,112) and former users (6.4%, n=639) based on reimbursed prescriptions within 365 days before surgery.

C

Comparator

Non-users of ACE inhibitors or angiotensin receptor blockers within 365 days before surgery (72.3%, n=7,181).

O

Outcome

7-day postoperative acute kidney injury (AKI) defined by Kidney Disease Improving Global Outcome (KDIGO) plasma creatinine criteria (increase in creatinine >=50% from baseline, increase >=0.3 mg/dL within 48 hours, creatinine >=4.0 mg/dL with acute increase >=0.5 mg/dL, or initiation of renal replacement therapy), with death treated as a competing risk.hard clinical

Main Result

Relative Risk: 1.2 (95% CI 1.09–1.32)

Absolute Event Rate: 26.4% vs 17.8%

Limitations

Incomplete information on whether current users were exposed to their medication on the day of surgery
Potential misclassification of current users as former users if medication was redeemed for an interval greater than 90 days
Inability to consider the urine output-based definition of AKI
Residual and unmeasured confounding by indication cannot be ruled out due to lack of data on perioperative blood pressure, fluid balance, and exact timing of other postoperative complications
Incomplete information on whether current users took their ACE-I/ARB medication on the actual day of surgery
Potential misclassification of current users as former users for prescriptions redeemed for an interval greater than 90 days
Could not include the urine output-based criteria for AKI
Residual and unmeasured confounding by indication (e.g., lack of data on intraoperative blood pressure, fluid balance, and administration)

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Implication

Preoperative current or former use of ACE inhibitors or ARBs identifies patients at a ~20% higher relative risk of acute kidney injury within 7 days after colorectal cancer surgery, warranting heightened perioperative renal monitoring.

Abstract

OBJECTIVES: It is unknown whether preoperative use of ACE inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) affects the risk of acute kidney injury (AKI) after colorectal cancer (CRC) surgery. We assessed the impact of preoperative ACE-I/ARB use on risk of AKI after CRC surgery. DESIGN: Observational cohort study. Patients were divided into three exposure groups-current, former and non-users-through reimbursed prescriptions within 365 days before the surgery. AKI within 7 days after surgery was defined according to the current Kidney Disease Improving Global Outcome consensus criteria. SETTING: Population-based Danish medical databases. PARTICIPANTS: A total of 9932 patients undergoing incident CRC surgery during 2005-2014 in northern Denmark were included through the Danish Colorectal Cancer Group Database. OUTCOME MEASURE: We computed cumulative incidence proportions (risk) of AKI with 95% CIs for current, former and non-users of ACE-I/ARB, including death as a competing risk. We compared current and former users with non-users by computing adjusted risk ratios (aRRs) using log-binomial regression adjusted for demographics, comorbidities and CRC-related characteristics. We stratified the analyses of ACE-I/ARB users to address any difference in impact within relevant subgroups. RESULTS: Twenty-one per cent were ACE-I/ARB current users, 6.4% former users and 72.3% non-users. The 7-day postoperative AKI risk for current, former and non-users was 26.4% (95% CI 24.6% to 28.3%), 25.2% (21.9% to 28.6%) and 17.8% (17.0% to 18.7%), respectively. The aRRs of AKI were 1.20 (1.09 to 1.32) and 1.16 (1.01 to 1.34) for current and former users, compared with non-users. The relative risk of AKI in current compared with non-users was consistent in all subgroups, except for higher aRR in patients with a history of hypertension. CONCLUSIONS: Being a current or former user of ACE-I/ARBs is associated with an increased risk of postoperative AKI compared with non-users. Although it may not be a drug effect, users of ACE-I/ARBs should be considered a risk group for postoperative AKI.

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Cite This Study

Slagelse et al. (2019) conducted a cohort in Colorectal cancer surgery (n=9,932). Preoperative ACE inhibitor or angiotensin receptor blocker use (current and former users) vs. Non-users of ACE inhibitors or angiotensin receptor blockers within 365 days before surgery was evaluated on 7-day postoperative acute kidney injury (AKI) defined according to KDIGO creatinine criteria (aRR 1.20, 95% CI 1.09-1.32).

synapsesocial.com/papers/6a75a53d7937f22c0fe8c592 https://doi.org/10.1136/bmjopen-2019-032964

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Renin–angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

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Key Points

Study Design

Structured PICO

Main Result

Limitations

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Implication

Abstract

Discussion

Cite This Study

Renin–angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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