title: Pre- and/or Intra-Operative Prescription of Diuretics, but Not Renin-Angiotensin-System Inhibitors, Is Significantly Associated with Acute Kidney Injury after Non-Cardiac Surgery: A Retrospective Cohort Study.
abstract: OBJECTIVE
  Pre- and/or intra-operative use of diuretics, angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) constitutes a potentially modifiable risk factor for postoperative acute kidney injury (AKI). It has been studied whether use of these drugs predicts AKI after cardiac surgery. The objective of this study was to examine whether administration of these agents was independently associated with AKI after non-cardiac surgery.
  
  
  METHODS
  This was a retrospective observational study. Inclusion criteria were adult patients (age ≥ 18) who underwent non-cardiac surgery under general anesthesia from 2007 to 2009 at Kyoto Katsura Hospital. Exclusion criteria were urological surgery, missing creatinine values, and preoperative dialysis. The exposures of interest were pre- and/or intra-operative use of diuretics or ACE-I/ARB. Outcome variables were postoperative AKI as defined by the AKI Network (increase in creatinine ≥ 0.3 mg/dL or 150% within 48 hours, or urine output < 0.5 ml/kg/hour for > 6 hours). Multivariable logistic regression analyses were conducted and adjusted for potential confounders. Propensity scores (PS) for receiving diuretics or ACE-I/ARB therapy were estimated and PS adjustment, PS matching, and inverse probability weighting were performed.
  
  
  RESULTS
  There were 137 AKI cases (5.0%) among 2,725 subjects. After statistical adjustment for patient and surgical characteristics, odds (95% CI) of postoperative AKI were 2.07 (1.10-3.89) (p = 0.02) and 0.89 (0.56-1.42) (p = 0.63) in users of diuretics and ACE-I/ARB, respectively, compared with non-users. PS adjustment, PS matching, and inverse probability weighting yielded similar results. The effect size of diuretics was significantly greater in the patients with lower propensity for diuretic use (p for interaction < 0.1).
  
  
  CONCLUSIONS
  Prescription of diuretics, but not ACE-I/ARB, was independently associated with postoperative AKI after non-cardiac surgery, especially in patients with low propensity for diuretic use. It might be reasonable to withhold preoperative diuretics in these patients.
authors.affiliation: Department of Nephrology, Kyoto Katsura Hospital, 17 Yamada-hirao-cho, Nishikyo-ku, Kyoto, 6158256, Japan; First Department of Internal Medicine, Nara Medical University, 840 Shijo-cho, Kashihara-shi, Nara, 634-8522, Japan.
authors.forename: Miho
authors.initials: M
authors.lastname: Tagawa
authors.affiliation: Department of Nephrology, Kyoto City Hospital, 1-2, Higashitakada-cho, Mibu, Nakagyo-ku, 6048845, Japan.
authors.forename: Ai
authors.initials: A
authors.lastname: Ogata
authors.affiliation: Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita-shi, Osaka, 5650871, Japan.
authors.forename: Takayuki
authors.initials: T
authors.lastname: Hamano
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology*; D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000494:pharmacology; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000494:pharmacology; D004232:Diuretics / Q000009:adverse effects*; D011307:Drug Prescriptions; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011300:Preoperative Care; D057216:Propensity Score; D012084:Renin-Angiotensin System / Q000187:drug effects*; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000009:adverse effects*
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D004232:Diuretics