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Renal medicine
Research
What are the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury? A systematic review and meta-analysis
  1. Penny Whiting1,2,
  2. Andrew Morden1,2,
  3. Laurie A Tomlinson3,4,
  4. Fergus Caskey2,3,
  5. Thomas Blakeman5,6,
  6. Charles Tomson7,
  7. Tracey Stone1,2,
  8. Alison Richards1,2,
  9. Jelena Savović1,2,
  10. Jeremy Horwood1,2
  1. 1The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  2. 2School of Social and Community Medicine, University of Bristol, Bristol, UK
  3. 3UK Renal Registry, Bristol, UK
  4. 4Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  5. 5Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK
  6. 6National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
  7. 7Department of Renal Medicine, Freeman Hospital, Newcastle Upon Tyne Hospitals Foundation Trust, Tyne and Wear, UK
  1. Correspondence to Dr Penny Whiting; penny.whiting{at}bristol.ac.uk

Abstract

Objectives To summarise evidence on temporary discontinuation of medications to prevent acute kidney injury (AKI).

Design Systematic review and meta-analysis of randomised and non-randomised studies.

Participants Adults taking diuretics, ACE inhibitors (ACEI), angiotensin receptor blockers (ARB), direct renin inhibitors, non-steroidal anti-inflammatories, metformin or sulfonylureas, experiencing intercurrent illnesses, radiological or surgical procedures.

Interventions Temporary discontinuation of any of the medications of interest.

Primary and secondary outcome measures Risk of AKI. Secondary outcome measures were estimated glomerular filtration rate and creatinine post-AKI, urea, systolic and diastolic blood pressure, death, clinical outcomes and biomarkers.

Results 6 studies were included (1663 participants), 3 randomised controlled trials (RCTs) and 3 prospective cohort studies. The mean age ranged from 65 to 73 years, and the proportion of women ranged from 31% to 52%. All studies were in hospital settings; 5 evaluated discontinuation of medication prior to coronary angiography and 1 prior to cardiac surgery. 5 studies evaluated discontinuation of ACEI and ARBs and 1 small cohort study looked at discontinuation of non-steroidal anti-inflammatory drugs. No studies evaluated discontinuation of medication in the community following an acute intercurrent illness. There was an increased risk of AKI of around 15% in those in whom medication was continued compared with those in whom it was discontinued (relative risk (RR) 1.17, 95% CI 0.99 to 1.38; 5 studies). When only results from RCTs were pooled, the increase in risk was almost 50% (RR 1.48, 95% CI 0.84 to 2.60; 3 RCTs), but the CI was wider. There was no difference between groups for any secondary outcomes.

Conclusions There is low-quality evidence that withdrawal of ACEI/ARBs prior to coronary angiography and cardiac surgery may reduce the incidence of AKI. There is no evidence of the impact of drug cessation interventions on AKI incidence during intercurrent illness in primary or secondary care.

Trial registration number PROSPERO CRD42015023210.

  • Acute kidney injury
  • Medication discontinuation
  • Sick day rules
  • Angiotensin-converting enzyme inhibitors
  • Angiotensin receptor blockers
  • NSAIDs

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjopen-2016-012674

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    Footnotes

    • Contributors CT, TB and FC conceived the idea for the review. PW, AM, JH and LAT drafted the article with the support of FC. AR developed the search strategy. FC, LAT, TB and CT served as content experts in the field of AKI. JH served as the overall supervisor and provided input on study methodology. JS provided methodological support. AM, PW and TS undertook screening and data extraction. PW and FC performed the risk of bias assessment. PW and JS performed the GRADE assessment. All authors contributed to the interpretation of results, commented on draft manuscripts and have given their approval for publication.

    • Funding This research is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol NHS Foundation Trust. TB was partly funded by the NIHR CLAHRC Greater Manchester. LAT is funded by a Wellcome Trust intermediate clinical fellowship (101143/Z/13/Z).

    • Disclaimer The funders had no role in the design of the study, data collection and analysis, decision to publish or preparation of the manuscript. However, the project outlined in this article may be considered to be affiliated to the work of the NIHR CLAHRC Greater Manchester and NIHR CLAHR West. The views expressed in this article are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.