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Renal/Inflammation/Protection

Preoperative ACE inhibition and renal dysfunction following cardiac surgery: 105

Penugonda, S. P.1; Khalil, N.1; Armstrong, M. A.2; Gilliland, H.1; McMurray, T. J.1; McBride, W. T.1

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 7

Introduction: Commencement of angiotensin converting enzyme inhibitors (ACEIs) one day following cardiac surgery in patients with moderate preoperative impairment of renal and cardiac function increases postoperative renal dysfunction [1]. Since many cardiac surgery patients receive ACEIs up to the day before surgery we investigated the hypothesis that patients who last received ACEIs on the preoperative day, would have greater postoperative renal dysfunction than patients who never received ACEIs preoperatively. Recently change in serum creatinine (ΔCr) has been shown to be a clinically useful measure of renal dysfunction after cardiac surgery [2].

Method: 244 patients undergoing elective cardiac surgery were consecutively enrolled. Exclusions were preoperative diabetes, liver or renal (Cr > 125 μmol/L) impairment. Serum creatinine was measured on the preoperative day (pre-op), and on the first (D1) second (D2) and fifth (D5) postoperative days respectively. The changes in serum creatinine (ΔCr) from the preoperative baseline (Crpre-op) were calculated for D1, D2 and D5 (for example, ΔCr on D1 (ΔCrD1 = CrD1 − Crpre-op). Between and within group comparisons were determined using unpaired and paired T-tests respectively.

Results: As shown in the figure, pre- and post-operative serum creatinine values were higher in ACEI (n = 108) than non ACEI patients (n = 136). Five ACEI (4.6%) and 2 non ACEI patients (1.5%) had D2 Cr above 140 μmol/L. No postoperative between group difference was noted in ΔCr at D1, D2 and D5.

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Discussion: The higher preoperative creatinine in the ACEI patients may arise directly from renal effects of the drug. Alternatively, hypertensive disease prior to ACEI administration may contribute. However preoperative ACEIs do not appear to increase ΔCr. Further work will determine if discontinuing ACEIs for longer preoperatively would result in lower serum creatinine levels.

References:

1 Manche A, Galea J, Busuttil W. Tolerance to ACE inhibitors after cardiac surgery. Eur J Cardiothorac Surg 1999; 15(1): 55-60.
2 Wijeysundera DN, Rao V, Beattie WS, et al. Evaluating surrogate measures of renal dysfunction after cardiac surgery. Anesth Analg 2003; 96(5): 1265-1273.
© 2004 European Society of Anaesthesiology