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Rate and Outcome of Acute Kidney Injury Following Hip Fracture Surgery in Diabetic Older Patients Treated with Renin–Angiotensin–Aldosterone Antagonists

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Abstract

Background

The use of renin–angiotensin–aldosterone system inhibitors has increased over the past few years. There are conflicting data as to their relationship with acute kidney injury following surgery.

Objectives

The objective of the article was to evaluate the risk of acute kidney injury in diabetic older patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and their medical outcomes following fragility hip fracture surgery.

Methods

Consecutive diabetic patients presenting with fragility hip fractures to our primary trauma center between January 2012 and June 2016 were included. Demographic and clinical data, including co-morbidities, medication use, and laboratory results, were collected from the electronic medical records. The primary outcome was the incidence of acute kidney injury; the secondary outcome was 1-year mortality.

Results

Two hundred and seventeen patients were included; 125 were receiving treatment with medications targeting the renin–angiotensin–aldosterone system. Demographic and clinical characteristics were similar between groups. No association was found between the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and the risk of acute kidney injury, which occurred in 25% of the cohort. Univariate analysis revealed that diuretic use, particularly furosemide, increased the risk of acute kidney injury during hospitalization (p = 0.003). However, in a multivariate analysis, only age and estimated glomerular filtration rates were associated with an increased risk of acute kidney injury. Patients with acute kidney injury were found to have increased mortality during the first post-operative year (p < 0.001).

Conclusions

Acute kidney injury is a frequent complication after hip fracture surgery in elderly diabetic patients and is associated with increased 1-year mortality; however, it was not found to be associated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker pre-fracture treatment.

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References

  1. Haugan K, Johnsen LG, Basso T, Foss OA. Mortality and readmission following hip fracture surgery: a retrospective study comparing conventional and fast-track care. BMJ Open. 2017;7(8):e015574. https://doi.org/10.1136/bmjopen-2016-015574.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Rosso F, Dettoni F, Bonasia DE, Olivero F, Mattei L, Bruzzone M, et al. Prognostic factors for mortality after hip fracture: operation within 48 hours is mandatory. Injury. 2016;47(Suppl. 4):S91–7. https://doi.org/10.1016/j.injury.2016.07.055.

    Article  PubMed  Google Scholar 

  3. Ryan DJ, Yoshihara H, Yoneoka D, Egol KA, Zuckerman JD. Delay in hip fracture surgery: an analysis of patient-specific and hospital-specific risk factors. J Orthop Trauma. 2015;29:343–8. https://doi.org/10.1097/BOT.0000000000000313.

    Article  PubMed  Google Scholar 

  4. Frenkel Rutenberg T, Daglan E, Heller S, Velkes S. A comparison of treatment setting for elderly patients with hip fracture, is the geriatric ward superior to conventional orthopedic hospitalization? Injury. 2017;48:1584–8. https://doi.org/10.1016/j.injury.2017.04.049.

    Article  PubMed  Google Scholar 

  5. Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekstrom W, Cederholm T, et al. Early operation on patients with a hip fracture improved the ability to return to independent living: a prospective study of 850 patients. J Bone Jt Surg Am. 2008;90:1436–42. https://doi.org/10.2106/JBJS.G.00890.

    Article  Google Scholar 

  6. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40:692–7. https://doi.org/10.1016/j.injury.2009.01.010.

    Article  PubMed  Google Scholar 

  7. Chang W, Lv H, Feng C, Yuwen P, Wei N, Chen W, et al. Preventable risk factors of mortality after hip fracture surgery: systematic review and meta-analysis. Int J Surg. 2018;52:320–8. https://doi.org/10.1016/j.ijsu.2018.02.061.

    Article  PubMed  Google Scholar 

  8. Anthony CA, Duchman KR, Bedard NA, Gholson JJ, Gao Y, Pugely AJ, et al. Hip fractures: appropriate timing to operative intervention. J Arthroplast. 2017;32:3314–8. https://doi.org/10.1016/j.arth.2017.07.023.

    Article  Google Scholar 

  9. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States, 1988–2012. JAMA. 2015;314:1021–9. https://doi.org/10.1001/jama.2015.10029.

    Article  CAS  PubMed  Google Scholar 

  10. Zghebi SS, Steinke DT, Carr MJ, Rutter MK, Emsley RA, Ashcroft DM. Examining trends in type 2 diabetes incidence, prevalence and mortality in the UK between 2004 and 2014. Diabetes Obes Metab. 2017;19:1537–45. https://doi.org/10.1111/dom.12964.

    Article  PubMed  Google Scholar 

  11. Ng YP, Balasubramanian GP, Heng YP, Kalaiselvan M, Teh YW, Cheong KM, et al. Renin angiotensin-aldosterone system (RAAS) blockers usage among type II diabetes mellitus patients: a retrospective study. Diabetes Metab Syndr. 2018;12:305–8. https://doi.org/10.1016/j.dsx.2017.12.005.

    Article  PubMed  Google Scholar 

  12. Lin Y-C, Chang Y-H, Yang S-Y, Wu K-D, Chu T-S. Update of pathophysiology and management of diabetic kidney disease. J Formos Med Assoc. 2018;117:662–75. https://doi.org/10.1016/j.jfma.2018.02.007.

    Article  CAS  PubMed  Google Scholar 

  13. Cittanova ML, Zubicki A, Savu C, Montalvan C, Nefaa N, Zaier K, et al. The chronic inhibition of angiotensin-converting enzyme impairs postoperative renal function. Anesth Analg. 2001;93:1111–5.

    Article  CAS  PubMed  Google Scholar 

  14. Radaelli G, Bodanese LC, Guaragna JCVDC, Borges AP, Goldani MA, Petracco JB, et al. The use of inhibitors of angiotensin-converting enzyme and its relation to events in the postoperative period of CABG. Rev Bras Cir Cardiovasc. 2011;26:373–9.

    Article  PubMed  Google Scholar 

  15. Zhang Y, Ma L. Effect of preoperative angiotensin-converting enzyme inhibitor on the outcome of coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2015;47:788–95. https://doi.org/10.1093/ejcts/ezu298.

    Article  PubMed  Google Scholar 

  16. Arora P, Rajagopalam S, Ranjan R, Kolli H, Singh M, Venuto R, et al. Preoperative use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers is associated with increased risk for acute kidney injury after cardiovascular surgery. Clin J Am Soc Nephrol. 2008;3:1266–73. https://doi.org/10.2215/CJN.05271107.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Benedetto U, Sciarretta S, Roscitano A, Fiorani B, Refice S, Angeloni E, et al. Preoperative angiotensin-converting enzyme inhibitors and acute kidney injury after coronary artery bypass grafting. Ann Thorac Surg. 2008;86:1160–5. https://doi.org/10.1016/j.athoracsur.2008.06.018.

    Article  PubMed  Google Scholar 

  18. Barodka V, Silvestry S, Zhao N, Jiao X, Whellan DJ, Diehl J, et al. Preoperative renin-angiotensin system inhibitors protect renal function in aging patients undergoing cardiac surgery. J Surg Res. 2011;167:e63–9. https://doi.org/10.1016/j.jss.2009.11.702.

    Article  CAS  PubMed  Google Scholar 

  19. Cheungpasitporn W, Thongprayoon C, Srivali N, O’Corragain OA, Edmonds PJ, Ungprasert P, et al. Preoperative renin-angiotensin system inhibitors use linked to reduced acute kidney injury: a systematic review and meta-analysis. Nephrol Dial Transplant. 2015;30:978–88. https://doi.org/10.1093/ndt/gfv023.

    Article  CAS  PubMed  Google Scholar 

  20. Thakar CV, Kharat V, Blanck S, Leonard AC. Acute kidney injury after gastric bypass surgery. Clin J Am Soc Nephrol. 2007;2:426–30. https://doi.org/10.2215/CJN.03961106.

    Article  PubMed  Google Scholar 

  21. Zainudheen A, Scott IA, Caney X. Association of renin angiotensin antagonists with adverse perioperative events in patients undergoing elective orthopaedic surgery: a case-control study. Intern Med J. 2017;47:999–1005. https://doi.org/10.1111/imj.13487.

    Article  CAS  PubMed  Google Scholar 

  22. Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9:283–8. https://doi.org/10.1002/jhm.2155.

    Article  PubMed  Google Scholar 

  23. Ling Q, Gu Y, Chen J, Chen Y, Shi Y, Zhao G, et al. Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis. BMC Anesthesiol. 2018;18:26. https://doi.org/10.1186/s12871-018-0487-7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Khan SK, Rushton SP, Courtney M, Gray AC, Deehan DJ. Elderly men with renal dysfunction are most at risk for poor outcome after neck of femur fractures. Age Ageing. 2013;42:76–81. https://doi.org/10.1093/ageing/afs152.

    Article  PubMed  Google Scholar 

  25. Porter CJ, Moppett IK, Juurlink I, Nightingale J, Moran CG, Devonald MAJ. Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury. BMC Nephrol. 2017;18:20. https://doi.org/10.1186/s12882-017-0437-5.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Bennet SJ, Berry OMB, Goddard J, Keating JF. Acute renal dysfunction following hip fracture. Injury. 2010;41:335–8. https://doi.org/10.1016/j.injury.2009.07.009.

    Article  PubMed  Google Scholar 

  27. Hong SE, Kim T-Y, Yoo J-H, Kim J-K, Kim SG, Kim HJ, et al. Acute kidney injury can predict in-hospital and long-term mortality in elderly patients undergoing hip fracture surgery. PLoS One. 2017;12:e0176259. https://doi.org/10.1371/journal.pone.0176259.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  CAS  PubMed  Google Scholar 

  29. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, et al. Updating and validating the Charlson Comorbidity Index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676–82. https://doi.org/10.1093/aje/kwq433.

    Article  PubMed  Google Scholar 

  30. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–12.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31. https://doi.org/10.1186/cc5713.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Auron M, Harte B, Kumar A, Michota F. Renin-angiotensin system antagonists in the perioperative setting: clinical consequences and recommendations for practice. Postgrad Med J. 2011;87:472–81. https://doi.org/10.1136/pgmj.2010.112987.

    Article  CAS  PubMed  Google Scholar 

  33. Zou Z, Yuan HB, Yang B, Xu F, Chen XY, Liu GJ, et al. Perioperative angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults. Cochrane Database Syst Rev. 2016;1:CD009210. https://doi.org/10.1002/14651858.CD009210.pub2.

    Article  Google Scholar 

  34. Khan S, Loi V, Rosner MH. Drug-induced kidney injury in the elderly. Drugs Aging. 2017;34:729–41. https://doi.org/10.1007/s40266-017-0484-4.

    Article  CAS  PubMed  Google Scholar 

  35. Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996;334:1448–60. https://doi.org/10.1056/NEJM199605303342207.

    Article  CAS  PubMed  Google Scholar 

  36. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008;55:146–54. https://doi.org/10.1007/BF03016088.

    Article  PubMed  Google Scholar 

  37. Lawrence JE, Fountain DM, Cundall-Curry DJ, Carrothers AD. Do patients taking warfarin experience delays to theatre, longer hospital stay, and poorer survival after hip fracture? Clin Orthop Relat Res. 2017;475:273–9. https://doi.org/10.1007/s11999-016-5056-0.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors thank Mrs. Phyllis Curchack for her editorial services.

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Authors and Affiliations

Authors

Contributions

TFR contributed to the study design, collection of data, interpretation of the results, and writing of the manuscript. AB contributed to the study design, collection of data, interpretation of the results, and writing of the manuscript. BR-Z was involved in the interpretation of the results, verified the analytical methods, and contributed to the draft review. YR was involved in the interpretation of data and draft review. SV contributed to the study design, data collection, interpretation of data, and draft review. AW contributed to the study design, data collection, interpretation of data, and draft review. YB designed and directed the project and participated in the interpretation of data and writing of the manuscript.

Corresponding author

Correspondence to Yichayaou Beloosesky.

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Funding

No sources of funding were used to assist in the preparation of this study.

Conflict of interest

Tal Frenkel Rutenberg, Abdelazeez Bdeir, Benaya Rozen-Zvi, Yoav Rosenthal, Steven Velkes, Avraham Weiss, and Yichayaou Beloosesky have no conflicts of interest that are directly relevant to the content of this study.

Ethical approval

The study was approved by the institutional ethics committee in accordance with the Declaration of Helsinki.

Informed consent

Informed consent was not necessary because this study is retrospective.

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Frenkel Rutenberg, T., Bdeir, A., Rozen-Zvi, B. et al. Rate and Outcome of Acute Kidney Injury Following Hip Fracture Surgery in Diabetic Older Patients Treated with Renin–Angiotensin–Aldosterone Antagonists. Drugs Aging 36, 667–674 (2019). https://doi.org/10.1007/s40266-019-00671-y

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