What are the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury? A systematic review and meta-analysis

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

Design: Systematic review and meta-analysis of randomized and non-randomized studies.

Participants: Adults taking diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, direct renin inhibitors, non-steroidal anti-inflammatories, metformin or sulfonylureas, experiencing inter-current 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 eGFR and creatinine at 24 hours, urea, systolic and diastolic blood pressure, death, clinical outcomes and biomarkers.

Results: Six studies were included (1,663 participants), three randomised trials and three prospective cohort studies. Mean age ranged from 65 to 73 years, the proportion of women ranged from 31 to 52%. All studies were in hospital settings; five evaluated discontinuation of medication prior to coronary angiography and one prior to cardiac surgery. Five studies evaluated discontinuation of ACE inhibitors and ARBs, one small cohort study looked at discontinuation of NSAIDS. No studies evaluated discontinuation of medication in the community following an acute inter-current illness. There was an increased risk of AKI of around 15% in those in whom medication was continued compared to those in whom it was discontinued (RR 1.17, 95% CI 0.99, 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, 2.60; 3 RCTs) but the confidence interval was wider. There was no difference between groups for any secondary outcomes.

Conclusions: There is low quality evidence that withdrawal of ACE inhibitors/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 inter-current illness in primary or secondary care.