Preoperative angiotensin axis blockade therapy, intraoperative hypotension, and the risks of postoperative acute kidney injury

We read with interest the analysis by Nielson et al., which concluded that patients undergoing major elective orthopedic surgery, who receive preoperative angiotensin axis blockade (AAB) therapy, have an associated increased risk of postinduction hypotension and postoperative acute kidney injury (AKI), with greater hospital length of stay.[1] We could not agree more with this conclusion.

Recently, we reported in the British Medical Journal our experiences with 2 patients who developed moderately severe AKI following surgical procedures while on concurrent AAB therapy, which led to prolonged hospital stays.[2, 3] The second patient was a 46‐year‐old obese Caucasian hypertensive male on triple‐whammy medications who developed intraoperative hypotension following an elective right‐hip arthroplasty.[3] Baseline serum creatinine more than doubled to 2.58 mg/dL within 36 hours. Hospital stay was prolonged. He improved with treatment before discharge.[3] We dubbed a new syndrome of quadruple whammy to represent perioperative AKI following intraoperative hypotension in patients on concurrent triple whammy medications.[2, 3]

We therefore support calls for the preemptive withholding of AAB before major elective surgical procedures, especially cardiovascular and orthopedic ones.[4] This is the cornerstone of a preventative nephrology paradigm called renoprevention, which we have repeatedly espoused since 2009.[5]

We read with interest the analysis by Nielson et al., which concluded that patients undergoing major elective orthopedic surgery, who receive preoperative angiotensin axis blockade (AAB) therapy, have an associated increased risk of postinduction hypotension and postoperative acute kidney injury (AKI), with greater hospital length of stay.[1] We could not agree more with this conclusion.

Recently, we reported in the British Medical Journal our experiences with 2 patients who developed moderately severe AKI following surgical procedures while on concurrent AAB therapy, which led to prolonged hospital stays.[2, 3] The second patient was a 46‐year‐old obese Caucasian hypertensive male on triple‐whammy medications who developed intraoperative hypotension following an elective right‐hip arthroplasty.[3] Baseline serum creatinine more than doubled to 2.58 mg/dL within 36 hours. Hospital stay was prolonged. He improved with treatment before discharge.[3] We dubbed a new syndrome of quadruple whammy to represent perioperative AKI following intraoperative hypotension in patients on concurrent triple whammy medications.[2, 3]

We therefore support calls for the preemptive withholding of AAB before major elective surgical procedures, especially cardiovascular and orthopedic ones.[4] This is the cornerstone of a preventative nephrology paradigm called renoprevention, which we have repeatedly espoused since 2009.[5]

We read with interest the analysis by Nielson et al., which concluded that patients undergoing major elective orthopedic surgery, who receive preoperative angiotensin axis blockade (AAB) therapy, have an associated increased risk of postinduction hypotension and postoperative acute kidney injury (AKI), with greater hospital length of stay.[1] We could not agree more with this conclusion.

Recently, we reported in the British Medical Journal our experiences with 2 patients who developed moderately severe AKI following surgical procedures while on concurrent AAB therapy, which led to prolonged hospital stays.[2, 3] The second patient was a 46‐year‐old obese Caucasian hypertensive male on triple‐whammy medications who developed intraoperative hypotension following an elective right‐hip arthroplasty.[3] Baseline serum creatinine more than doubled to 2.58 mg/dL within 36 hours. Hospital stay was prolonged. He improved with treatment before discharge.[3] We dubbed a new syndrome of quadruple whammy to represent perioperative AKI following intraoperative hypotension in patients on concurrent triple whammy medications.[2, 3]

We therefore support calls for the preemptive withholding of AAB before major elective surgical procedures, especially cardiovascular and orthopedic ones.[4] This is the cornerstone of a preventative nephrology paradigm called renoprevention, which we have repeatedly espoused since 2009.[5]