Statin therapy did not prevent acute kidney injury after cardiac surgeryBillings FT et al., JAMA 2016
High-Dose Perioperative Atorvastatin and Acute Kidney Injury Following Cardiac Surgery
A Randomized Clinical Trial
Billings FT, Hendricks PA, Schildcrout JS, et al.
JAMA 2016; published online ahead of print
BackgroundApproximately 30% of patients undergoing cardiac surgery are complicated with acute kidney injury (AKI), and postoperative dialysis rates are increasing [1,2]. AKI is related to higher rates of postoperative arrhythmias, respiratory failure, systemic infection, and myocardial infarction, and has been independently associated with a 5-fold increase of in-hospital death [3-5].
Statins affect several mechanisms underlying AKI, and short-term statin treatment has been shown to limit vascular superoxide generation [6,7], reduce endothelial dysfunction by restoring endothelial-derived nitric oxide synthase activity during hypoxia , attenuate lymphocyte activation . These effects decrease inflammation, endothelial dysfunction, and oxidant stress, mechanisms implicated in AKI development .
However, observational studies testing whether statin therapy may reduce AKI after cardiac surgery have yielded conflicting results [11,12]. This study tested the hypothesis that short-term administration of high-dose perioperative atorvastatin reduces AKI (defined as: increase of 0.3mg/dL in serum creatinine concentration within 48 hours of surgery, according to Acute Kidney Injury Network criteria)  after cardiac surgery.
The group of statin-naïve patients was stopped prematurely due to increased AKI rates in patients with chronic kidney disease (CKD) who were randomised to atorvastatin. Later, the study was stopped completely for futility.
- Overall, AKI occurred in 20.8% in the atorvastatin group vs 19.5% in the placebo group (RR: 1.06; 95%CI: 0.78-1.46; P = 0.75)
- Median serum creatinine concentrations increased by 0.07 mg/dL (10th-90th percentile: −0.13 to 0.51 mg/dL) within the first 48 postoperative hours among participants on atorvastatin compared with 0.07 mg/dL (10th-90th percentile: −0.12 to 0.52 mg/dL) in the placebo group (mean difference: −0.01 mg/dL; 95% CI: −0.06 to 0.04 mg/dL; P = 0.89)
- In patients already on statin therapy AKI occurred in 20.4% in the atorvastatin group vs 22.4% in the placebo group (RR: 0.91; 95%CI: 0.63-1.32; P = 0.63).
- In statin-naive patients, AKI occurred in 21.6% in the atorvastatin group vs 13.4% in the placebo group (RR: 1.61; 0.86-3.01; P = 0.15).
- In statin-naïve patients, serum creatinine concentration increased more in the atorvastatin group (median: 0.11mg/dL, 10th-90th percentile: −0.11 to 0.56mg/dL) than in the placebo group (median: 0.05mg/dL (10th-90th percentile: −0.12 to 0.33mg/dL) (mean difference: 0.08 mg/dL; 95%CI: 0.01-0.15mg/dL; P = 0.007).
- In patients with CKD at baseline, the incidence of AKI was 35.7% in the atorvastatin group and 32.6% in the placebo group (RR: 1.09; 95%CI: 0.73-1.65; P = 0.76).
- In the patients with CKD and naive to statin treatment, AKI occurred in 52.9% in the atorvastatin group vs. 15.8% in the placebo group (RR: 3.35; 95% CI: 1.12-10.05; P = 0.03).
ConclusionIn patients undergoing cardiac surgery, high-dose perioperative atorvastatin treatment compared with placebo did not reduce the risk or severity of AKI following surgery. In patients naive to statins, there was some evidence that statin therapy may increase the risk of AKI in those with preexisting CKD. In patients already on statins, perioperative statin continuation or withdrawal did not affect postoperative AKI. These results do not support the initiation of high-dose statin therapy to prevent AKI following cardiac surgery.
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