Perioperative Statins in Cardiac Surgery and Acute Kidney Injury

Bellomo, Rinaldo

doi:10.1001/jama.2016.0245

Cited by 14 publications

(7 citation statements)

References 20 publications

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“…Our systematic review, including 25 studies in cardiac surgery, of whom 5 with low risk of bias, confirms the previous findings of possible negative effects of statins on renal function of cardiac surgery patients. For many years, perioperative statins were considered an attractive therapy for preventing AKI following cardiac surgery, hypothesis based mainly on the positive results from retrospective series or high risk of bias RCTs [ 50 ]. Nowadays, high-quality RCTs support the lack of a kidney-protective effect [ 6 , 7 , 30 ].…”

Section: Discussionmentioning

confidence: 99%

“…The exact mechanisms of increased occurrence of AKI related to statin use need to be elucidated. There are possible effects of statin in kidney function, including mitochondrial dysfunction leading to overall cellular energy imbalance [ 50 – 52 ]. Further research is needed, especially in the non-cardiac surgery setting, where evidence is still limited, not allowing any conclusion on possible renal effects of statin in this population.…”

Section: Discussionmentioning

confidence: 99%

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Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Putzu

Silva

Almeida

et al. 2018

Ann. Intensive Care

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BackgroundThe effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative outcome.MethodsElectronic databases were searched up to May 1, 2018, for randomized controlled trials of perioperative statin therapy versus placebo or no treatment in adult cardiac or non-cardiac surgery. Postoperative outcomes were: myocardial infarction, stroke, acute kidney injury (AKI), and mortality. We calculated risk ratio (RR) or odds ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses. We performed meta-regression and subgroup analyses to assess the possible influence of statin therapy regimen on clinical outcomes and trial sequential analysis to evaluate the risk of random errors and futility.ResultsWe included data from 35 RCTs involving 8200 patients. Perioperative statin therapy was associated with lower incidence of postoperative myocardial infarction in non-cardiac surgery (OR = 0.44 [95% CI 0.30–0.64], p < 0.0001), but not in cardiac surgery (OR = 0.93 [95% CI 0.70–1.24], p = 0.61) (psubgroup = 0.002). Higher incidence of AKI was present in cardiac surgery patients receiving perioperative statins (RR = 1.15 [95% CI 1.00–1.31], p = 0.05), nonetheless not in non-cardiac surgery (RR = 1.52 [95% CI 0.71–3.26], p = 0.28) (psubgroup = 0.47). No difference in postoperative stroke and mortality was present in either cardiac or non-cardiac surgery. However, low risk of bias trials performed in cardiac surgery showed a higher mortality with statins versus placebo (OR = 3.71 [95% CI 1.03–13.34], p = 0.04). Subgroup and meta-regression analyses failed to find possible relationships between length of statin regimens and clinical outcomes. Trial sequential analysis suggested no firm conclusions on the topic.ConclusionsPerioperative statins appear to be protective against postoperative myocardial infarction in non-cardiac surgery and associated with higher AKI in cardiac surgery. Possible positive or even negative effects on mortality could not be excluded and merits further investigations. Currently, no randomized evidence supports the systematic administration of statins in surgical patients.Electronic supplementary materialThe online version of this article (10.1186/s13613-018-0441-3) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Putzu

Silva

Almeida

et al. 2018

Ann. Intensive Care

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“…For many years, statin treatment was considered an attractive therapy for reducing AKI following cardiac surgery [54], an idea mainly based on retrospective data [16, 55–59], and according to this hypothesis, some large RCTs have been performed to test whether statins effectively decrease postoperative AKI [21, 42]. However, RCTs support the lack of a kidney-protective effect [21, 22, 42, 60, 61], as do the most recent systematic reviews [17, 60].…”

Section: Discussionmentioning

confidence: 99%

Perioperative statin therapy in cardiac surgery: a meta-analysis of randomized controlled trials

et al. 2016

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BackgroundSeveral studies suggest beneficial effects of perioperative statin therapy on postoperative outcome after cardiac surgery. However, recent randomized controlled trials (RCTs) show potential detrimental effects. The objective of this systematic review is to examine the association between perioperative statin therapy and clinical outcomes in cardiac surgery patients.MethodsElectronic databases were searched up to 1 November 2016 for RCTs of preoperative statin therapy versus placebo or no treatment in adult cardiac surgery. Postoperative outcomes were acute kidney injury, atrial fibrillation, myocardial infarction, stroke, infections, and mortality. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using fixed-effects meta-analyses. Primary analysis was restricted to trials with low risk of bias according to Cochrane methodology, and sensitivity analyses examined whether the risk of bias of included studies was associated with different results. We performed trial sequential analysis (TSA) to test the strength of the results.ResultsWe included data from 23 RCTs involving 5102 patients. Meta-analysis of trials with low risk of bias showed that statin therapy was associated with an increase in acute kidney injury (314 of 1318 (23.82%) with statins versus 262 of 1319 (19.86%) with placebo; OR 1.26 (95%CI 1.05 to 1.52); p = 0.01); these results were supported by TSA. No difference in postoperative atrial fibrillation, myocardial infarction, stroke, infections, or mortality was present. On sensitivity analysis, statin therapy was associated with a slight increase in hospital mortality. Meta-analysis including also trials with high or unclear risk of bias showed no beneficial effects of statin therapy on any postoperative outcomes.ConclusionsThere is no evidence that statin therapy in the days prior to cardiac surgery is beneficial for patients’ outcomes. Particularly, statins are not protective against postoperative atrial fibrillation, myocardial infarction, stroke, or infections. Statins are associated with a possible increased risk of acute kidney injury and a detrimental effect on hospital survival could not be excluded. Future RCTs should further evaluate the safety profile of this therapy in relation to patients’ outcomes and assess the more appropriate time point for discontinuation of statins before cardiac surgery.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1560-6) contains supplementary material, which is available to authorized users.

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“…9-11 Purported benefits include reduction of atrial fibrillation, acute kidney injury, and death. Some of these same benefits have been reported in the cardiac surgical population including coronary artery bypass grafting (CABG) and valve surgery, 12-16 while other studies show no difference, or even deleterious effects. 17, 18 To date, there have been no studies evaluating ascending aortic replacement, despite evidence suggesting this disease processes is on the rise.…”

Section: Introductionmentioning

confidence: 63%

Preoperative Statin Use Not Associated With Improved Outcomes After Ascending Aortic Repair

Tyerman

Hawkins

Mehaffey

et al. 2018

Seminars in Thoracic and Cardiovascular Surgery

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Statins have potent pleiotropic effects that have been correlated with improved perioperative cardiovascular surgery outcomes. We hypothesize that statins may improve morbidity and mortality after ascending aortic surgery. Within a statewide database consisting of 19 centers a total of 1804 patients had ascending aortic repair with or without aortic valve replacement (2004-2016). Patients were stratified by preoperative statin therapy for analysis. To account for baseline differences, patients were propensity matched in a 1:1 fashion by baseline characteristics. Patient characteristics and outcomes were analyzed by paired analysis. Of 1804 patients undergoing ascending aortic repair, 35% took statins preoperatively. After matching, 386 patients in each group were well matched with no statistically significant baseline or operative differences. There was no statistically significant difference in outcomes between patients taking statins preoperatively and those not taking statins, including operative mortality (3.6% vs 3.1%, P = 0.68) and major morbidity (18.4% vs 17.1%, P = 0.62). Postoperative atrial fibrillation (27.2% vs 28.5%, P = 0.71) and acute kidney injury (3.1% vs 4.2%, P = 0.41) also showed no statistically significant difference. Statins have no apparent clinical impact on perioperative outcomes after ascending aortic aneurysm repair. Considering recent evidence suggesting statins may increase perioperative risk of acute kidney injury, there is insufficient evidence to recommend starting preoperative statin before ascending aortic repair.

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Perioperative Statins in Cardiac Surgery and Acute Kidney Injury

Cited by 14 publications

References 20 publications

Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Perioperative statin therapy in cardiac surgery: a meta-analysis of randomized controlled trials

Preoperative Statin Use Not Associated With Improved Outcomes After Ascending Aortic Repair

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