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Ann Thorac Surg 2009;87:1653-1654. doi:10.1016/j.athoracsur.2009.01.019
© 2009 The Society of Thoracic Surgeons
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Umberto Benedetto
Giovanni Melina
Antonino Roscitano
Riccardo Sinatra
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Correspondence

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Umberto Benedetto, MD, Giovanni Melina, MD, Simone Refice, MD, Antonino Roscitano, MD, Emiliano Angeloni, MD, Riccardo Sinatra, MD

Cardiac Surgery Department II School of Medicine, University of Rome "La Sapienza", Policlinico S. Andrea, Via di Grottarossa, Rome, 1039 Italy

(Email: u2benedetto{at}libero.it).

To the Editor:

We thank Dr Bouzas-Mosquera and colleagues [1] for his interest regarding our study [2], and we are pleased to comment on the discordant results recently reported by Arora and colleagues [3]. Several important differences exist between the two studies, such as type of surgical procedures included and the definition of acute kidney injury, which make comparison difficult. Moreover, some methodological aspects raise concerns regarding their conclusion.

A major concern of their study [3] was the higher number of congestive heart failure (CHF) patients included in the angiotensin-converting enzyme (ACE) inhibitor group (26% vs 12%). The authors added the left ventricular dysfunction in CHF definition as well. It is well known that congestive heart failure and left ventricular dysfunction are main determinants in acute kidney injury (AKI) after surgery. These conditions increase the risk of low cardiac output syndrome, which is the most important pathogenic mechanism in postoperative AKI. The authors performed a statistical adjustment including propensity scores in the logistic model, but this cannot exclude treatment bias regarding such an important aspect. The impact of this methodological limit was confirmed by high collinearity between propensity score and CHF reported by the authors [3]. Taking into account such aspects, a propensity score matched analysis would have been more reliable for their analysis.

Finally, the logistic model used by the authors was based on the assumption that hypertension affects the use of ACE inhibitors, but not the occurrence of AKI [3]. A recent prospective, large, multicenter study including 4,801 on-pump CABG patients raises some concerns regarding such an assumption [4]. Patients with pulsatile hypertension were found to be three times more likely to die a renal-related death.

As stated in our conclusion, we agree with Bouzas-Mosquera and colleagues [1] that further randomized studies are needed before a formal recommendation on the preoperative use of ACE inhibitor for the prevention of postoperative AKI.

We are grateful to have the opportunity to address Dr Bouzas-Mosquera and colleagues [1] valuable comments.


   References
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 References
 

  1. Bouzas-Mosquera A, Álvarez-García N, Peteiro J. Angiotensin-converting enzyme inhibitors and risk of acute kidney injury after cardiac surgery (letter) Ann Thorac Surg 2009;87:1653.[Free Full Text]
  2. Benedetto U, Sciarretta S, Roscitano A, et al. Preoperative angiotensin-converting enzyme inhibitors and acute kidney injury after coronary artery bypass grafting Ann Thorac Surg 2008;86:1160-1165.[Abstract/Free Full Text]
  3. Arora P, Rajagopalam S, Ranjan 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;3:1266-1273.[Abstract/Free Full Text]
  4. Aroson S, Fontes ML, Miao Y, Mangano DT. Risk index for perioperative penal dysfunction failure Circulation 2007;115:733-742.[Abstract/Free Full Text]

Related Article

Angiotensin-Converting Enzyme Inhibitors and Risk of Acute Kidney Injury After Cardiac Surgery
Alberto Bouzas-Mosquera, Nemesio Álvarez-García, and Jesús Peteiro
Ann. Thorac. Surg. 2009 87: 1653. [Extract] [Full Text] [PDF]




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Riccardo Sinatra
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