Proton-pump inhibitors use, and risk of acute kidney injury: a meta-analysis of observational studies

Side Effects of Long-Term Proton Pump Inhibitor Use: A Review

Proton pump inhibitors (PPIs) are widely used, and concerns about overuse have been raised. Therefore, side effects are important to be aware of and several suggested side effects of long-term use have been studied. In this MiniReview, we sum up the evidence of side effects related to long-term PPI treatment. Suspected side effects are mainly related to increased susceptibility to infections, secondary hypergastrinaemia, impeded absorption of micronutrients or idiosyncratic reactions. Most of the potential side effects have only been evaluated in observational studies demonstrating conflicting and weak associations with a substantial risk of confounding. However, a high probability of causality seems to be established for the side effects increased risk of gastrointestinal infections and rebound acid hypersecretion following discontinuation of treatment due to secondary hypergastrinaemia. The risk of side effects should not be a reason to withhold PPIs from patients with a true indication, and worry about poorly proven side effects should not lead to unnecessary discontinuation. The most important safety issue regarding PPI therapy is to critically evaluate the indication when initiating treatment and reconsidering the indication in long-term-treated patients.

Acid-suppressive drugs and risk of kidney disease: A systematic review and meta-analysis

BACKGROUND AND AIM

More concerns had been raised about the risk of kidney disease (KD) associated with acid-suppressive drugs. But whether they could directly increase such risk remained unclear. Meta-analysis was conducted to comprehensively investigate this relationship.

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and three Chinese databases were searched until April 2017 for observational studies investigating the associations between acid-suppressive drugs and KD. Pooled log (odds ratios [ORs]) or log (hazard ratios [HRs]) with standard errors for KD risk were calculated using the generic inverse variance method and random-effect model.

RESULTS

Ten studies involving 128 020 KD patients were included. Proton pump inhibitor (PPI) therapy was associated with higher risks of acute interstitial nephritis (OR, 2.78; 95% confidence interval [CI], 1.25-6.17), acute kidney injury (AKI) (HR, 1.85; 95% CI, 1.33-2.59), chronic kidney disease (CKD) (HR, 1.47; 95% CI, 1.03-2.09), and end-stage renal disease (ESRD) (HR, 1.61; 95% CI, 1.26-2.04) than non-PPI therapy. Additionally, PPI significantly increased the risks of AKI (HR, 1.32; 95% CI, 1.16-1.51), CKD (HR, 1.28; 95% CI, 1.24-1.33), and ESRD (HR, 1.96; 95% CI, 1.21-3.17) compared with histamine 2 receptor antagonist (H2 RA). Relationship between H2 RA therapy and AKI (OR, 0.98; 95% CI, 0.90-1.07) or CKD (OR, 1.00; 95% CI, 0.89-1.11) was not found.

CONCLUSIONS

Proton pump inhibitor therapy significantly increased the risks of acute interstitial nephritis, AKI, CKD, and ESRD. Similar risks were not identified for H2 RA therapy. More clinical trials are needed to confirm our findings.

Association of proton pump inhibitor use with renal outcomes in patients with coronary artery disease

Background

Several studies have suggested that proton pump inhibitor (PPI) use is associated with adverse renal outcomes, but obvious evidence for this association is lacking. We investigated the association between PPI use and adverse renal outcomes in patients who had undergone percutaneous coronary intervention.

Methods

Of the 1,284 patients hospitalized for percutaneous coronary intervention between January 2007 and May 2012, 934 patients with baseline estimated glomerular filtration rate greater than 60 mL/min/1.73 m² were enrolled. Multivariable Cox models were used to examine whether PPI use was associated with acute and chronic adverse renal outcomes.

Results

In adjusted time-dependent Cox models, PPI use was associated with acute kidney injury (hazard ratio [HR], 1.46; 95% confidence interval [95% CI], 1.05–2.02), especially in patients aged 65 years or younger (HR, 2.08; 95% CI, 1.09 3.96) or in patients with diabetes (HR, 2.00; 95% CI, 1.23–3.25). In multivariable Cox models, the association between duration of PPI use and chronic kidney disease development was not statistically significant (HR of heavy users, 1.50; 95% CI, 0.61–3.67), but a longer duration of PPI use was associated with mild renal progression in patients younger than 65 years (HR of heavy users, 2.24; 95% CI, 1.09–4.60).

Conclusion

Our results suggest that PPI use increases the risk of AKI development, and that PPI use is more significantly associated with acute and chronic renal injuries in younger patients.

[Proton pump inhibitors and kidney]

Assumed for a long time to be very well tolerated, proton pump inhibitors (PPIs) are widely prescribed for inpatients and outpatients; often beyond their validated indications. Nevertheless, many very varied side effects (pneumopathy, ischemic heart disease, dementia) have been associated with the PPIs during the last decade. Renal toxicity is mainly the occurrence of acute interstitial nephritis (AIN), related to a drug-class effect, involving cellular immunity. AINs, which occur especially in elderly patients, can be difficult to diagnose, with frequently isolated acute kidney injury, appearing with variable delay after the introduction of PPIs. Although sensitive to steroid therapy, patients frequently have an incomplete recovery of the kidney function. Very recently, the risk of chronic kidney disease (CKD) and the risk of progression of CKD among PPIs users have been well demonstrated in several large independent epidemiological studies. It is a low, but a significant side effect because of the millions of PPI prescriptions. Although further studies are needed to investigate the pathophysiological mechanisms leading the use of PPI to CKD, it is appropriate for the physicians to limit PPIs to their correct indications and to monitor renal function during these treatments.

Associations of Proton-Pump Inhibitors and H2 Receptor Antagonists with Chronic Kidney Disease: A Meta-Analysis

BACKGROUND/AIMS

The aim of this meta-analysis was to assess the risks of chronic kidney disease (CKD) and/or end-stage kidney disease (ESRD) in patients who are taking proton-pump inhibitors (PPIs) and/or H2 receptor antagonists (H2RAs).

METHODS

Comprehensive literature review was conducted utilizing MEDLINE and EMBASE databases through April 2017 to identify all studies that investigated the risks of CKD or ESRD in patients taking PPIs/H2RAs versus those without PPIs/H2RAs. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this study is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017067252).

RESULTS

Five studies with 536,902 participants were patients were identified and included in the data analysis. When compared with non-PPIs users, the pooled risk ratio (RR) of CKD or ESRD in patients with PPI use was 1.33 (95% CI 1.18-1.51). Pre-specified subgroup analysis (stratified by CKD or ESRD status) demonstrated pooled RRs of 1.22 (95% CI 1.14-1.30) for association between PPI use and CKD and 1.88 (95% CI 1.71-2.06) for association between PPI use and ESRD, respectively. However, there was no association between the use of H2RAs and CKD with a pooled RR of 1.02 (95% CI 0.83-1.25). When compared with the use of H2RAs, the pooled RR of CKD in patients with PPI use was 1.29 (95% CI 1.22-1.36).

CONCLUSIONS

Our study demonstrates statistically significant 1.3-fold increased risks of CKD and ESRD in patients using PPIs, but not in patients using H2RAs.