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Garg AX, Cuerden M, Aguado H, Amir M, Belley-Cote EP, Bhatt K, Biccard BM, Borges FK, Chan M, Conen D, Duceppe E, Efremov S, Eikelboom J, Fleischmann E, Giovanni L, Gross P, Jayaram R, Kirov M, Kleinlugtenbelt Y, Kurz A, Lamy A, Leslie K, Likhvantsev V, Lomivorotov V, Marcucci M, Martínez-Zapata MJ, McGillion M, McIntyre W, Meyhoff C, Ofori S, Painter T, Paniagua P, Parikh C, Parlow J, Patel A, Polanczyk C, Richards T, Roshanov P, Schmartz D, Sessler D, Short T, Sontrop JM, Spence J, Srinathan S, Stillo D, Szczeklik W, Tandon V, Torres D, Van Helder T, Vincent J, Wang CY, Wang M, Whitlock R, Wittmann M, Xavier D, Devereaux PJ. Effect of a Perioperative Hypotension-Avoidance Strategy Versus a Hypertension-Avoidance Strategy on the Risk of Acute Kidney Injury: A Clinical Research Protocol for a Substudy of the POISE-3 Randomized Clinical Trial. Can J Kidney Health Dis 2022; 9:20543581211069225. [PMID: 35024154 PMCID: PMC8744204 DOI: 10.1177/20543581211069225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Most patients who take antihypertensive medications continue taking them on
the morning of surgery and during the perioperative period. However, growing
evidence suggests this practice may contribute to perioperative hypotension
and a higher risk of complications. This protocol describes an acute kidney
injury substudy of the Perioperative Ischemic Evaluation-3 (POISE-3) trial,
which is testing the effect of a perioperative hypotension-avoidance
strategy versus a hypertension-avoidance strategy in patients undergoing
noncardiac surgery. Objective: To conduct a substudy of POISE-3 to determine whether a perioperative
hypotension-avoidance strategy reduces the risk of acute kidney injury
compared with a hypertension-avoidance strategy. Design: Randomized clinical trial with 1:1 randomization to the intervention (a
perioperative hypotension-avoidance strategy) or control (a
hypertension-avoidance strategy). Intervention: If the presurgery systolic blood pressure (SBP) is <130 mmHg, all
antihypertensive medications are withheld on the morning of surgery. If the
SBP is ≥130 mmHg, some medications (but not angiotensin receptor blockers
[ACEIs], angiotensin receptor blockers [ARBs], or renin inhibitors) may be
continued in a stepwise manner. During surgery, the patients’ mean arterial
pressure (MAP) is maintained at ≥80 mmHg. During the first 48 hours after
surgery, some antihypertensive medications (but not ACEIs, ARBs, or renin
inhibitors) may be restarted in a stepwise manner if the SBP is ≥130
mmHg. Control: Patients receive their usual antihypertensive medications before and after
surgery. The patients’ MAP is maintained at ≥60 mmHg from anesthetic
induction until the end of surgery. Setting: Recruitment from 108 centers in 22 countries from 2018 to 2021. Patients: Patients (~6800) aged ≥45 years having noncardiac surgery who have or are at
risk of atherosclerotic disease and who routinely take antihypertensive
medications. Measurements: The primary outcome of the substudy is postoperative acute kidney injury,
defined as an increase in serum creatinine concentration of either ≥26.5
μmol/L (≥0.3 mg/dL) within 48 hours of randomization or ≥50% within 7 days
of randomization. Methods: The primary analysis (intention-to-treat) will examine the relative risk and
95% confidence interval of acute kidney injury in the intervention versus
control group. We will repeat the primary analysis using alternative
definitions of acute kidney injury and examine effect modification by
preexisting chronic kidney disease, defined as a prerandomization estimated
glomerular filtration rate <60 mL/min/1.73 m2. Results: Substudy results will be analyzed in 2022. Limitations: It is not possible to mask patients or providers to the intervention;
however, objective measures will be used to assess acute kidney injury. Conclusions: This substudy will provide generalizable estimates of the effect of a
perioperative hypotension-avoidance strategy on the risk of acute kidney
injury.
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Affiliation(s)
| | | | | | - Mohammed Amir
- Shifa International Hospital (STMU), Islamabad, Pakistan
| | | | - Keyur Bhatt
- SIDS Hospital & Research Centre, Guntur, India
| | | | | | - Matthew Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong
| | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | - Mikhail Kirov
- Northern State Medical University of the Ministry of Healthcare of the Russian Federation, Arkhangelsk, Russia
| | | | | | - Andre Lamy
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | - Sandra Ofori
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | - Toby Richards
- The University of Western Australia, Perth, Australia
| | | | | | | | - Tim Short
- Auckland District Health Board, New Zealand
| | | | | | | | - David Stillo
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | - C Y Wang
- University of Malaya, Kuala Lumpur, Malaysia
| | | | | | | | - Denis Xavier
- St. John's National Academy of Health Sciences, Bangalore, India
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