Aprotinin plus ACE inhibitors during off-pump surgery linked to renal dysfunction

By Sara Carrillo de Albornoz

08 February 2008

The Lancet 2008; 371: 475-482

MedWire News: Patients undergoing off-pump cardiac surgery who are treated with aprotinin and preoperative angiotensin-converting enzyme (ACE) inhibitors are at high risk for postoperative renal dysfunction, UK researchers report in The Lancet.

"We recommend that it might be beneficial for patients to discontinue any use of an ACE inhibitor before undergoing elective off-pump cardiac surgery, particularly patients with a history of renal impairment," say Kai Zacharowski and colleagues from the Bristol Royal Infirmary.

Aprotinin is an antifibrinolytic serine protease inhibitor that reduces peri-operative bleeding and decreases the need for blood transfusion and re-operation in patients undergoing cardiac surgery, but concerns have been raised about its role in renal impairment, the authors comment.

Zacharowski and team examined the association between aprotinin and renal dysfunction in 9012 patients undergoing cardiac surgery, of whom 5434 were operated on-pump and 3672 off-pump.

They separately analyzed the incidence of renal dysfunction in patients treated with aprotinin, tranexamic acid, or no antifibrinolytic therapy in combination with or without pre-operative ACE inhibitors.

After propensity adjustment, only patients undergoing off-pump surgery and treated with both ACE inhibitors and aprotinin were at high risk for postoperative renal dysfunction (odds ratio=2.87, p=0.013).

Among patients undergoing on-pump surgery, aprotinin - with or without ACE inhibitors - did not significantly increase the risk for renal dysfunction.

Zacharowski and co-workers conclude: "Our results have shown that aprotinin seems to be safe during on-pump cardiac surgery.

"However, the combination of aprotinin and ACE inhibitors during off -pump cardiac surgery is associated with a significant risk of postoperative renal dysfunction."

They add: "The international communities of cardiac anesthesia and surgery face controversy regarding the use of aprotinin."

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