2 March 2017

Chronic kidney disease and PPIs

Clinical Renal

 

Patients on long-term PPIs can develop chronic renal disease in the absence of intervening acute kidney injury, a study shows.

Patients taking PPIs who developed chronic kidney disease did not tend to have acute kidney injury beforehand, according to a study in Kidney International.

The proportion of PPI effect mediated by acute kidney injury was only around 50% for each of the chronic renal outcomes examined in the study (including incident chronic renal disease, chronic renal disease progression, and end-stage renal disease).  This indicated that a significant number of patients with PPI-induced chronic renal disease have never had an acute episode.

Doctors are very used to detecting and managing acute kidney injury and subsequently tailoring management to prevent chronic kidney disease, said Associate Professor David Gracey, a nephrologist at the University of Sydney.

“The link between acute kidney injury from PPIs and chronic kidney disease is well recognised,” he said. “This study suggests that more vigilance is required in patients with more subtle chronic changes.”

Monitoring for acute kidney injury in patients using PPIs is “not sufficient to guard against the development of chronic kidney disease and end-stage renal disease,” the authors said.

The retrospective, five-year study followed around 125,500 patients using medications including esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole.

Taking PPIs for a longer period of time was associated with a greater risk of poor chronic renal outcomes in the study.

Detecting subtle loss of renal function over years requires careful and regular screening for renal impairment, Professor Gracey said.

“The estimated glomerular filtration rate (eGFR) is the best test that is widely used for this,” he continued. Patients should also have their urinary albumin:creatinine ratio and blood pressure checked annually.

“Review of a patient’s previous results and any change over a prolonged period of time (months to years) is vital,” Professor Gracey said.

This was particularly important for patients at risk of renal disease, including cigarette smokers, those with diabetes or hypertension and in older patients with pre-existing renal impairment.

Other investigations should also be performed to exclude albuminuria, proteinuria and renal risk factors, such as hypertension. But alternative therapies to PPIs should be considered in all patients known to have chronic renal changes, Professor Gracey said.

There were a few alternative therapies to PPIs, but the commonest was probably ranitidine, he said.

Ranitidine is available over the counter and does not have the same renal side effects as PPIs. However, it needs to be taken twice a day and may not be as effective.