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.

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2 Comments on "Chronic kidney disease and PPIs"

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Justin Coleman
2 years 4 months ago

Sound advice re PPIs, thanks, as I think they are one of the most overused medications in Australia, too often put on the ‘set-and-forget’ list of prescription repeats.
However, I’m confused by Prof Gracey’s suggestion that doctors are far more used to managing acute renal injury than chronic renal failure, unless perhaps by ‘doctors’ he is referring to ED consultants or anaesthetists. In general practice, there would barely be a doctor in Australia who doesn’t spend considerably more time on CRF than acute – unless you start bending definitions, such as calling every UTI an ‘acute renal injury’.

David Gracey
David Gracey
2 years 4 months ago

Justin, I was specifically referring to managing renal issues related to PPIs, which have been mostly considered an acute nephrotoxin. I was trying to point our that chronic changes related to their use probably have flown under the radar until now. This study highlights the importance of vigilance for chronic changes related PPI use, not just the well known acute syndromes. I was in no way commenting upon the broader management of chronic kidney disease by General Practitioners.