The aim of this systematic review was to assess the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on postoperative renal function. Eight randomized placebo-controlled double-blinded trials (n=345) were identified from searches of MEDLINE, EMBASE and the Cochrane Controlled Trials Register databases. The summary effect size and 95% confidence intervals (95%CI) were calculated by a weighted mean difference analysis using a random-effects model. The NSAIDs (diclofenac, ketorolac, indomethacin, ibuprofen) were used for up to three days after surgery. There were no reported cases of postoperative renal failure requiring dialysis. NSAIDs reduced creatinine clearance by 22 ml.min−1 (95%CI: 7 to 37), sodium output by 54 mmol.day−1 (95%CI: 5 to 103) and potassium output by 38 mmol.day−1 (95%CI: 19 to 56) on Day 1 but not on Day 2. Serum creatinine increased on Day 2 by 15μmol.l−1 (95%CI: 2 to 28). Urine volume did not change significantly at any time. There was therefore a clinically unimportant transient reduction in renal function. NSAIDs should not be withheld from patients with normal preoperative renal function because of concerns about postoperative renal impairment.
Royal College of Anaesthetists.Guidelines for the use of non-steroidal anti-inflammatory drugs in the perioperative period.Royal College of Anaesthetists, London1998.
2.
FeldmanH.I., KinmanJ.L., BerlinJ.A.. Parenteral ketorolac: the risk for acute renal failure. Ann Intern Med1997; 126: 193–199.
3.
StromB.L., BerlinJ.A., KinmanJ.L.. Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A post-marketing surveillance study. JAMA1996; 275: 376–382.
4.
RomsingJ., Walther-LarsenS.Peri-operative use of non-steroidal anti-inflammatory drugs in children: analgesic efficacy and bleeding. Anaesthesia1997; 52: 673–683.
5.
MylesP.S., PowerI.Does ketorolac cause postoperative renal failure: how do we assess the evidence?Br J Anaesth1998; 80: 420–421.
6.
MurrayM.D., BraterD.C.Renal toxicity of the nonsteroidal anti-inflammatory drugs. Ann Rev Pharmacol Toxicol1993; 33: 435–465.
PowerI., CummingA.D., PughG.C.Effect of diclofenac on renal function and prostacyclin generation after surgery. Br J Anaesth1992; 69: 451–456.
15.
IrwinM.G., RoulsonC.J., JonesR.D., ChengI.K., VisramA.R., ChanY.M.Perioperative administration of rectal diclofenac sodium. The effect on renal function in patients undergoing minor orthopaedic surgery. Eur J Anaesthesiol1995; 12: 403–406.
16.
TurnerG.A., GorringeJ.Indomethacin as adjunct analgesia following open cholecystectomy. Anaesth Intensive Care1994; 22: 25–29.
17.
VarrassiG., PanellaL., PiroliA.. The effects of peri-operative ketorolac infusion on postoperative pain and endocrine-metabolic response. Anesth Analg1994; 78: 514–519.
18.
BrinkmannA., SeelingW., WolfC.F.. Ibuprofen does not impair renal function in patients undergoing infrarenal aortic surgery with epidural anaesthesia. Intensive Care Med1998; 24: 322–328.
19.
PerttunenK., NilssonE., KalsoE.IV diclofenac and ketorolac for pain after thoracoscopic surgery. Br J Anaesth1999; 82: 221–227.
20.
MulrowC.D., OxmanA.D., eds. Cochrane Collaboration Handbook. In: The Cochrane Library [database on disk and CDROM].The Cochrane Collaboration, Oxford1996.
21.
JadadA.R., MooreR.A., CarrollD.. Assessing the quality of reports of randomized clinical trials: is blinding necessary?Control Clin Trials1996; 17: 1–12.
22.
MoherD., PhamB., JonesA.. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses. Lancet1998; 352: 609–613.
23.
SchulzK.F., ChalmersI., HayesR.J., AltmanD.G.Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA1995; 273: 408–412.
24.
StreinerD.L., NormanG.R.Health measurement scales: a practical guide to their development and use.Oxford University Press, New York1989; 79–96.
25.
PetittiD.B.Meta-analysis, decision analysis and cost-effectiveness analysis: methods for quantitative synthesis in medicine.Oxford University Press, New York1994; 111–113.
26.
MostellerF., ColditzG.A.Understanding research synthesis (meta-analysis). Ann Rev Pub Health1996; 17: 1–23.
27.
FollmannD., ElliottP., SuhI., CutlerJ.Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol1992; 45: 769–773.
28.
ReadyL.B., BrownC.R., StahlgrenL.H.. Evaluation of intravenous ketorolac administered by bolus or infusion for treatment of postoperative pain. A double-blind, placebo-controlled, multicenter study. Anesthesiology1994; 80: 1277–1286.
29.
HornefferP.J., MillerR.H., PearsonT.A., RykielM.F., ReitzB.A., GardnerT.J.The effective treatment of postpericardiotomy syndrome after cardiac operations. A randomized placebo-controlled trial. J Thorac Cardiovasc Surg1990; 100: 292–296.
30.
CastiglioneG., HaufM.E., PanasciaE., ScuderiC., CrimiG.Does the preoperative administration of ketorolac improve postoperative analgesia?Minerva Anestesiol1997; 63: 237–243.
31.
FredmanB., ZoharE., GolanE., TillingerM., BernheimJ., JedeikinR.Diclofenac does not decrease renal blood flow or glomerular filtration in elderly patients undergoing orthopedic surgery. Anesth Analg1999; 88: 149–154.
32.
CharlsonM.E., MacKenzieC.R., GoldJ.P., ShiresG.T.Postoperative changes in serum creatinine: when do they occur and how much is important?Ann Surg1989; 209: 328–333.
33.
BuggeJ.F.Renal effects and complications of NSAIDs for routine post-operative pain relief: increased awareness of a real problem is needed. Baillieres Clin Anaesthesiol1995; 9: 483–492.
EggerM., SmithG.D.Misleading meta-analysis. Br Med J1995; 310: 752–754.
36.
KellenM., AronsonS., RoizenM.F., BarnardJ., ThistedR.A.Predictive and diagnostic tests of renal failure: a review. Anesth Analg1994; 78: 134–142.
37.
WallerD.G., FlemingJ.S., RamseyB., GrayJ.The accuracy of creatinine clearance with and without urine collection as a measure of glomerular filtration rate. Postgrad Med J1991; 67: 42–46.
38.
CryerB., FeldmanM.Cyclooxygenase-1 and cyclooxygenase-2 selectivity of widely used nonsteroidal anti-inflammatory drugs. Am J Med1998; 104: 413–421.
39.
VaneJ.R., BottingR.M.Mechanism of action of anti-inflammatory drugs. Adv Exp Med Biol1997; 433: 131–138.
