Polyethylene glycol bowel preparation does not eliminate the risk of acute renal failure: a population-based case-crossover study

Background and study aims: Polyethylene glycol (PEG) bowel preparations are regarded as effective and safe for colonoscopy; however, recent reports have indicated a risk of acute renal failure (ARF). This population-based case-crossover study evaluated the association between PEG and ARF in screening colonoscopy patients aged ≥ 50 years.

Patients and methods: Korean Health Insurance Review and Assessment Service (HIRA) claims data from 1 January 2005 to 31 December 2009 were used in the study. The study population consisted of patients aged ≥ 50 years who were first hospitalized for ARF following colonoscopy involving PEG bowel preparation. For each patient, PEG use in a 1-, 2-, or 4-week period prior to the first hospital admission date for ARF (hazard period) was compared with PEG use in four earlier 1-, 2-, or 4-week control periods. Conditional logistic regression analysis was used to estimate odds ratios (ORs) and 95 % confidence intervals (CIs), adjusting for concomitant medications that could induce ARF.

Results: The total number of study patients was 1064 (59 % were male). A greater proportion of patients used PEG during the hazard period than during the control periods (for 4-week time window: 8.8 % vs. 3.2 %). The adjusted ORs for ARF incidence when applying the 1-, 2-, and 4-week periods were 3.1 (95 %CI 2.06 – 4.73), 2.5 (95 %CI 1.76 – 3.53), and 2.1 (95 %CI 1.61 – 4.85), respectively.

Conclusions: The use of PEG was associated with the risk of ARF. Adequate hydration and renal function monitoring should be assured before and after colonoscopy, regardless of the bowel preparation regimen used.

• References

• 1 Rex DK, Johnson DA, Lieberman DA et al. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. Am J Gastroenterol 2000; 95: 868-877
• 2 Rabeneck L, Paszat LF, Saskin R et al. Association between colonoscopy rates and colorectal cancer mortality. Am J Gastroenterol 2010; 105: 1627-1632
• 3 Occhipinti KE, Di Palma JA. How to choose the best preparation for colonoscopy. Nat Rev Gastroenterol Hepatol 2009; 6: 279-286
• 4 Davis GR, Santa Ana CA, Morawski SG et al. Development of a lavage solution associated with minimal water and electrolyte absorption or secretion. Gastroenterology 1980; 78: 991-995
• 5 Beck DE, Harford FJ, DiPalma JA et al. Bowel cleansing with polyethylene glycol electrolyte lavage solution. South Med J 1985; 78: 1414-1416
• 6 DiPiro JT, Michael KA, Clark BA et al. Absorption of polyethylene glycol after administration of a PEG-electrolyte lavage solution. Clin Pharm 1986; 5: 153-155
• 7 Nelson DB, Barkun AN, Block KP et al. Technology Status Evaluation report. Colonoscopy preparations. May 2001. Gastrointest Endosc 2001; 54: 829-832
• 8 Dykes C, Cash BD. Key safety issues of bowel preparations for colonoscopy and importance of adequate hydration. Gastroenterol Nurs 2008; 31: 30-35
• 9 Chun YJ, Park MK, Kim JS et al. Acute renal failure caused by oral polyethylene glycol ingestion. Korean J Gastrointest Endosc 2007; 34: 161-163
• 10 Russmann S, Lamerato L, Marfatia A et al. Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol. Am J Gastroenterol 2007; 102: 2655-2663
• 11 Choi NK, Chang Y, Jung SY et al. A population-based case-crossover study of polyethylene glycol use and acute renal failure risk in the elderly. World J Gastroenterol 2011; 17: 651-656
• 12 Choi NK, Chang Y, Choi YK et al. Signal detection of rosuvastatin compared to other statins: data-mining study using national health insurance claims database. Pharmacoepidemiol Drug Saf 2010; 19: 238-246
• 13 Delaney JA, Suissa S. The case-crossover study design in pharmacoepidemiology. Stat Methods Med Res 2009; 18: 53-65
• 14 Maclure M, Mittleman MA. Should we use a case-crossover design?. Annu Rev Public Health 2000; 21: 193-221
• 15 Mittleman MA, Maclure M, Tofler GH et al. Triggering of acute myocardial infarction by heavy exertion: protection against triggering by regular exertion. N Engl J Med 1993; 329: 1677-1683
• 16 Chang CH, Chen HC, Lin JW et al. Risk of hospitalization for upper gastrointestinal adverse events associated with nonsteroidal anti-inflammatory drugs: a nationwide case-crossover study in Taiwan. Pharmacoepidemiol Drug Saf 2011; 20: 763-771
• 17 Mittleman MA, Maclure M, Robins JM. Control sampling strategies for casecrossover studies: an assessment of relative efficiency. Am J Epidemiol 1995; 142: 91-98
• 18 Lien YH. Is bowel preparation before colonoscopy a risky business for the kidney?. Nat Clin Pract Nephrol 2008; 4: 606-614
• 19 Guo X, Nzerue C. How to prevent, recognize, and treat drug-induced nephrotoxicity. Cleve Clin J Med 2002; 69: 289-312
• 20 Pannu N, Nadim MK. An overview of drug-induced acute kidney injury. Crit Care Med 2008; 36: 216-S223
• 21 Ho JM, Cavalcanti RB. A shocking bowel preparation: severe electrolyte disturbances after polyethylene glycol-based bowel preparation. J Am Geriatr Soc 2009; 57: 1729-1730
• 22 Lichtenstein GR, Cohen LB, Uribarri J. Review article: bowel preparation for colonoscopy – the importance of adequate hydration. Aliment Pharmacol Ther 2007; 26: 633-641
• 23 Brady HR, Brenner BM. Acute renal failure. In: et al. DL Kasper, eds. Harrison’s Principles of Internal Medicine. 16th. edn. New York: McGraw-Hill; 2005: 1644-1653
• 24 Venkataraman R, Kellum JA. Prevention of acute renal failure. Chest 2007; 131: 300-308
• 25 Nissenson AR. Acute renal failure: definition and pathogenesis. Kidney Int Suppl 1998; 66: 7-10
• 26 Park BJ, Sung JH, Park KD et al. Report of the evaluation for validity of discharged diagnoses in Korean Health Insurance database. Seoul: Seoul National University; 2003: 19-52