#1934 NSAIDs: painkillers or kidney killers? The ICU perspective

Abstract Background and Aims Non-steroidal anti-inflammatory drugs (NSAID) are widely used in Intensive Care Units (ICU) for pain management. However, their nephrotoxic potential raises concerns. The relationship between NSAID use and acute kidney injury (AKI) in critically ill patients remains controversial. Identifying risk factors for AKI in this population is essential to improve outcomes, particularly given the heterogeneity of patient profiles and admission types. This retrospective cohort study investigates the association between NSAID use and AKI in critically ill patients. Method We included 1157 ICU patients admitted between 2015 and 2023 at Vila Franca de Xira Hospital. NSAID exposure was defined as administration for ≥24 consecutive hours. AKI was diagnosed and staged according to KDIGO criteria (stages 1–3). Patients with pre-existing advanced chronic kidney disease (defined as CKD-EPI ≤ 20 mL/min/1.73 m2), early death (within 24 hours), and early AKI (within 48 hours of admission) were excluded. Patients were stratified by admission type (medical, elective surgery, and urgent surgery) and NSAID use. Multivariate logistic regression was performed to identify independent risk factors for AKI, while Cox proportional hazards models evaluated long-term survival. Results The total cohort included 1157 patients, of which 851 medical admissions (73.6%) and 306 surgical admissions (26.4%) [166 elective (54.2%) and 140 urgent (45.8%)]. NSAID use was more common in surgical patients (62.1% in urgent surgery, 61.4% in elective surgery) compared to medical patients (23.5%, P < 0.001). AKI was more prevalent in medical admissions (P < 0.001), but severe AKI was more frequent in urgent surgery admissions (P = 0.003). NSAID use was associated with a higher incidence of AKI (67.2% vs. 51.2%, P = 0.009) and severe AKI (34.4% vs. 26.7%, P = 0.008). Surgical patients on NSAIDs had increased rates of AKI compared to those not exposed (43.4% vs. 26.5%, P = 0.003). Independent risk factors for severe AKI included NSAID use (OR 1.978, 95% CI 1.429–2.738, P < 0.001), diabetes Mellitus (OR 2.616, 95% CI 1.758–3.893, P < 0.001), chronic hepatic disease (OR 1.666, 95% CI 1.212–2.291, P = 0.002), SAPSII score (OR 1.025, 95% CI 1.008–1.041, P = 0.003), invasive mechanical ventilation (IMV) (OR 2.056, 95% CI 1.259–3.357, P = 0.004), and sepsis (OR 2.070, 95% CI 1.125–3.811, P = 0.019). Among NSAID-exposed patients, independent risk factors for severe AKI included SAPSII (OR 1.025, 95% CI 1.008–1.041, P = 0.003), and IMV (OR 2.056, 95% CI 1.259–3.357, P = 0.004, and sepsis (OR 2.070, 95% CI 1.125–3.811, P = 0.019). Survival was worse for medical admissions (log-rank 0.004) (Fig. 1). Over two years, survival was significantly lower in patients with severe AKI (log-rank <0.001) (Fig. 2). Conclusion NSAID use significantly increases the risk of AKI, particularly in surgical patients. Severe AKI independently worsens long-term survival, irrespective of the underlying cause. Identifying high-risk patients, ensuring hemodynamic stability, and considering alternative analgesic strategies may help reduce the incidence and severity of AKI in critically ill patients.