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Original Investigation |

Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease

Benjamin Lazarus, MBBS1,2; Yuan Chen, MS1; Francis P. Wilson, MD, MS3; Yingying Sang, MS1; Alex R. Chang, MD, MS4; Josef Coresh, MD, PhD1,5; Morgan E. Grams, MD, PhD1,5
[+] Author Affiliations
1Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland
2Department of Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
3Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
4Division of Nephrology, Geisinger Health System, Danville, Pennsylvania
5Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
JAMA Intern Med. 2016;176(2):. doi:10.1001/jamainternmed.2015.7193.
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Importance  Proton pump inhibitors (PPIs) are among the most commonly used drugs worldwide and have been linked to acute interstitial nephritis. Less is known about the association between PPI use and chronic kidney disease (CKD).

Objective  To quantify the association between PPI use and incident CKD in a population-based cohort.

Design, Setting, and Participants  In total, 10 482 participants in the Atherosclerosis Risk in Communities study with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2 were followed from a baseline visit between February 1, 1996, and January 30, 1999, to December 31, 2011. The data was analyzed from May 2015 to October 2015. The findings were replicated in an administrative cohort of 248 751 patients with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2 from the Geisinger Health System.

Exposures  Self-reported PPI use in the Atherosclerosis Risk in Communities study or an outpatient PPI prescription in the Geisinger Health System replication cohort. Histamine2 (H2) receptor antagonist use was considered a negative control and active comparator.

Main Outcomes and Measures  Incident CKD was defined using diagnostic codes at hospital discharge or death in the Atherosclerosis Risk in Communities Study, and by a sustained outpatient estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 in the Geisinger Health System replication cohort.

Results  Among 10 482 participants in the Atherosclerosis Risk in Communities study, the mean (SD) age was 63.0 (5.6) years, and 43.9% were male. Compared with nonusers, PPI users were more often of white race, obese, and taking antihypertensive medication. Proton pump inhibitor use was associated with incident CKD in unadjusted analysis (hazard ratio [HR], 1.45; 95% CI, 1.11-1.90); in analysis adjusted for demographic, socioeconomic, and clinical variables (HR, 1.50; 95% CI, 1.14-1.96); and in analysis with PPI ever use modeled as a time-varying variable (adjusted HR, 1.35; 95% CI, 1.17-1.55). The association persisted when baseline PPI users were compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01-1.91) and with propensity score–matched nonusers (HR, 1.76; 95% CI, 1.13-2.74). In the Geisinger Health System replication cohort, PPI use was associated with CKD in all analyses, including a time-varying new-user design (adjusted HR, 1.24; 95% CI, 1.20-1.28). Twice-daily PPI dosing (adjusted HR, 1.46; 95% CI, 1.28-1.67) was associated with a higher risk than once-daily dosing (adjusted HR, 1.15; 95% CI, 1.09-1.21).

Conclusions and Relevance  Proton pump inhibitor use is associated with a higher risk of incident CKD. Future research should evaluate whether limiting PPI use reduces the incidence of CKD.

Figures in this Article

Figures

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Figure 1.
Prevalence of Proton Pump Inhibitor (PPI) Ever Use Over Time in the Atherosclerosis Risk in Communities Study
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Figure 2.
Association Between Proton Pump Inhibitor Use and Incident Kidney Disease Stratified By Subgroups

Young refers to an age that is below the cohort median (62 years in the Atherosclerosis Risk in Communities study and 50 years in the Geisinger Health System replication cohort). ACE-I indicates angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; CKD, chronic kidney disease; and PPI, proton pump inhibitor.

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