S7 The Use of Rectal Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Is Safe and Effective in Patients With Early-Stage CKD Undergoing ERCP: A Comparative Matched Analysis of Real-World Data

Introduction: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a common and serious complication of ERCP. Rectal nonsteroidal anti-inflammatory drugs (NSAIDs) like indomethacin and diclofenac are widely used for prevention due to their anti-inflammatory effects. However, in patients with early-stage chronic kidney disease (CKD), these drugs may increase the risk of acute kidney injury (AKI). We aimed to assess renal safety by measuring the incidence of AKI following NSAIDs use and the prophylactic benefit against PEP in early-stage CKD patients. Methods: Through the TriNetX U.S. Collaborative Network, we identified patients with early-stage CKD (stage 1, 2, 3a and 3b) who underwent ERCP and received prophylactic rectal indomethacin or diclofenac and compared them to a matched control group of CKD patients who did not receive prophylaxis. The primary outcome was the development of AKI following ERCP. Secondary outcomes included post-ERCP pancreatitis (PEP), gastrointestinal bleeding, intensive care unit admission, acute necrotizing pancreatitis, sepsis, intubation, and overall mortality. We matched the groups based on baseline characteristics, co-morbidities, and pertinent medications that increase the risk of kidney injury like diuretics, ACE or ARBs to eliminate hidden confounders. Results: Before matching, a total of 8,010 patients with CKD stages 1, 2, 3a and 3b who underwent ERCP and received rectal NSAIDs and 14,934 who did not receive NSAIDs were identified. After propensity score matching, each group included 7,970 patients with similar baseline characteristics. The mean age was approximately 72 years in both groups, with balanced sex and racial distribution. There was no difference in the incidence of AKI between groups (9% in both groups, P = 0.912). PEP occurred slightly less in the NSAID group (8.6% vs 9.5%, P = 0.050), while gastrointestinal bleeding was marginally more frequent among NSAID group (2.6% vs 2.2%, P = 0.049). No significant differences were observed in acute necrotizing pancreatitis (0.1% in both), ICU admission (3.2% vs 3.6%, P = 0.207), intubation (0.5% vs 0.4%, P = 0.459), sepsis (2.4% vs 2.6%, P = 0.648), or mortality (0.7% vs 0.9%, P = 0.059). Conclusion: In patients with early-stage CKD undergoing ERCP, prophylactic rectal NSAIDs use was not associated with increased risk of AKI, with decreased incidence of PEP. This overall safety profile suggests NSAIDs may be used cautiously in this population with proper clinical oversight.