S2202 The Safety of Peri-ERCP Rectal Prophylactic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in Patients With Advanced Chronic Kidney Disease (GFR <30)

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 prophylaxis due to their anti-inflammatory effects. However, their use in patients with advanced chronic kidney disease (CKD) raises concerns about nephrotoxicity with a risk of acute kidney injury (AKI). Real-world data on the safety of NSAID use in CKD stages 4–5 in the context of endoscopic procedures is limited. We aimed to assess and weigh the renal safety with the incidence of AKI following NSAIDs use vs the prophylactic benefit of protecting against PEP in advanced CKD patients. Methods: Utilizing the TriNetX US Collaborative Network, we identified CKD stage 4 and 5 patients (with GFR <30, excluding those on dialysis/renal replacement therapy) who underwent ERCP and received rectal NSAIDs prophylaxis during the procedure, and compared them to another matched group of CKD patients who underwent ERCP and did not receive prophylaxis. The primary outcome was the development of AKI following the ERCP. Secondary outcomes included PEP, gastrointestinal bleeding (GIB), ICU admission, acute necrotizing pancreatitis (ANP), sepsis, intubation, and mortality. We matched the groups based on baseline characteristics, co-morbidities, and pertinent medications that increase the risk of kidney injury (including diuretics, ACEi, ARBs, etc.) to rule out potential confounders. Results: A total of 1,490 patients with CKD stages 4 or 5 received NSAIDs and 3,773 patients who did not were identified before propensity score matching, all of whom underwent ERCP. After matching, each group included 1,470 patients with comparable baseline characteristics. There was no significant difference in the incidence of AKI between both groups (13% vs 12%, P = 0.243). However, PEP was less common in the NSAID group (8% vs 10%, P = 0.027). There was no difference in rates of GIB, intubation, sepsis, or mortality. Notably, ANP occurred only in the non-NSAIDs group (0% vs 0.7%, P = 0.002). Conclusion: In patients with advanced CKD (GFR <30) undergoing ERCP, NSAIDs were not linked to higher risks of AKI, GI bleeding, or mortality; they were associated with lower PEP risk. These findings suggest that, with appropriate patient selection, NSAIDs may be safely used in this high risk patient population for single doses.