Acute Kidney Injury in Patients Continued on Renin-Angiotensin System Blockers During Hospitalization

Alabdan, Numan; Gosmanova, Elvira O.; Tran, Nhu Quynh; Oliphant, Carrie S.; Hu, Pan; Broyles, Joyce E.; Hudson, Joanna Q.

doi:10.1016/j.amjms.2016.09.012

Cited by 8 publications

(9 citation statements)

References 21 publications

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“…In our cohort, continued ACEi/ARB use during critical illness was associated with an increased AKI risk in patients with sepsis, shock, or eGFRs < 30 mL/min/1.73 m 2 . These results are compatible with previous observations that CKD and hypotension are likely risk factors for AKI development after ACEi/ARB treatment [25].…”

Section: Effects Of Raas Blockade In Patients With Sepsis and Other Ssupporting

confidence: 93%

“…Whether ACEi/ARB use increases the AKI risk after major surgery is also controversial. Some retrospective studies suggest that patients receiving ACEis/ARBs are more susceptible to AKI when undergoing surgery [25,37], whereas a prospective study [6] and a randomized controlled trial [38] produced the opposite results. Our results also do not support ACEi/ARB withdrawal in patients undergoing major surgery.…”

Section: Effects Of Raas Blockade In Patients With Sepsis and Other Smentioning

confidence: 99%

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Renin-Angiotensin-Aldosterone System Blockade Strategies and the Risk of Acute Kidney Injury in Septic and Critically Ill Patients

Chou¹,

Yang²,

Wu³

et al. 2020

Preprint

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Background: Renin-angiotensin-aldosterone system (RAAS) blockers are widely used for the treatment of hypertension and heart failure, but the usage of angiotensin- converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB) demands caution due to a potential risk of causing acute kidney injury (AKI). Whether long-term RAAS blockade increases AKI risk and should be withdrawn during critical illness remains inconclusive. This study aimed to investigate the associations between RAAS blockade strategies and AKI incidence in patients admitted to intensive care units (ICUs). Methods: Twenty-four hundred dialysis-free patients admitted to ICUs during December 2015–July 2017 were enrolled. Patients with pre-ICU AKI (n=568) were excluded when examining in-ICU AKI events. Patients using ACEi or ARB for more than 1 month before hospitalization were defined as long-term ACEi/ARB users. ACEi/ARB users were further grouped by ACEi/ARB continuation/withdrawal at ICU admission. Daily urine output and serum creatinine were measured in ICU. The primary outcome was occurrence of AKI within 48 hours after ICU admission, and the secondary outcome was all-cause mortality within 1 year. Results: Totally 1181 (49.2%) AKI cases and 895 (37.3%) deaths within 1 year occurred. ACEis/ARBs were continued for 122 patients and withdrawn for 239 patients. ACEi/ARB users were older and had lower initial estimated glomerular filtration rates (eGFRs). Compared with non-use, long-term ACEi/ARB use [odds ratio (OR) 1.03, 95% confidence interval (CI) 0.85–1.26, p=0.741] and continued ICU use (OR 1.14, 95% CI 0.78–1.68, p=0.491) were not associated with increased AKI risk. ACEi/ARB use was associated with less 1-year mortality. However, compared with withdrawal, continued ACEi/ARB use in ICUs was associated with higher AKI incidence among patients with sepsis (OR 2.89, 95% CI 1.35–6.20, p=0.006). Conclusions: Long-term RAAS blockade was not associated with a higher AKI or mortality incidence during acute illness. Continued ACEi/ARB use in ICUs may increase AKI risk in septic patients. Long-term and continued ACEi/ARB use are recommended, with cautious evaluation at ICU admission.

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Section: Effects Of Raas Blockade In Patients With Sepsis and Other Ssupporting

confidence: 93%

Section: Effects Of Raas Blockade In Patients With Sepsis and Other Smentioning

confidence: 99%

Renin-Angiotensin-Aldosterone System Blockade Strategies and the Risk of Acute Kidney Injury in Septic and Critically Ill Patients

Chou¹,

Yang²,

Wu³

et al. 2020

Preprint

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“…It was indeed our work at the Mayo Clinic Health System in Northwestern Wisconsin that spurred the work of El Nahas and his group from the Sheffield Kidney Institute, Sheffield in the United Kingdom who concluded in 2010 that discontinuation of ACEI/ARB had undoubtedly delayed the onset of RRT in the majority of those studied and that this observation might justify a rethink of our approach to the inhibition of the renin-angiotensin-aldosterone system (RAAS) in patients with advanced CKD who are nearing the start of RRT (11,12). Some other investigators around the world have shown similar reports raising concerns about the potential nephrotoxicity of angiotensin blockade especially in the elderly (>65-year old) with more advanced CKD (13)(14)(15). As a result of these legitimate concerns, we now have a randomized controlled trial to determine whether the pre-emptive withdrawal of ACEI/ARB in patients with advanced CKD would result in improved cardiorenal outcomes -the ongoing STOP ACEi Trial (16,17).…”

Section: Discussionmentioning

confidence: 74%

“…In our small 100-patient experience in northwestern Wisconsin, we were able to demonstrate an association of angiotensin blockade with SORO-ESRD (7-10). A just published report from Saudi Arabia revealed an association of continued angiotensin blockade with hospital-acquired AKI (15). Besides, we had demonstrated in a 13-year retrospective analysis of 1461 ESRD patient managed at Mayo Clinic, Rochester, 2001-2013, an incidence rate of SORO-ESRD of 10% but we were not able to show any association between SORO-ESRD and concurrent angiotensin blockade (21).…”

Section: Lorffab and Soro-esrdmentioning

confidence: 91%

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Late onset renal failure from angiotensin blockade (LORFFAB) and the syndrome of rapid onset endstage renal disease (SORO-ESRD) revisited – Two case reports from Mayo Clinic Health System, Northwestern Wisconsin, USA; a review paper

Onuigbo¹,

Samuel²,

Agbasi³

2018

J Renal Inj Prev

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In 2005, we had described for the first time, the syndrome of late onset renal failure from angiotensin blockade (LORFFAB), represented by the observed accelerated loss of kidney function in patients on a priori stable doses of an angiotensin converting enzyme inhibitor and/or an angiotensin receptor blocker, for more than three months, with this acute kidney injury (AKI) occurring despite the absence of any identifiable known precipitating factors. Moreover, in 2010, we had described the syndrome of rapid onset end-stage renal disease (SORO-ESRD), represented by acute yet irreversible renal failure following medical illness or surgical procedures, again sometimes in association with concurrent angiotensin blockade. In this article, we describe two representative case reports, one each of both syndromes, and discuss the implications of LORFFAB and SORO-ESRD in current nephrology practice paradigms.Please cite this paper as: Onuigbo M, Samuel E, Agbasi N. Late onset renal failure from angiotensin blockade (LORFFAB) and the syndrome of rapid onset end-stage renal disease (SORO-ESRD) revisited -Two case reports from Mayo Clinic Health System, Northwestern Wisconsin, USA; a review paper. J Renal Inj Prev. 2018;7(2):58-63. DOI: 10.15171/jrip.2018.15. In 2005, we described for the first time, the syndrome of late onset renal failure from angiotensin blockade (LORFFAB). This is accelerated loss of kidney function in patients on a priori stable doses of an angiotensin converting enzyme inhibitor and/or an angiotensin receptor blocker (ARB), for more than 3 months, with this acute kidney injury (AKI) occurring in the absence of any identifiable known precipitating factors. Moreover, in 2010, we described the syndrome of rapid onset end-stage renal disease (SORO-ESRD). This is acute yet irreversible renal failure following medical illness or surgical procedures, again sometimes in association with concurrent angiotensin blockade. In this article, we describe two representative case reports, one case for LORFFAB and another case for SORO-ESRD and subsequently discuss the implications of LORFFAB and SORO-ESRD in current nephrology practice paradigms. Whereas we support the consensus that angiotensin blockade, for now, remains the mainstay of renoprotection, we however must draw attention to the potential for nephrotoxicity from angiotensin blockade under certain clinical scenarios including the ones described here and more. The association of LORFFAB and SORO-ESRD demands further investigation.

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Association of Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Use With Outcomes After Acute Kidney Injury

et al. 2018

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; for the Interdisciplinary Chronic Disease Collaboration IMPORTANCE Patients with acute kidney injury (AKI) are at an increased long-term risk of death. Effective strategies that improve long-term outcomes in patients with AKI are unknown. OBJECTIVE To evaluate whether the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) after hospital discharge is associated with better outcomes in patients with AKI. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Alberta Kidney Disease Network population database to evaluate 46 253 adults 18 years or older with an episode of AKI during a hospitalization between July 1, 2008, and March 31, 2015, in Alberta, Canada. All patients who survived to hospital discharge were followed up for a minimum of 2 years. EXPOSURES Use of an ACEI or ARB within 6 months after hospital discharge. MAIN OUTCOMES AND MEASURES The primary outcome was mortality; secondary outcomes included hospitalization for a renal cause, end-stage renal disease (ESRD), and a composite outcome of ESRD or sustained doubling of serum creatinine concentration. An AKI was defined as a 50% increase between prehospital and peak in-hospital serum creatinine concentrations. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not have a prescription for an ACEI or ARB within 6 months after hospital discharge. RESULTS The study evaluated 46 253 adults (mean [SD] age, 68.6 [16.4] years; 24 436 [52.8%] male). Within 6 months of discharge, 22 193 (48.0%) of the participants were prescribed an ACEI or ARB. After adjustment for comorbidities, ACEI or ARB use before admission, demographics, baseline kidney function, other factors related to index hospitalization, and prior health care services, ACEI or ARB use was associated with lower mortality in patients with AKI after 2 years (adjusted hazard ratio, 0.85; 95% CI, 0.81-0.89). However, patients who received an ACEI or ARB had a higher risk of hospitalization for a renal cause (adjusted hazard ratio, 1.28; 95% CI, 1.12-1.46). No association was found between ACEI or ARB use and progression to ESRD. CONCLUSIONS AND RELEVANCE Among patients with AKI, ACEI or ARB therapy appeared to be associated with lower mortality but a higher risk of hospitalization for a renal cause. These results suggest a potential benefit of ACEI or ARB use after AKI, but cautious monitoring for renal-specific complications may be warranted.

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Acute Kidney Injury in Patients Continued on Renin-Angiotensin System Blockers During Hospitalization

Cited by 8 publications

References 21 publications

Renin-Angiotensin-Aldosterone System Blockade Strategies and the Risk of Acute Kidney Injury in Septic and Critically Ill Patients

Renin-Angiotensin-Aldosterone System Blockade Strategies and the Risk of Acute Kidney Injury in Septic and Critically Ill Patients

Late onset renal failure from angiotensin blockade (LORFFAB) and the syndrome of rapid onset endstage renal disease (SORO-ESRD) revisited – Two case reports from Mayo Clinic Health System, Northwestern Wisconsin, USA; a review paper

Association of Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Use With Outcomes After Acute Kidney Injury

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