Long-term follow-up of acute renal failure caused by angiotensin converting enzyme inhibitors

Abstract

Angiotensin converting enzyme (ACE) inhibitors are useful in the treatment of hypertension and heart failure. However, acute renal failure (ARF) may occur in patients who are taking these drugs in situations associated with decreased glomerular filtration pressure, such as dehydration caused by acute diarrhea or diuretic therapy. Sixty-four patients who were admitted to the intensive care unit for ARF associated with ACE inhibitor therapy were followed for more than 5 years. In this historical retrospective study, we documented that 45 patients were treated for hypertension (group I) and 19 were treated for heart failure (group II). Their mean age was 71.2+/-11.6 years. Patients with ARF presented with overt dehydration in 91% and 84% of the cases in groups I and II, respectively. Hypovolemia was caused by diuretics or gastrointestinal fluid loss. Bilateral artery-renal stenosis or stenosis in a solitary kidney was documented in 22% and 10% of patients in groups I and II, respectively. The probability of survival was 91% and 49% at 1 year and 64% and 18% at 5 years, for groups I and II, respectively. Acute renal failure required hemodialysis in seven patients, but none of them became dialysis dependent. In the subgroup of patients with preexisting chronic renal failure, all the patients except for one who belonged to group II died within 2 years. In both groups, after resolution of ARF, plasma creatinine concentration returned to baseline level and the course of renal function was not significantly worsened. In conclusion, ARF associated with ACE inhibitors is likely to occur in many patients without renal artery stenosis after unexpected dehydration, especially in older patients with congestive heart failure. In both groups of patients, in the absence of preexisting chronic uremia, recovery of renal function occurred without sequelae, even after an episode of acute tubular necrosis requiring dialysis.

Renal Considerations in Angiotensin Converting Enzyme Inhibitor Therapy

“…In the only broad-based trial of ACE inhibitors versus angiotensin-receptor antagonists in CHF, there was no difference in the frequency with which renal function changed over a 48-week period of study-drug administration. 52 It is not known whether the timing of ACE inhibitor administration influences the development of renal failure. Diuretic action, especially that of loop diuretics, is critically dependent on a threshold MAP.…”

Acute Tubular Necrosis due to Captopril

“…Our patient was on a high dose of diuretic for his condition and his intravascular volume was decreased as he had a low urinary chloride. Age is probably an important factor in our patient since older patients are more liable to develop ARF following therapy with ACE inhibitors [14].…”

Diarrhoea, vomiting and ACE inhibitors: – an important cause of acute renal failure

“…10 A proportion of such patients will be found on further investigation to have bilateral renovascular disease or stenosis in a solitary kidney. 11 Elevation of serum creatinine can also occur if renal perfusion pressure falls for any reason in patients taking ACE inhibitors.…”

“…[2][3][4] On the other hand, ACE inhibitors may lead to the loss of renal function in patients with bilateral renovascular disease, 5,6 when co-administered with NSAIDs 7 or large doses of diuretics 8 and, when there is marked volume depletion. 9,10 Studies of patients presenting with acute renal failure to renal units suggest that ACE inhibitors are implicated in 8% of cases. 9 Against this background, we wish to report three cases of severe acute renal failure in patients who developed intercurrent diarrhoeal illnesses while taking ACE inhibitors, together with the results of a survey to determine the frequency with which diarrhoea and vomiting are associated with acute renal failure in patients taking ACE inhibitors at the time of their admission as medical emergencies to a district general hospital.…”