Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers on Acute Kidney Injury in Emergency Medical Admissions

Abstract

Background: Acute kidney injury (AKI) has been observed in up to 20% of adult hospital admissions. Sepsis, diarrhea and heart failure, all causing reduced effective volume, are considered risk factors for AKI, especially among patients treated with medications that block the Renin-Angiotensin System (RAS), such as angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). We aimed to determine the incidence of acute kidney injury (AKI) in emergency medical admissions in relation to the use and dosage of ACEi/ARB. Methods: A single-center observational study conducted in 577 consecutive medical admissions via the Emergency Room (ER) at a University General Hospital in Athens, Greece, between June and July 2018. Patients with incomplete medical records, discharged within 24 h, maintained on chronic renal replacement therapy, admitted to the Cardiology Department or the ICU were excluded. Thus, a total of 309 patients were finally included in this analysis. Results: We compared 86 (28%) patients who presented in the ER with AKI (AKIGroup) with 223 (72%) patients without AKI (non-AKI Group) at the time of admission. Patients in the AKI Group were more frequently male (58% vs. 46%, p = 0.06), with a higher frequency of diarrhea (16% vs. 6%, p = 0.006), edema (15% vs. 6%, p = 0.014) and lower systolic blood pressure (120 (107–135) vs. 126 (113–140), p = 0.007) at presentation, despite higher prevalence of hypertension (64% vs. 47%, p = 0.006). Overall, ACEi/ARB were more likely to have been prescribed in the AKI Group than in the non-AKI Group (49% vs. 28%, p = 0.001). Interestingly, AKI was more frequently observed in patients treated with the target or above target dosage of ACEi/ARB, but not in those receiving lower than the recommended dosage. Conclusion: The risk of AKI in emergency medical admissions is higher among users of ACEIs/ARB at target or above target dosages. Physicians should adjust RAS blockade according to estimated Glomerular Filtration Rate (eGFR) and advise their patients to withhold ACEi/ARB in cases of acute illness.

The effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in critically ill patients with acute kidney injury: An observational study using the MIMIC database

“…An increased risk of AKI was observed in patients who received ACEI/ARBs in combination with non-steroidal anti-inflammatory drugs and diuretics ( Lapi et al, 2013 ). Patients with ACEI/ARBs had a higher risk of AKI during admission for medical emergencies ( Feidakis et al, 2021 ). It is common clinical practice to discontinue or avoid the use of ACEI/ARBs in the context of AKI and other acute conditions because of concerns regarding altered renal hemodynamics.…”

Role of the Renin Angiotensin Aldosterone System in the Pathogenesis of Sepsis-Induced Acute Kidney Injury: A Systematic Review

“…Current analysis examining RAAS inhibitor use as a risk factor with regard to S-AKI similarly provides mixed conclusions. One study observed a higher risk of AKI for emergency medical admissions in patients using ACEi/ARBs compared to non-AKI admissions [70]. A meta-analysis assessing a large cohort of septic patients found several characteristics significantly associated with increased risk of S-AKI; however, these risk factors vary greatly, including underlying comorbidities such as diabetes mellitus and HTN, use of ACEi/ARBs and diuretics, infection source, and microbial type.…”

“…For this reason, it is suitable to compare differences in blood pressure during sepsis with regard to those with and without prior use of ACEi/ARBs. A study assessing the risk for AKI in emergency medical admissions observed that of all patients with prior ACEi/ARBs use, patients with significantly lower systolic blood pressure were more at risk of developing AKI [70]. Another study found that mean arterial pressure (MAP) was significantly lower in septic patients who developed AKI compared to those who did not.…”

“…The presence of underlying comorbidities in the patient may hinder proper blood pressure management, and ACEi/ARB therapy intensifies this phenomenon. In several studies [70][71][72][73][74][75], patients with underlying comorbidities on RAAS inhibitor therapy had an increased risk for S-AKI compared to those without underlying comorbidities on RAAS inhibitor therapy. This suggests that RAAS inhibitors have a role in aggravating existing conditions and advancing hypotension.…”

The clinical case of successful combined treatment of refractory arterial hypertension. Case report

“…В связи с этим принято решение о коррекции суточных доз (снижение спиронолактона до 25 мг/сут, торасемида -до 5 мг/сут, гидрохлортиазида -до 12,5 мг/сут). Вероятнее всего, увеличение уровня креатинина обусловлено острым почечным повреждением, связанным c дополнительной ишемией почек на фоне снижения значений АД, а также применением потенциально нефротоксичных препаратов (блокатор рецепторов ангиотензина II) в сочетании с водным дисбалансом, возникшим от присутствия в гипотензивной терапии диуретиков [5,6] Пациентка выписана на 6-компонентной антигипертензивной терапии, учитывая синусовую тахикардию, а также бронхиальную астму в анамнезе, вместо β-адреноблокаторов с ритмурежающей целью назначен ивабрадин 7,5 мг/сут. ЧСС на этом фоне 70-75 уд/мин.…”