Department of Nephrology, University of Toronto, Toronto, Ontario, Canada.
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
JAMA Intern Med. 2018 Dec 1;178(12):1681-1690. doi: 10.1001/jamainternmed.2018.4749.
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.
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.
Use of an ACEI or ARB within 6 months after hospital discharge.
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.
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.
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.
急性肾损伤 (AKI) 患者的长期死亡风险增加。目前尚不清楚哪些策略能有效改善 AKI 患者的长期预后。
评估 AKI 患者出院后使用血管紧张素转换酶抑制剂 (ACEI) 或血管紧张素受体阻滞剂 (ARB) 是否与更好的结局相关。
设计、设置和参与者:这项回顾性队列研究使用了来自加拿大艾伯塔省肾脏病网络人群数据库的数据,纳入了 2008 年 7 月 1 日至 2015 年 3 月 31 日期间在艾伯塔省住院期间发生 AKI 的 46253 例 18 岁及以上成年人。所有存活至出院的患者均进行了至少 2 年的随访。
出院后 6 个月内使用 ACEI 或 ARB。
主要结局为死亡率;次要结局包括因肾脏原因、终末期肾病 (ESRD) 住院,以及 ESRD 或血清肌酐浓度持续倍增的复合结局。AKI 的定义为住院期间血清肌酐浓度从入院前到峰值增加 50%。采用倾向评分构建了一个匹配对队列,包括出院后 6 个月内使用 ACEI 或 ARB 的患者和未使用 ACEI 或 ARB 的患者。
该研究共评估了 46253 例成年人(平均 [标准差] 年龄,68.6 [16.4] 岁;24436 [52.8%] 为男性)。出院后 6 个月内,22193 例(48.0%)患者使用了 ACEI 或 ARB。在调整了合并症、入院前 ACEI 或 ARB 使用情况、人口统计学特征、基线肾功能、与指数住院相关的其他因素以及既往医疗保健服务后,ACEI 或 ARB 的使用与 AKI 患者 2 年后的死亡率降低相关(校正后的危险比,0.85;95%CI,0.81-0.89)。然而,使用 ACEI 或 ARB 的患者因肾脏原因住院的风险更高(校正后的危险比,1.28;95%CI,1.12-1.46)。ACEI 或 ARB 的使用与进展为 ESRD 之间无关联。
在 AKI 患者中,ACEI 或 ARB 治疗似乎与死亡率降低相关,但肾脏原因导致住院的风险增加。这些结果表明 ACEI 或 ARB 使用后可能对 AKI 有益,但需要谨慎监测肾脏特异性并发症。