Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD.
Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA.
Mayo Clin Proc. 2019 Nov;94(11):2220-2229. doi: 10.1016/j.mayocp.2019.05.031. Epub 2019 Oct 13.
To assess the patterns of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACE-I/ARB) discontinuation in the setting of chronic kidney disease (CKD) progression in real-world clinical practice.
We identified incident ACE-I/ARB users with a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73 m and without end-stage renal disease in the Geisinger Health System between January 1, 2004, and December 31, 2015. We investigated the associations of CKD stage, hospitalizations with and without acute kidney injury (AKI), serum potassium, bicarbonate level, thiazide, and loop diuretic use with ACE-I/ARB discontinuation.
Among the 53,912 ACE-I/ARB users, the mean age was 59.9 years, and 50.6% were female. More than half of users discontinued ACE-I/ARB within 5 years of therapy initiation. The risk of ACE-I/ARB discontinuation increased with more advanced CKD stage. For example, patients who initiated ACE-I/ARB with CKD stage G4 (eGFR: 15-29 mL/min/1.73 m) were 2.09-fold (95% CI, 1.87-2.34) more likely to discontinue therapy than those with eGFR ≥ 90 mL/min/1.73 m. Potassium level greater than 5.3 mEq/L, systolic blood pressure ≤ 90 mm Hg, bicarbonate level < 22 mmol/L, and intervening hospitalization-particularly AKI-related-were also strong risk factors for ACE-I/ARB discontinuation. Thiazide diuretic use was associated with lower risk, whereas loop diuretic use was associated with higher risk of discontinuation.
In a real-world cohort, discontinuation of ACE-I/ARB was common, particularly in patients with lower eGFR. Hyperkalemia, hypotension, low bicarbonate level, and hospitalization (AKI-related, in particular) were associated with a higher risk of ACE-I/ARB discontinuation. Additional studies are needed to evaluate the risk-benefit balance of discontinuing ACE-I/ARB in the setting of CKD progression.
在真实临床环境中评估慢性肾脏病（CKD）进展情况下血管紧张素转换酶抑制剂（ACE-I）和血管紧张素受体阻滞剂（ARB）停药的模式。
我们在 2004 年 1 月 1 日至 2015 年 12 月 31 日期间，在 Geisinger 健康系统中，识别出基线估计肾小球滤过率（eGFR）≥15 mL/min/1.73 m 且无终末期肾病的新发 ACE-I/ARB 使用者。我们研究了 CKD 分期、伴有或不伴有急性肾损伤（AKI）的住院治疗、血清钾、碳酸氢盐水平、噻嗪类和袢利尿剂的使用与 ACE-I/ARB 停药的关系。
在 53912 名 ACE-I/ARB 使用者中，平均年龄为 59.9 岁，50.6%为女性。超过一半的使用者在治疗开始后 5 年内停止使用 ACE-I/ARB。ACE-I/ARB 停药的风险随着 CKD 分期的进展而增加。例如，开始 ACE-I/ARB 治疗时 CKD 分期 G4（eGFR：15-29 mL/min/1.73 m）的患者，与 eGFR≥90 mL/min/1.73 m 的患者相比，停止治疗的可能性高 2.09 倍（95%CI，1.87-2.34）。血清钾>5.3 mEq/L、收缩压≤90 mmHg、碳酸氢盐水平<22 mmol/L 以及介入性住院治疗，特别是 AKI 相关住院治疗，也是 ACE-I/ARB 停药的强危险因素。噻嗪类利尿剂的使用与较低的风险相关，而袢利尿剂的使用与停药的风险较高相关。
在真实世界队列中，ACE-I/ARB 的停药很常见，尤其是在 eGFR 较低的患者中。高钾血症、低血压、低碳酸氢盐水平和住院治疗（特别是 AKI 相关）与 ACE-I/ARB 停药风险增加相关。需要进一步研究来评估在 CKD 进展情况下停止 ACE-I/ARB 的风险-获益平衡。
