Department of Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota.
Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota.
J Am Soc Nephrol. 2023 Oct 1;34(10):1721-1732. doi: 10.1681/ASN.0000000000000196. Epub 2023 Aug 7.
Among patients with CKD, optimal use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers after AKI is uncertain. Despite these medications' ability to reduce risk of mortality and other adverse outcomes, there is concern that ACEi/ARB use may delay recovery of kidney function or precipitate recurrent AKI. Prior studies have provided conflicting data regarding the optimal timing of these medications after AKI and have not addressed the role of kidney recovery in determining appropriate timing. This study in US Veterans with diabetes mellitus and proteinuria demonstrated an association between ACEi/ARB use and lower mortality. This association was more pronounced with earlier post-AKI ACEi/ARB use and was not meaningfully affected by initiating ACEis/ARBs before versus after recovery from AKI.
Optimal use of angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) after AKI is uncertain.
Using data derived from electronic medical records, we sought to estimate the association between ACEi/ARB use after AKI and mortality in US military Veterans with indications for such treatment (diabetes and proteinuria) while accounting for AKI recovery. We used ACEi/ARB treatment after hospitalization with AKI (defined as serum creatinine ≥50% above baseline concentration) as a time-varying exposure in Cox models. The outcome was all-cause mortality. Recovery was defined as return to ≤110% of baseline creatinine. A secondary analysis focused on ACEi/ARB use relative to AKI recovery (before versus after).
Among 54,735 Veterans with AKI, 31,146 deaths occurred over a median follow-up period of 2.3 years. Approximately 57% received an ACEi/ARB <3 months after hospitalization. In multivariate analysis with time-varying recovery, post-AKI ACEi/ARB use was associated with lower risk of mortality (adjusted hazard ratio [aHR], 0.74; 95% confidence interval [CI], 0.72 to 0.77). The association between ACEi/ARB use and mortality varied over time, with lower mortality risk associated with earlier initiation ( P for interaction with time <0.001). In secondary analysis, compared with those with neither recovery nor ACEi/ARB use, risk of mortality was lower in those with recovery without ACEi/ARB use (aHR, 0.90; 95% CI, 0.87 to 0.94), those without recovery with ACEi/ARB use (aHR, 0.69; 95% CI, 0.66 to 0.72), and those with ACEi/ARB use after recovery (aHR, 0.70; 95% CI, 0.67 to 0.73).
This study demonstrated lower mortality associated with ACEi/ARB use in Veterans with diabetes, proteinuria, and AKI, regardless of recovery. Results favored earlier ACEi/ARB initiation.
在急性肾损伤（AKI）后，血管紧张素转换酶抑制剂（ACEi）或血管紧张素 II 受体阻滞剂（ARBs）的最佳使用方法仍不确定。
我们利用电子病历数据，旨在估计 AKI 后 ACEi/ARB 的使用与有此类治疗适应证（糖尿病和蛋白尿）的美国退伍军人死亡率之间的关联，同时考虑 AKI 的恢复情况。我们将 AKI 住院后（定义为血清肌酐较基线浓度升高≥50%）的 ACEi/ARB 治疗作为 Cox 模型中的时间变化暴露。结果是全因死亡率。恢复定义为恢复至≤110%的基线肌酐。二次分析侧重于 AKI 恢复前后（使用 ACEi/ARB 的时间）的关系。
在 54735 名患有 AKI 的退伍军人中，中位随访 2.3 年后有 31146 人死亡。约有 57%的退伍军人在住院后<3 个月接受 ACEi/ARB 治疗。在具有时间变化恢复的多变量分析中，AKI 后 ACEi/ARB 的使用与较低的死亡率风险相关（调整后的危险比[ aHR]，0.74；95%置信区间[CI]，0.72 至 0.77）。ACEi/ARB 使用与死亡率之间的关联随时间而变化，较早开始使用 ACEi/ARB 与较低的死亡率风险相关（时间交互作用的 P 值<0.001）。在二次分析中，与既无恢复也无 ACEi/ARB 使用的患者相比，无 ACEi/ARB 使用的患者（ aHR，0.90；95%CI，0.87 至 0.94）、有 ACEi/ARB 使用但无恢复的患者（ aHR，0.69；95%CI，0.66 至 0.72）和 ACEi/ARB 使用后恢复的患者（ aHR，0.70；95%CI，0.67 至 0.73）的死亡率较低。
本研究表明，在患有糖尿病、蛋白尿和 AKI 的退伍军人中，无论是否恢复，使用 ACEi/ARB 均可降低死亡率。结果有利于早期开始 ACEi/ARB 治疗。
