Chou Ruey-Hsing, Yang Shang-Feng, Wu Cheng-Hsueh, Tsai Yi-Lin, Lu Ya-Wen, Guo Jiun-Yu, Huang Po-Hsun, Lin Shing-Jong
Division of Cardiology, Department of Medicine.
Department of Critical Care Medicine, Taipei Veterans General Hospital.
Acta Cardiol Sin. 2023 Sep;39(5):709-719. doi: 10.6515/ACS.202309_39(5).20230301B.
Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) are commonly used for hypertension and cardiovascular diseases. However, whether their use increases the risk of acute kidney injury (AKI) and should be discontinued during acute illness remains controversial.
This retrospective study enrolled 952 dialysis-free patients who were admitted to intensive care units (ICUs) between 2015 and 2017, including 476 premorbid long-term (> 1 month) ACEi/ARB users. Propensity score matching was performed to adjust for age, gender, comorbidities, and disease severity. The primary endpoint was the occurrence of AKI during hospitalization, and the secondary endpoint was mortality or dialysis within 1 year.
Compared with non-users, the ACEi/ARB users were not associated with an increased AKI risk during hospitalization [66.8% vs. 70.4%; hazard ratio (HR): 1.13, 95% confidence interval (CI): 0.97-1.32, p = 0.126]. However, the ACEi/ARB users with sepsis (HR: 1.29, 95% CI: 1.04-1.60, p = 0.021) or hypotension (HR: 1.21, 95% CI: 1.02-1.14, p = 0.034) were found to have an increased AKI risk in subgroup analysis. Nevertheless, compared with the non-users, the ACEi/ARB users were associated with a lower incidence of mortality or dialysis within 1 year (log-rank p = 0.011).
Premorbid ACEi/ARB usage did not increase the incidence of AKI, and was associated with a lower 1-year mortality and dialysis rate in patients admitted to ICUs. Regarding the results of subgroup analysis, renin-angiotensin-aldosterone system blockade may still be safe and beneficial in the absence of sepsis or circulation failure. Further large-scale studies are needed to confirm our findings.
血管紧张素转换酶抑制剂（ACEI）和血管紧张素受体阻滞剂（ARB）常用于治疗高血压和心血管疾病。然而，它们的使用是否会增加急性肾损伤（AKI）的风险以及在急性疾病期间是否应停用仍存在争议。
这项回顾性研究纳入了2015年至2017年间入住重症监护病房（ICU）的952例未接受透析的患者，其中包括476例病前长期（>1个月）使用ACEI/ARB的患者。采用倾向评分匹配法对年龄、性别、合并症和疾病严重程度进行调整。主要终点是住院期间发生AKI，次要终点是1年内的死亡率或透析情况。
与未使用者相比，ACEI/ARB使用者在住院期间发生AKI的风险并未增加[66.8%对70.4%；风险比（HR）：1.13，95%置信区间（CI）：0.97 - 1.32，p = 0.126]。然而，亚组分析发现，患有脓毒症（HR：1.29，95%CI：1.04 - 1.60，p = 0.021）或低血压（HR：1.21，95%CI：1.02 - 1.14，p = 0.034）的ACEI/ARB使用者发生AKI的风险增加。尽管如此，与未使用者相比，ACEI/ARB使用者1年内死亡率或透析发生率较低（对数秩检验p = 0.011）。
病前使用ACEI/ARB并未增加AKI的发生率，且与入住ICU患者1年较低的死亡率和透析率相关。关于亚组分析结果，在没有脓毒症或循环衰竭的情况下，肾素 - 血管紧张素 - 醛固酮系统阻断可能仍然是安全有益的。需要进一步的大规模研究来证实我们的发现。
