Tan Byorn W L, Tan Bryce W Q, Akalya K, Hong Wei-Zhen, Da Yi, Low Sanmay, Ng Wan-Ying, Chua Horng-Ruey
Department of Medicine, National University Hospital, Singapore.
Division of Nephrology, Department of Medicine, National University Hospital, Singapore.
Kidney Med. 2025 Mar 20;7(5):100996. doi: 10.1016/j.xkme.2025.100996. eCollection 2025 May.
RATIONALE & OBJECTIVE: Acute kidney injury (AKI) is common in hospitalized adults and a risk factor for chronic kidney disease and mortality. The effect of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) post-AKI on mortality and long-term kidney function remains unclear.
Propensity-weighted retrospective observational cohort study.
SETTING & PARTICIPANTS: A total of 3,289 patients with AKI admitted to a tertiary care hospital from November 2015-October 2016, with follow-up until September 2020.
ACEi/ARB use within 180 days post-AKI.
All-cause mortality, and major adverse kidney events (MAKE) as defined by composite of renal replacement therapy post-AKI, sustained estimated glomerular filtration rate (eGFR) decline >30% from baseline, or eGFR ≤15 mL/min/1.73 m.
We generated propensity weights for ACEi/ARB use post-AKI, using age, sex, comorbid conditions, prior medication, intensive care unit admission, severe sepsis, and index AKI Kidney Disease: Improving Global Outcomes severity. Cox proportional hazard models were used to test associations of post-AKI ACEi/ARB with mortality, MAKE, and joint models for eGFR slopes.
A total of 2,309 (70.2%) participants died or experienced MAKE by end of follow-up. 161 (4.9%) and 406 (12.3%) patients initiated or resumed prior ACEi/ARB use within 180 days post-AKI, respectively. Although the overall cohort had no significant mortality association with post-AKI ACEi/ARB use, a significant association with lower mortality was observed in patients with KDIGO 3 AKI (HR, 0.40; 95% CI, 0.21-0.75; = 0.003). However, post-AKI ACEi/ARB use was associated with increased MAKE in patients without cardiovascular indications for ACEi/ARB use (HR, 1.52; 95% CI, 1.17-1.98; = 0.03). Although post-AKI use of ACEi/ARB was associated with acute eGFR decline (initial eGFR change -2.3 mL/min/1.73 m/year; 95% CI, -3.1 to -1.5; < 0.001), no association with longer-term eGFR decline was observed.
Retrospective observational study on heterogeneous AKI cohort without data on ACEi/ARB cumulative exposure.
Early ACEi/ARB post-AKI was not associated with better long-term survival or kidney function but was associated with lower mortality in patients with KDIGO 3 AKI.
急性肾损伤（AKI）在住院成人中很常见，是慢性肾脏病和死亡的危险因素。AKI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）对死亡率和长期肾功能的影响尚不清楚。
倾向加权回顾性观察队列研究。
2015年11月至2016年10月期间，共有3289例AKI患者入住一家三级护理医院，随访至2020年9月。
AKI后180天内使用ACEi/ARB。
全因死亡率，以及主要不良肾脏事件（MAKE），定义为AKI后肾脏替代治疗、持续估计肾小球滤过率（eGFR）较基线下降>30%或eGFR≤15 mL/min/1.73 m²的综合指标。
我们根据年龄、性别、合并症、既往用药情况、入住重症监护病房、严重脓毒症和索引AKI的肾脏病改善全球预后（KDIGO）严重程度，生成AKI后使用ACEi/ARB的倾向权重。采用Cox比例风险模型检验AKI后ACEi/ARB与死亡率、MAKE的关联，以及eGFR斜率的联合模型。
共有2309例（70.2%）参与者在随访结束时死亡或发生MAKE。分别有161例（4.9%）和406例（12.3%）患者在AKI后180天内开始或恢复使用既往的ACEi/ARB。虽然总体队列中AKI后使用ACEi/ARB与死亡率无显著关联，但在KDIGO 3期AKI患者中观察到与较低死亡率有显著关联（风险比[HR]，0.40；95%置信区间[CI]，0.21 - 0.75；P = 0.003）。然而，在无ACEi/ARB心血管适应证的患者中，AKI后使用ACEi/ARB与MAKE增加相关（HR，1.52；95% CI，1.17 - 1.98；P = 0.03）。虽然AKI后使用ACEi/ARB与急性eGFR下降相关（初始eGFR变化为-2.3 mL/min/1.73 m²/年；95% CI，-3.1至-1.5；P < 0.001），但未观察到与长期eGFR下降有关联。
对异质性AKI队列的回顾性观察研究，无ACEi/ARB累积暴露数据。
AKI后早期使用ACEi/ARB与更好的长期生存或肾功能无关，但与KDIGO 3期AKI患者的较低死亡率相关。
