Angiotensin II Receptor Blockers but Not Angiotensin-Converting Enzyme Inhibitors Are Associated With a Reduced Risk of Acute Kidney Injury After Major Surgery.

Shao-Yu Yang,Yung-Ming Chen,Nsarf Study Group Nsarf Study Group,Tai-Shuan Lai,Tao-Min Huang,Yi-Ping Huang,Vin-Cent Wu,Shuei-Liong Lin,Chun-Hao Tsao,Nai-Kuan Chou

doi:10.3389/fphar.2021.662301

Abstract

Objective: We investigated the respective effects of preoperative angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on the incidence of postoperative acute kidney injury (AKI) and mortality. Methods: In this nested case-control study, we enrolled 20,276 patients who received major surgery. We collected their baseline demographic data, comorbidities and prescribed medication, the outcomes of postoperative AKI and mortality. AKI was defined by the criteria suggested by KDIGO (Kidney disease: Improving Global Outcome). Logistic regression was used to assess the impact of exposure to ACEIs or ARBs. Results: Compared with patients without ACEI/ARB, patient who received ARBs had a significantly lower risk for postoperative AKI (adjusted odds ratio (OR) 0.82, p = 0.007). However, ACEI users had a higher risk for postoperative AKI than ARB users (OR 1.30, p = 0.027), whereas the risk for postoperative AKI was not significantly different between the ACEI users and patients without ACEI/ARB (OR 1.07, p = 0.49). Compared with patients without ACEI/ARB, both ACEI and ARB users were associated with a reduced risk of long-term all-cause mortality following surgery (OR 0.47, p = 0.002 and 0.60, p < 0.001 in ACEI and ARB users, respectively), without increasing the risk of hyperkalemia during the index hospitalization (p = 0.20). The risk of long-term all-cause mortality following surgery in ACEIs and ARBs users did not differ significantly (OR 0.74, p = 0.27). Furthermore, the higher the defined daily dose of ARB, the better the protection against AKI provided. Conclusion: Our study revealed that preoperative use of ARBs was associated with reduced postoperative AKI, which is better in high quantity, whereas preoperative use of ACEIs or ARBs were both associated with reduced mortality and did not increase the risk of hyperkalemia.

Highlights

Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers are both used frequently in the treatment of patients with hypertension, congestive heart failure, or chronic kidney disease
Some studies showed that ACEIs/ARBs were not associated with postoperative AKI (Tagawa et al, 2015; Bonavia et al, 2019), and a study suggested that preoperative ACEIs/ARBs are associated with reduced postoperative AKI requiring dialysis and even reduced mortality (Shah et al, 2014)
Beyond the effects on postoperative AKI, we found that preoperative use of both ACEIs and ARBs within 90 days before surgery were associated with reduced postoperative long-term all-cause mortality

Summary

Introduction

Angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers are both used frequently in the treatment of patients with hypertension, congestive heart failure, or chronic kidney disease. Postoperative acute kidney injury remains common, even though perioperative care has improved greatly; in high-risk patients, the incidence of AKI may be as high as 20–40% (Bauerle et al, 2011). Previous studies exploring the impacts of preoperative use of ACEIs/ARBs on postoperative AKI provided conflicting data. Though a retrospective cohort study of 1,358 adults revealed that preoperative use of ACEIs/ARBs associated with an increased risk for AKI after cardiovascular surgery (Arora et al, 2008), a newer prospective cohort study of 1,594 adults revealed that preoperative ACEIs/ARBs usage was associated with functional but not structural AKI after cardiac surgery (Coca et al, 2013). Some studies showed that ACEIs/ARBs were not associated with postoperative AKI (Tagawa et al, 2015; Bonavia et al, 2019), and a study suggested that preoperative ACEIs/ARBs are associated with reduced postoperative AKI requiring dialysis and even reduced mortality (Shah et al, 2014). The risk and benefit of perioperative use of ACEIs/ARBs remained uncertain

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Conclusion