Use of Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) after Actute Kidney Injury
15 Nov 2018
ACE Inhibitors and ARBs are drugs that have transformed clinical care. There is strong randomised trial evidence for improved clinical outcomes from these drugs for patients with heart failure with reduced left ventricular function, and for proteinuric kidney disease. They are also recommended for use for the treatment of hypertension and after ischaemic heart disease. These multiple indications have led to them being one of the most commonly prescribed drug groups. However, in recent years there has been growing concern about their potential for ‘nephrotoxicity’. They are widely believed to be associated with AKI, particularly in patients who are hypovolaemic or septic. Multiple guidelines recommend dose reduction or cessation of these drugs for patients who have developed or are at risk of AKI. However, it is often unclear whether, and when, the drugs should be restarted, particularly when patients are at risk of further AKI. We do know that patients are at high risk of readmission with cardiac failure after AKI but it is not clear how much this is due to cessation of ACEI/ARB drugs as part of AKI management. In addition, AKI itself is associated with increased risk of future adverse outcomes including mortality and development of chronic kidney disease. Do these drugs offer specific benefits after AKI? These issues are at the heart of daily clinical work, and yet there is minimal evidence to help us make these important decisions. In this nephrology journal club blog, Laurie Tomlinson discusses whether a recently published observational study on this topic provides evidence that can be applied to routine practice.