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Stopping renin-angiotensin system blockers after acute kidney injury and risk of adverse outcomes: parallel population-based cohort studies in English and Swedish routine care.
BMC Med. 2020 07 29; 18(1):195.BM

Abstract

BACKGROUND

The safety of restarting angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) after acute kidney injury (AKI) is unclear. There is concern that previous users do not restart ACEI/ARB despite ongoing indications. We sought to determine the risk of adverse events after an episode of AKI, comparing prior ACEI/ARB users who stop treatment to those who continue.

METHODS

We conducted two parallel cohort studies in English and Swedish primary and secondary care, 2006-2016. We used multivariable Cox regression to estimate hazard ratios (HR) for hospital admission with heart failure (primary analysis), AKI, stroke, or death within 2 years after hospital discharge following a first AKI episode. We compared risks of admission between people who stopped ACEI/ARB treatment to those who were prescribed ACEI/ARB within 30 days of AKI discharge. We undertook sensitivity analyses, including propensity score-matched samples, to explore the robustness of our results.

RESULTS

In England, we included 7303 people with AKI hospitalisation following recent ACEI/ARB therapy for the primary analysis. Four thousand three (55%) were classified as stopping ACEI/ARB based on no prescription within 30 days of discharge. In Sweden, we included 1790 people, of whom 1235 (69%) stopped treatment. In England, no differences were seen in subsequent risk of heart failure (HR 1.10; 95% confidence intervals (CI) 0.93-1.30), AKI (HR 0.90; 95% CI 0.77-1.05), or stroke (HR 0.99; 95% CI 0.71-1.38), but there was an increased risk of death (HR 1.27; 95% CI 1.15-1.41) in those who stopped ACEI/ARB compared to those who continued. Results were similar in Sweden: no differences were seen in risk of heart failure (HR 0.91; 95% CI 0.73-1.13) or AKI (HR 0.81; 95% CI 0.54-1.21). However, no increased risk of death was seen (HR 0.94; 95% CI 0.78-1.13) and stroke was less common in people who stopped ACEI/ARB (HR 0.56; 95% CI 0.34-0.93). Results were similar across all sensitivity analyses.

CONCLUSIONS

Previous ACEI/ARB users who continued treatment after an episode of AKI did not have an increased risk of heart failure or subsequent AKI compared to those who stopped the drugs.

Links

Authors+Show Affiliations

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. patrick.bidulka1@lshtm.ac.uk.

Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef, Leiden, 2333ZA, The Netherlands.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Sussex Kidney Unit, Royal Sussex County Hospital, Brighton, BN2 5BE, UK.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef, Leiden, 2333ZA, The Netherlands.

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12, Stockholm, Sweden.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

MeSH

Acute Kidney InjuryAdolescentAdultAgedAged, 80 and overAngiotensin Receptor AntagonistsAngiotensin-Converting Enzyme InhibitorsCohort StudiesFemaleHumansMaleMiddle AgedProportional Hazards ModelsSwedenUnited KingdomYoung Adult

Pub Type(s)

Journal Article

Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

32723383

Citation

Bidulka, Patrick, et al. "Stopping Renin-angiotensin System Blockers After Acute Kidney Injury and Risk of Adverse Outcomes: Parallel Population-based Cohort Studies in English and Swedish Routine Care." BMC Medicine, vol. 18, no. 1, 2020, p. 195.

Bidulka P, Fu EL, Leyrat C, et al. Stopping renin-angiotensin system blockers after acute kidney injury and risk of adverse outcomes: parallel population-based cohort studies in English and Swedish routine care. BMC Med. 2020;18(1):195.

Bidulka, P., Fu, E. L., Leyrat, C., Kalogirou, F., McAllister, K. S. L., Kingdon, E. J., Mansfield, K. E., Iwagami, M., Smeeth, L., Clase, C. M., Bhaskaran, K., van Diepen, M., Carrero, J. J., Nitsch, D., & Tomlinson, L. A. (2020). Stopping renin-angiotensin system blockers after acute kidney injury and risk of adverse outcomes: parallel population-based cohort studies in English and Swedish routine care. BMC Medicine, 18(1), 195. https://doi.org/10.1186/s12916-020-01659-x

Bidulka P, et al. Stopping Renin-angiotensin System Blockers After Acute Kidney Injury and Risk of Adverse Outcomes: Parallel Population-based Cohort Studies in English and Swedish Routine Care. BMC Med. 2020 07 29;18(1):195. PubMed PMID: 32723383.

* Article titles in AMA citation format should be in sentence-case

TY - JOUR T1 - Stopping renin-angiotensin system blockers after acute kidney injury and risk of adverse outcomes: parallel population-based cohort studies in English and Swedish routine care. AU - Bidulka,Patrick, AU - Fu,Edouard L, AU - Leyrat,Clémence, AU - Kalogirou,Fotini, AU - McAllister,Katherine S L, AU - Kingdon,Edward J, AU - Mansfield,Kathryn E, AU - Iwagami,Masao, AU - Smeeth,Liam, AU - Clase,Catherine M, AU - Bhaskaran,Krishnan, AU - van Diepen,Merel, AU - Carrero,Juan-Jesus, AU - Nitsch,Dorothea, AU - Tomlinson,Laurie A, Y1 - 2020/07/29/ PY - 2020/02/25/received PY - 2020/06/08/accepted PY - 2020/7/30/entrez PY - 2020/7/30/pubmed PY - 2021/2/4/medline KW - Acute kidney injury KW - Angiotensin II receptor blocker (ARB) KW - Angiotensin-converting enzyme inhibitor (ACEI) KW - Heart failure SP - 195 EP - 195 JF - BMC medicine JO - BMC Med VL - 18 IS - 1 N2 - BACKGROUND: The safety of restarting angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) after acute kidney injury (AKI) is unclear. There is concern that previous users do not restart ACEI/ARB despite ongoing indications. We sought to determine the risk of adverse events after an episode of AKI, comparing prior ACEI/ARB users who stop treatment to those who continue. METHODS: We conducted two parallel cohort studies in English and Swedish primary and secondary care, 2006-2016. We used multivariable Cox regression to estimate hazard ratios (HR) for hospital admission with heart failure (primary analysis), AKI, stroke, or death within 2 years after hospital discharge following a first AKI episode. We compared risks of admission between people who stopped ACEI/ARB treatment to those who were prescribed ACEI/ARB within 30 days of AKI discharge. We undertook sensitivity analyses, including propensity score-matched samples, to explore the robustness of our results. RESULTS: In England, we included 7303 people with AKI hospitalisation following recent ACEI/ARB therapy for the primary analysis. Four thousand three (55%) were classified as stopping ACEI/ARB based on no prescription within 30 days of discharge. In Sweden, we included 1790 people, of whom 1235 (69%) stopped treatment. In England, no differences were seen in subsequent risk of heart failure (HR 1.10; 95% confidence intervals (CI) 0.93-1.30), AKI (HR 0.90; 95% CI 0.77-1.05), or stroke (HR 0.99; 95% CI 0.71-1.38), but there was an increased risk of death (HR 1.27; 95% CI 1.15-1.41) in those who stopped ACEI/ARB compared to those who continued. Results were similar in Sweden: no differences were seen in risk of heart failure (HR 0.91; 95% CI 0.73-1.13) or AKI (HR 0.81; 95% CI 0.54-1.21). However, no increased risk of death was seen (HR 0.94; 95% CI 0.78-1.13) and stroke was less common in people who stopped ACEI/ARB (HR 0.56; 95% CI 0.34-0.93). Results were similar across all sensitivity analyses. CONCLUSIONS: Previous ACEI/ARB users who continued treatment after an episode of AKI did not have an increased risk of heart failure or subsequent AKI compared to those who stopped the drugs. SN - 1741-7015 UR - https://www.unboundmedicine.com/medline/citation/32723383/Stopping_renin_angiotensin_system_blockers_after_acute_kidney_injury_and_risk_of_adverse_outcomes:_parallel_population_based_cohort_studies_in_English_and_Swedish_routine_care_ DB - PRIME DP - Unbound Medicine ER -