ACE-I or ARB therapy in patients with low eGFR
Background: ACE-I and ARB therapy is widely used for hypertension, albuminuric chronic kidney disease, heart failure with reduced ejection fraction, and coronary artery disease. They are known to potentially cause hemodynamic reductions in eGFR, hyperkalemia, and acute kidney injury. We know to temporarily discontinue ACE-I or ARB in patients with eGFR less than 60 mL/min per 1.73 m2 who have serious intercurrent illness that increases the risk of acute kidney injury, but existing literature evaluating the risks and benefits of using ACE-I and ARBs in individuals with advanced chronic kidney disease is conflicting.
Dr. Hanesh Kumar
Study design: Retrospective, propensity score–matched cohort study.
Setting: Geisinger Health System, serving central and northeastern Pennsylvania.
Synopsis: Total of 3,909 individuals were included in the study who were receiving ACE-I or ARB and experienced eGFR below 30 mL/min per 1.73 m2. Of these 1,235 discontinued ACE-I or ARB therapy within 6 months after the eGFR decrease and 2,674 did not. At median 2.9 years’ follow-up, 434 (35.1%) patients who discontinued ACE-I or ARB therapy had died versus 786 (29.1%) who did not discontinue. Similarly, the risk of MACE (major adverse cardiovascular events) was higher among those who discontinued therapy (n = 494; 40.0%) than it was among those who did not discontinue therapy (n = 910; 34.0%). Among those who discontinued, 87 individuals (7.0%) developed end-stage kidney disease, compared with the 176 (6.6%) who did not discontinue. Additionally, in individuals with an eGFR decrease by 40% or more for 1 year while receiving ACE-I or ARB therapy, discontinuing therapy was associated with higher risk of mortality (32.6% vs. 20.5%).
Although this study is observational it has a large sample size and confounding factors have been accounted for by propensity score matching. The results are clinically relevant in daily practice.
Bottom line: Continuing ACE-I or ARB after an eGFR decrease to below 30 mL/min per m2 is associated with lower risk of mortality and MACE without significant increased risk of end-stage kidney disease.
Citation: Qiao Y et al. Association between renin-angiotensin system blockade discontinuation and all-cause mortality among persons with low estimated glomerular filtration rate. JAMA Intern Med. 2020 Mar 9;180(5):718-26.
Dr. Kumar is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.
