Stopping RAS inhibitors increases risk of mortality, MI and stroke in patients of AKI

Netherlands: In survivors with moderate-to-severe acute kidney injury (AKI), stopping renin-angiotensin system inhibitors (RASi) was linked to a similar risk of recurrent AKI than RASi continuation but a greater risk of mortality, myocardial infarction (MI), and stroke, says an article published in Clinical Kidney Journal.

After an episode of acute renal damage, the risk-benefit ratio of continuing with renin-angiotensin system inhibitors remains uncertain. Stopping RASi therapy might end recurring AKI or hyperkalemia, but it could also rob patients of its cardiovascular advantages. Due to these limitations, Roemer J. Janse and colleagues conducted this study to investigate the risk of negative clinical outcomes among long-term RASi users who experienced moderate or severe AKI during hospitalization and the association between stopping RASi within three months of being discharged from the hospital and stopping RASi.

Results of long-term RASi users who had AKI (stage 2 or 3, or clinically classified) during hospitalization in Stockholm and Sweden between 2007 and 2018 were examined. Following discharge, stopping RASi before 3 months was contrasted with maintaining RASi. The composite of all-cause mortality, myocardial infarction (MI), and stroke served as the study's main outcomes. Our secondary endpoint was recurrent AKI, and we looked at hyperkalemia as a promising control. 75 confounders were balanced by using Propensity Score Overlap Weighted Cox models to derive hazard ratios (HRs). We also identified weighted absolute risk differences (ARDs).

The key findings of this study were as follows:

1. A total of 10 165 people were recruited in the trial, with a median follow-up of 2.3 years.

2. Of them, 4429 quit RASi, and 5736 continued it.

3. The median kidney function prior to the initial episode of AKI was 55 mL/min/1.73 m2, and the median age was 78 years.

4. Following weighing, those who discontinued compared to those who remained had a higher risk of mortality, MI, and stroke, a comparable risk of recurrent AKI, and a lower risk of hyperkalemia.

In conclusion, stopping RASi therapy was linked to a higher risk of mortality, MI, and stroke, but also to a comparable risk of recurrent AKI among RASi users with a guideline indication for the treatment. "In the absence of randomized clinical trials, these findings may help doctors make clinical decisions," added the authors.

Reference: 

Janse, R. J., Fu, E. L., Clase, C. M., Tomlinson, L., Lindholm, B., van Diepen, M., Dekker, F. W., & Carrero, J.-J. (2022). Stopping versus continuing renin–angiotensin–system inhibitors after acute kidney injury and adverse clinical outcomes: an observational study from routine care data. In Clinical Kidney Journal (Vol. 15, Issue 6, pp. 1109–1119). Oxford University Press (OUP). https://doi.org/10.1093/ckj/sfac003