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ACE Inhibitors and ARBs in Perioperative Period Sameer Gupta, MD; Aaron Dall, MD; Chandra Chandran, MD
Medical College of Wisconsin, Milwaukee, WI St. Joseph’s Healthcare system, Paterson, NJ
INTRODUCTION
Ø ACE Inhibitors and Angiotensin Receptor Blockers (ACEI, ARBs) are among the most common drugs prescribed.
Ø Their mechanism of ac@on is by inhibi@on of vasoconstric@on mediated by Angiotensin II, of glomerular efferent arteriole. This physiological response helps the kidney to maintain Glomerular Filtra@on Rate (GFR) in hypovolemic states.
Ø Surgery and anesthesia changes the renal blood flow and if pa@ents are on these drugs, it may have an effect on renal func@on. Hence, we evaluated the rela@on between the periopera@ve use of these medica@ons and renal func@on.
DISCUSSION
CONCLUSION
Ø ACE inhibitors and ARBs seem to have higher incidence of AKI when used in preopera@ve state.
Ø We may consider holding them in the periopera@ve period to avoid poten@al harm. Since the half life of these drugs are less than 24 hours, holding them a day prior to surgery or just the morning dose on the day of surgery should be enough to avoid the adverse effects on the kidney.
Ø Furthermore, males, African Americans and pa@ents undergoing cardiac surgery seem to have higher incidence of AKI post surgery while on ACEI/ARB.
METHODS
RESULTS
Figure 1 Figure 2
Figure 3
Figure 5
Figure 4 Ø In a retrospec@ve analysis, we evaluated 607 pa@ents who underwent a surgery
from January 2008 to November 2010. Ø The types of surgeries included cardiac, orthopedic and general. They were all
elec@ve surgeries and admiYed on the day of surgery and stayed for minimum of two days in order for us to see the follow up laboratory studies.
Ø These pa@ents were asked to take their rou@ne medica@ons on the morning of surgery. AKI was defined as an increase in crea@nine of 0.3 mg/dl and above.
Ø Fisher’s exact test was used to analyze a 2 by 2 con@ngency table and a p value of 0.05 was obtained which is sta@s@cally significant
Ø Out of the 607 pa@ents 192 were on ACEI/ARBs and 415 were not. Ø 125 (20.6%) out of 607 pa@ents developed AKI. Ø Of 192 pa@ents on the ACEI/ARBs, 49 developed AKI (25.5%). Ø Of 415 pa@ents who were not on ACEI/ARBs, 76 developed AKI (18.3%). Ø The pa@ents were further divided based on sex, race, cardiac or non
cardiac surgeries. Based on these divisions, there were 268 males and 339 females. 67 (25%) males had AKI. 84 males were on ACE/ARB and 25 (29.8%) had AKI.
Ø 58 (17.1%) of females had AKI and 24 (22.2%) out of 108 females on ACE/ARB had AKI.
Ø 116 were African Americans and 29 (25%) had AKI and 10 (28.6%) out of 35 on ACE/ARB had AKI.
Ø There were 491 white/Hispanic pa@ents. 95 (19.3%) had AKI. 39 (24.7%) out of 158 on ACE/ARB had AKI.
Ø Out of 544 pa@ents who underwent non cardiac surgeries, 95 (17.5%) had AKI. 43 (25.1%) out of 171 on ACE/ARB had AKI from this group.
Ø 63 pa@ents underwent CABG and 30 (47.6%) had AKI. 6 (28.6%) out of 21 who were on ACE/ARB in this group had AKI.
Ø ACE Inhibitors and Angiotensin Receptor Blockers (ACEI, ARBs) are one of the most frequently used classes of an@hypertensive drugs .
Ø They are also used in the management of CHF and various nephropathies.
Ø Although use of ACEI increases survival in pa@ents with conges@ve heart failure (CHF) and retards the progression of renal disease, its use has been associated with the development of AKI in sebngs where maintenance of glomerular filtra@on requires efferent arteriolar constric@on, which is blocked by ACEI or angiotensin II receptor antagonists.
Ø The associa@on of ACEI therapy with AKI acer cardiac surgery has been controversial.
Ø In our study, factors that were significantly associated with development of AKI included African American race and cardiac surgery.
REFERENCES
Ø BenedeYo U, et al: Preopera@ve Angiotensin-‐Conver@ng Enzyme Inhibitors and Acute Kidney Injury 1 Acer Coronary Artery Bypass Gracing. Annals of Thoracic Surgery. (2008). 86:1160-‐6.
Ø Arora P, et al: Preopera@ve Use of Angiotensin Conver@ng Enzyme
Inhibitors/Angiotensin Receptor Blockers Is associated with increased risk for acute kidney injury acer cardiovascular surgery. Clin J Am Soc Nephrol 3: 1266-‐1273, 2008
0
5
10
15
20
25
30
Males Females
29.8
22.2
AKI
0
50
100
150
200
250
300
350
400
450
ACE-‐I/ARB Controls
49 76
143
339 No AKI
AKI
22.00%
23.00%
24.00%
25.00%
26.00%
27.00%
28.00%
29.00%
AA Caucasians
28.60%
24.70%
AKI on ACEI/ARB
AKI on ACEI/ARB
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Cardiac Non cardiac
47.60%
17.50%
AKI
AKI
23.00%
24.00%
25.00%
26.00%
27.00%
28.00%
29.00%
Cardiac Non Cardiac
28.60%
25.10%
AKI on ACEI/ARBs
AKI on ACEI/ARBs