sameer gupta, md; aaron dall, md; chandra chandran, md … · ace inhibitors and arbs in...

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