Renin-angiotensin aldosterone system inhibitors usage among hospitalized patients with acute kidney injury: a retrospective study

Abstract

Background: Although not recommended for potential risk of worsening kidney dysfunction, continuation of renin-angiotensin aldosterone system inhibitor (RAASi) during an episode of acute kidney injury (AKI) is not rare in clinical practice, and the risk-benefit ratio for RAASi therapy should always be carefully evaluated. Limited data exists regarding the reasons for RAASi continuation during the acute course of AKI and its impact on kidney and overall outcomes. Materials and methods: This retrospective study used electronic medical records from the clinical data warehouse of Peking University First Hospital to screen all adult admissions who developed AKI during hospitalization and were prescribed RAASi within 48 h prior to AKI onset between 1 January 2018 and 31 December 2020. Patients were further divided into RAASi discontinuers and continuers based on whether RAASi was withdrawn within 48 h after AKI onset. The primary outcome was non-recovery from AKI at discharge; the secondary outcomes were failure of full recovery from AKI and in-hospital mortality. Results: A total of 321 patients were prescribed RAASi within 48 h prior to AKI onset, of which RAASi therapy was continued in 196 (61.1%) cases (RAASi continuers). Under-recognition of AKI was considered the main reason for the continuation of RAASi (143 cases, 72.9%), followed by the exclusion of RAASi as the culprit drug (31 cases, 15.8%), strong indications for RAASi (20 cases, 10.2%) and transient AKI (18 cases, 6.6%). The non-recovery rates were 58.6% and 29.6% in RAASi continuers and discontinuers, respectively. After fully adjustment, RAASi continuation was associated with an increased risk of non-recovery (RR, 1.727; 95% CI 1.179, 2.588) and failure of full recovery from AKI (RR, 1.427; 95% CI 1.062, 1.938) at discharge. A non-significant association was observed between RAASi continuation and in-hospital mortality in both unadjusted and adjusted model. Conclusions: Under-recognition of AKI was predominant and might be the main reason for continuing RAASi after AKI onset. Continuation of RAASi during an AKI episode was associated with poor kidney recovery in the short term. Timely recognition of AKI should be improved, and a dynamic risk-benefit ratio evaluation for RAASi is required to achieve optimal management.