Can Angiotensin Receptor Blockers (ARBs) be given in Acute Kidney Injury (AKI)?

From the Guidelines

Angiotensin receptor blockers (ARBs) should not be discontinued in acute kidney injury (AKI) if the increase in serum creatinine is less than 30% from baseline, in the absence of volume depletion, as evidenced by the 2023 study 1.

Key Considerations

• The decision to continue or discontinue ARBs in AKI should be based on the individual patient's risk-benefit ratio, considering factors such as volume status, blood pressure, and underlying kidney function.
• ARBs can reduce intravascular volume, renal blood flow, and/or glomerular filtration, which may worsen kidney function during acute injury.
• However, the 2023 study 1 suggests that elevations in serum creatinine up to 30% from baseline with renin-angiotensin system (RAS) blockers, such as ARBs, should not be confused with AKI.
• The study also notes that ACE inhibitors and ARBs should not be discontinued for minor increases in serum creatinine (<30%) in the absence of volume depletion.

Clinical Implications

• In patients with AKI, careful monitoring of kidney function, blood pressure, and volume status is crucial when continuing or reintroducing ARBs.
• The benefits of ARBs in patients with chronic kidney disease, such as renoprotective effects, should be weighed against the potential risks in the context of AKI.
• The 2022 study 1 supports the continuation of RAS blockade, including ARBs, in patients with diabetes and kidney disease, as long as the increase in serum creatinine is less than 30% and there is no associated hyperkalemia.

From the FDA Drug Label

7.3 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Including Selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors) In patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, coadministration of NSAIDs, including selective COX-2 inhibitors, with angiotensin II receptor antagonists (including losartan) may result in deterioration of renal function, including possible acute renal failure. The antihypertensive effect of angiotensin II receptor antagonists, including losartan, may be attenuated by NSAIDs, including selective COX-2 inhibitors.

Use of ARBs in AKI:

• The FDA drug label warns about the potential deterioration of renal function when using ARBs, including losartan, in patients with compromised renal function.
• It is recommended to monitor renal function periodically in patients receiving losartan and NSAID therapy.
• However, the label does not explicitly state that ARBs cannot be given in AKI, but it does advise caution and close monitoring.
• Key considerations:
  • Monitor serum potassium levels and renal function.
  • Avoid combined use of RAS inhibitors.
  • Closely monitor blood pressure, renal function, and electrolytes in patients on losartan and other agents that affect the RAS.
  • Avoid use of aliskiren with losartan in patients with renal impairment (GFR <60 mL/min) 2.

From the Research

Use of ARBs in AKI

• The use of Angiotensin Receptor Blockers (ARBs) in patients with Acute Kidney Injury (AKI) is a topic of ongoing debate, with some studies suggesting potential benefits and others raising concerns about adverse effects 3, 4, 5, 6, 7.
• A study published in the American Journal of Nephrology found that acute exposure to an ACEI/ARB before or during an episode of AKI was not associated with persistent AKD at the time of first clinic visit, suggesting that the receipt of such agents does not impede kidney recovery following AKI 3.
• Another study published in Frontiers in Pharmacology found that ACEI/ARB treatment during an episode of AKI may decrease all-cause mortality, but increases the risk of AKD 4.
• A systematic review and meta-analysis published in Frontiers in Pharmacology found that exposure to ACEi/ARB after AKI is associated with lower risks of all-cause mortality, recurrent AKI, and progression to incident CKD 5.
• However, a study published in Nephron Clinical Practice suggested that ACEIs and ARBs may cause unrecognized significant worsening renal failure in CKD patients, sometimes irreversible, and that more caution is required regarding their use, especially in older hypertensive patients 6.
• A retrospective cohort study published in JAMA Internal Medicine found that ACEI or ARB use after hospital discharge was associated with lower mortality but a higher risk of hospitalization for a renal cause in patients with AKI 7.

Key Findings

• The use of ARBs in AKI may be associated with lower mortality rates, but also increases the risk of AKD and hospitalization for renal causes 4, 5, 7.
• The decision to use ARBs in AKI should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 6.
• Further research is needed to fully understand the effects of ARBs in AKI and to determine the optimal treatment strategies for patients with AKI 4, 5, 7.