Renin-angiotensin-aldosterone system blockade is associated with higher risk of contrast-induced acute kidney injury in patients with diabetes

Abstract

As the incidence of diabetes and cardiovascular comorbidities continues to rise, driven by increased prevalence of obesity and an aging population, so does the demand for percutaneous coronary intervention (PCI) to restore cardiac blood flow. Renin-angiotensin-aldosterone system (RAAS) inhibitors are commonly prescribed to hypertensive diabetic patients to prevent diabetic nephropathy. However, evidence suggests that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the risk of contrast-induced acute kidney injury (CIAKI) following coronary angiography (CAG) and PCI. We therefore conducted a retrospective, multicenter study applying the propensity score matching method to evaluate the impact of RAAS inhibition on CIAKI in diabetic patients undergoing CAG/PCI. Among 2240 subjects that met the inclusion criteria, 704 patients in the ACEIs/ARBs group were successfully matched to eligible control patients. The incidence of CIAKI (serum creatinine increase ≥0.5 mg/dl or ≥25% from baseline within 72 h post-CAG/PCI) was significantly higher in the ACEIs/ARBs group than in the control group (26.6% vs. 16.2%, P<0.001). However, control patients showed increased risk of overall adverse cardiovascular events (4.1% vs. 1.8% for ACEIs/ARBs; P=0.016). These data indicate that RAAS inhibition increases the risk of CIAKI in diabetic patients, but confers protection against early cardiovascular events.

Keywords: angiotensin receptor blockers; angiotensin-converting enzyme inhibitors; contrast-induced acute kidney injury; coronary angiography; diabetes mellitus.

Figure 1

Summary of study design, methods, and results. Propensity score matching (PSM) was conducted on 1310 ACEIs/ARBs patients and 930 controls from four medical centers, resulting in 704 patient pairs. After merging matched data from each center, 659 patient pairs were obtained. The conditional logistic model was used to evaluate the association between ACEIs/ARBs use and CIAKI incidence.

Figure 2

Impact of RAAS inhibition on CIAKI incidence. (A) Incidence of CIAKI in the PSM-matched cohort under different definitions. (B) Incidence of CIAKI in the matched cohort at different times post-CAG/PCI. We screened 52/704 pairs of patients within the PSM-matched cohort who had serum creatinine values documented at 24, 48, and 72 h post-procedure. (C) Incidence of CIAKI in the unmatched cohort at different times post-CAG/PCI. We screened 613/2240 patients who had serum creatinine values documented at 24, 48, and 72 h post-procedure.

Figure 3

Subgroup analysis of the effect of RAAS blockers on CIAKI incidence in the matched cohort. n = number of patients with CIAKI; N = total number of patients in each subgroup; eGFR, estimated glomerular filtration rate; LVEF, left ventricular ejection fraction.