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Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: cohort study

Published on Mar 9, 2017in BMJ27.604
· DOI :10.1136/bmj.j791
Morten Schmidt27
Estimated H-index: 27
(Lond: University of London),
Kathryn E. Mansfield8
Estimated H-index: 8
(Lond: University of London)
+ 4 AuthorsLaurie A. Tomlinson17
Estimated H-index: 17
(Lond: University of London)
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Abstract
Objective  To examine long term cardiorenal outcomes associated with increased concentrations of creatinine after the start of angiotensin converting enzyme inhibitor/angiotensin receptor blocker treatment. Design  Population based cohort study using electronic health records from the Clinical Practice Research Datalink and Hospital Episode Statistics. Setting  UK primary care, 1997-2014. Participants  Patients starting treatment with angiotensin converting enzyme inhibitors or angiotensin receptor blockers (n=122 363). Main outcome measures  Poisson regression was used to compare rates of end stage renal disease, myocardial infarction, heart failure, and death among patients with creatinine increases of 30% or more after starting treatment against those without such increases, and for each 10% increase in creatinine. Analyses were adjusted for age, sex, calendar period, socioeconomic status, lifestyle factors, chronic kidney disease, diabetes, cardiovascular comorbidities, and use of other antihypertensive drugs and non-steroidal anti-inflammatory drugs. Results  Among the 2078 (1.7%) patients with creatinine increases of 30% or more, a higher proportion were female, were elderly, had cardiorenal comorbidity, and used non-steroidal anti-inflammatory drugs, loop diuretics, or potassium sparing diuretics. Creatinine increases of 30% or more were associated with an increased adjusted incidence rate ratio for all outcomes, compared with increases of less than 30%: 3.43 (95% confidence interval 2.40 to 4.91) for end stage renal disease, 1.46 (1.16 to 1.84) for myocardial infarction, 1.37 (1.14 to 1.65) for heart failure, and 1.84 (1.65 to 2.05) for death. The detailed categorisation of increases in creatinine concentrations ( Conclusions  Increases in creatinine after the start of angiotensin converting enzyme inhibitor/angiotensin receptor blocker treatment were associated with adverse cardiorenal outcomes in a graduated relation, even below the guideline recommended threshold of a 30% increase for stopping treatment.
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#1Patrick Bidulka (Lond: University of London)
#2Masao Iwagami (Lond: University of London)H-Index: 6
Last. Laurie A. Tomlinson (Lond: University of London)H-Index: 17
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#1Leonardo Grabinski Bottino (UFRGS: Universidade Federal do Rio Grande do Sul)
#2Flávio Danni Fuchs (UFRGS: Universidade Federal do Rio Grande do Sul)H-Index: 42
Introduction: Angiotensin receptor blockers (ARBs) are recommended as preferential drugs in the treatment of hypertension by guidelines. In this review, we reappraise their effectiveness to preventing major cardiovascular outcomes and the recent concerns with new adverse effects.Areas covered: ARBs were not superior to placebo in the prevention of all-cause deaths and combined cardiovascular events in seven randomized controlled trials (RCT). Several meta-analyses, with large number of participa...
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#1Youmei Shen (Nanjing Medical University)
#2Jing Wang (Nanjing Medical University)H-Index: 4
Last. Minglong Chen (Nanjing Medical University)H-Index: 19
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#1William G. Herrington (University of Oxford)H-Index: 18
#2Natalie Staplin (Clinical Trial Service Unit)H-Index: 12
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Compared to other specialties, nephrology has reported relatively few clinical trials, and most of these are too small to detect moderate treatment effects. Consequently, interventions that are commonly used by nephrologists have not been adequately tested and some may be ineffective or harmful. More randomized trials are urgently needed to address important clinical questions in patients with kidney disease. The use of robust surrogate markers may accelerate early-phase drug development. Howeve...
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#1Bhagwan Dass (UF: University of Florida)H-Index: 9
#2Michelle Dimza (UF: University of Florida)
Last. Rajesh Mohandas (UF: University of Florida)H-Index: 8
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Introduction The long-term benefits of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on outcomes in patients with chronic congestive heart failure are well-known, making them one of the most widely prescribed medications. However, the administration of ACEIs/ARBs in acute decompensated heart failure (ADHF) can increase the risk of morbidity and mortality secondary to worsening renal function (WRF). A decrease in estimated glomerular filtration rate (eG...
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Erhohter Blutdruck bleibt eine Hauptursache von kardiovaskularen Erkrankungen, Behinderung und fruhzeitiger Sterblichkeit in Osterreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine haufige Herausforderung fur Arztinnen und Arzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erh...
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#1Wendy McCallum (Tufts Medical Center)H-Index: 1
#2Hocine Tighiouart (Tufts University)H-Index: 47
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Although blood pressure (BP) control is a major goal in chronic kidney disease (CKD), no worldwide overview of either its achievement or antihypertensive prescriptions is currently available. To evaluate this we compared crude prevalence of uncontrolled BP among 17 cohort studies, including 34 602 individuals with estimated glomerular filtration rate under 60 ml/min/1.73 m2 and treated hypertension across four continents, and estimated observed to expected prevalence ratios, adjusted for potenti...
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