Initiating or resuming renin-angiotensin-aldosterone system (RAAS) blockade after acute kidney injury (AKI) can improve survival — even before full AKI recovery — in patients with diabetic kidney disease, a new study finds.

Cautious use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) after AKI may be a form of renalism, “a lack of patient-benefiting care for the sake of disproportionate concern for patients’ kidneys,” according to Daniel P. Murphy MD, MS, of the University of Minnesota in Minneapolis, and colleagues.

In a study of 54,735 US veterans with diabetes and proteinuria who had an AKI hospitalization, use of ACEi/ARB after discharge was significantly associated with a 26% lower risk for all-cause mortality, the investigators reported in the Journal of the American Society of Nephrology. Initiating or resuming ACEi/ARB within 30 days of discharge was associated with the greatest reduction in mortality risk (43%), but using the medications within 2 years still provided survival benefits.

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Mortality risk was 30% and 31% lower in ACEi/ARB initiators with and without AKI recovery, defined as 110% or less of baseline creatinine, respectively, compared with those with no medication use and no AKI recovery, the investigators reported. Death risk was 10% lower in patients who experienced AKI recovery but did not use ACEi/ARB after hospitalization.

Post-discharge ACEi/ARB use was associated with a survival advantage regardless of patients’ AKI stage and baseline estimated glomerular filtration rate above 15 mL/min/1.73m2. Patients with heart failure also benefitted.

With respect to ACEi/ARB use prior to AKI hospitalization, former users had a greater mortality risk reduction than former nonusers: 31% vs 16%, Dr Murphy’s team reported.

Among the 54,735 veterans, 31,146 died within a median of 2.3 years. Approximately 57% received an ACEi/ARB within 3 months after AKI hospitalization. By 12 months, 30% of veterans still had not initiated or resumed ACEi/ARB and 23% had not recovered from AKI.

“Overall, our study contributes important data to the efforts to determine the optimal care for patients with diabetic kidney disease after AKI,” Dr Murphy’s team wrote. “Among our cohort of survivors of hospitalization with AKI, over half died during the study period. This high mortality burden, which is consistent with prior studies, demonstrates a need for interventions after patients experience AKI.”

The study is limited by the mostly older male population (mean age 68.8), with few women (3%) and young adults represented. Patients with a kidney transplant or on dialysis prior to AKI or soon after discharge were excluded from the study. Dialysis during AKI admission affected 0.9% vs 2% of patient with ACEi/ARB use vs nonuse after discharge.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Murphy DP, Wolfson J, Reule S, Johansen KL, Ishani A, Drawz PE. Renin-angiotensin-aldosterone system blockade after acute kidney injury with or without recovery among US veterans with diabetic kidney disease. J Am Soc Nephrol. Published online August 7, 2023. doi:10.1681/ASN.000000000000019