Even Small Creatinine Increases After ACE Inhibitor/ARB Treatment Signal Risk

By Joe Elia

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

Patients starting renin-angiotensin system blockade who show even small rises in creatinine levels face increased cardiorenal risk, according to a cohort study in The BMJ.

U.K. researchers used national health records to track outcomes in some 120,000 patients starting treatment with angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). All had undergone creatinine measurement before and within 2 months after starting treatment.

Less than 2% had creatinine increases of 30% or more. That group — compared with those who had smaller increases — showed greater risk for end-stage renal disease (rate ratio, 3.4), myocardial infarction (1.5), heart failure (1.4), and all-cause mortality (1.8).

The authors noted elevated risks even at creatinine increases of 10–19%. Thus, they are skeptical of current guidelines advising that therapy should stop only at creatinine increases of 30%.

NEJM Journal Watch Cardiology editor-in-chief Dr. Harlan Krumholz comments: "This study, leveraging massive data from real-world practice, highlights the prognostic importance of even minor elevations in creatinine after initiation of renin-angiotensin system blockade, affirms the utility of monitoring renal function, and suggests the need to reevaluate the benefits of the therapy and increase levels of vigilance for those individuals with elevations."