Preoperative angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use and acute kidney injury after high-risk cardiac surgery: a multicenter
prospective cohort study

Iñigo Rubio; Angel Candela; Gemma Echarri; Raquel Callejas; Eduardo Tamayo; David Nagore; Jorge M. Núñez-Córdoba; Marc Vives

doi:10.1016/j.bjane.2026.844786

Original Investigation

Preoperative angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use and acute kidney injury after high-risk cardiac surgery: a multicenter prospective cohort study

Uso pré-operatório de inibidores da enzima conversora de angiotensina ou bloqueadores dos receptores de angiotensina e lesão renal aguda após cirurgia cardíaca de alto risco: um estudo de coorte prospectivo multicêntrico

Iñigo Rubio, Angel Candela, Gemma Echarri, Raquel Callejas, Eduardo Tamayo, David Nagore, Jorge M. Núñez-Córdoba, Marc Vives

http://dx.doi.org/10.1016/j.bjane.2026.844786 Braz J Anesthesiol, vol.76, n4, 844786, 2026

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Abstract

Background

The impact of preoperative Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers (ACEI/ARB) on cardiac surgery-associated Acute Kidney Injury (AKI) remains elusive. We sought to evaluate the association of ACEI/ARB use with stage 2 or 3 AKI and in-hospital mortality, while evaluating whether preoperative withholding versus continuation strategies modulate clinical outcomes.

Methods

Multicenter prospective cohort study involving 14 Spanish and British hospitals. The study population comprised high-risk cardiac surgery patients (Cleveland Clinic Score ≥ 4).

Results

Among 249 patients (mean age: 69.5 years; 39% women; 53.8% ACEI/ARB users), the overall incidence of stage 2 or 3 AKI was 32.9%. ACEI/ARB use was associated with a significantly higher likelihood of stage 2 to 3 AKI (38.8% vs. 26.1%; adjusted OR = 2.79; 95% CI 1.47–5.30; p = 0.002). The adjusted risk difference was 0.188 (95% CI 0.079–0.298; p = 0.001), yielding a number needed to harm of 5.3. Sensitivity analyses confirmed the robustness of these findings, with an E-value of 2.73 (lower limit: 1.72) and consistent results using augmented inverse probability weighting (average treatment effect: 0.191; 95% CI 0.081–0.300; p = 0.001). No statistically significant associations were observed in in-hospital mortality or the impact of preoperative withholding versus continuation strategies on clinical outcomes.

Conclusion

This study suggests preoperative ACEI/ARB use may be associated with an increased incidence of stage 2 or 3 AKI. While differences in in-hospital mortality and preoperative withholding versus continuation strategies did not reach statistical significance, these findings reveal clinical trends that warrant further investigation.

Keywords

Acute kidney injury; Angiotensin-converting enzyme inhibitors; Angiotensin receptor antagonists; Cardiac surgical procedures; Kidney diseases; Risk factors

Resumo

Introdução

O impacto do uso pré-operatório de Inibidores da Enzima Conversora de Angiotensina ou Bloqueadores dos Receptores de Angiotensina (IECA/BRA) na Lesão Renal Aguda (LRA) associada à cirurgia cardíaca permanece incerto. Buscou-se avaliar a associação do uso de IECA/BRA com a LRA estágio 2 ou 3 e mortalidade hospitalar, avaliando se as estratégias de suspensão versus continuação pré-operatória modulam os desfechos clínicos.

Métodos

Estudo de coorte prospectivo multicêntrico envolvendo 14 hospitais espanhóis e britânicos. A população do estudo compreendeu pacientes submetidos à cirurgia cardíaca de alto risco (Cleveland Clinic Score ≥ 4).

Resultados

Entre 249 pacientes (média de idade: 69,5 anos; 39% mulheres; 53,8% usuários de IECA/BRA), a incidência global de LRA estágio 2 ou 3 foi de 32,9%. O uso de IECA/BRA foi associado a uma probabilidade significativamente maior de LRA estágio 2 a 3 (38,8% vs. 26,1%; OR ajustada = 2,79; IC 95% 1,47–5,30; p = 0,002). A diferença de risco ajustada foi de 0,188 (IC 95% 0,079–0,298; p = 0,001), resultando em um número necessário para causar dano de 5,3. Análises de sensibilidade confirmaram a robustez desses achados, com um valor-E de 2,73 (limite inferior: 1,72) e resultados consistentes usando a ponderação de probabilidade inversa aumentada (efeito médio do tratamento: 0,191; IC 95% 0,081–0,300; p = 0,001). Não foram observadas associações estatisticamente significativas na mortalidade hospitalar ou no impacto das estratégias de suspensão versus continuação pré-operatória nos desfechos clínicos.

Conclusão

Este estudo sugere que o uso pré-operatório de IECA/BRA pode estar associado a um aumento na incidência de LRA estágio 2 ou 3. Embora as diferenças na mortalidade hospitalar e nas estratégias de suspensão versus continuação pré-operatória não tenham atingido significância estatística, esses achados revelam tendências clínicas que justificam investigações adicionais.

Palavras-chave

Lesão renal aguda; Inibidores da enzima conversora de angiotensina; Antagonistas dos receptores de angiotensina; Procedimentos cirúrgicos cardíacos; Doenças renais; Fatores de risco

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Submitted date:
01/02/2026

Accepted date:
06/14/2026