title: Effects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: Results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patients Receiving Cardiac Catheterization (CAPTAIN) trial.
abstract: BACKGROUND
  It is unclear if holding angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) prior to coronary angiography reduces contrast-induced acute kidney injury (AKI). We undertook a randomized trial to investigate the effect of holding ACEI/ARB therapy prior to coronary angiography on the incidence of AKI.
  
  
  METHODS
  We randomly assigned 208 patients with moderate renal insufficiency (creatinine ≥ 1.7mg/dL within 3 months and/or documented creatinine ≥ 1.5mg/dL within 1 week before cardiac catheterization) to hold ACEI/ARB ≥24 hours preprocedure or continue ACEI/ARB. The primary outcome was the incidence of AKI defined as an absolute rise in serum creatinine of ≥0.5mg/dL from baseline and/or a relative rise in serum creatinine of ≥25% compared with baseline measured at 48 to 96 hours postcardiac catheterization.
  
  
  RESULTS
  All patients were taking an ACEI (72.1%) or ARB (27.9%) prior to randomization. At 48 to 96 hours, the primary outcome occurred in 18.4% of patients who continued ACEI/ARB compared with 10.9% of the patients who held ACEI/ARB (hazard ratio 0.59, 95% CI 0.30-1.19, P = .16). In a prespecified secondary outcome, there was a lower rise in mean serum creatinine after the procedure in patients who held ACEI/ARB (0.3 ± 0.5 vs 0.1 ± 0.3mg/dL, P = .03). The clinical composite of death, myocardial infarction, ischemic stroke, congestive heart failure, rehospitalization for cardiovascular cause, or need for dialysis preprocedure occurred in 3.9% who continued ACEI/ARB compared with 0% who held the ACEI/ARB (hazard ratio 0.11, 95% CI 0.01-2.96, P = .06).
  
  
  CONCLUSIONS
  In this pilot study of patients with moderate renal insufficiency undergoing cardiac catheterization, with-holding ACEI/ARB resulted in a non-significant reduction in contrast-induced AKI and a significant reduction in post-procedural rise of creatinine. This low cost intervention could be considered when referring a patient for cardiac catheterization.
authors.affiliation: Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Bainey
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.
authors.forename: Sherali
authors.initials: S
authors.lastname: Rahim
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.
authors.forename: Krystal
authors.initials: K
authors.lastname: Etherington
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rokoss
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.
authors.forename: Madhu K
authors.initials: MK
authors.lastname: Natarajan
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.
authors.forename: James L
authors.initials: JL
authors.lastname: Velianou
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada.
authors.forename: Sonya
authors.initials: S
authors.lastname: Brons
authors.affiliation: Interventional Cardiology Research Group and Division of Cardiology, Department of Medicine, McMaster University, and Hamilton Health Sciences Hamilton, Ontario, Canada. Electronic address: smehta@mcmaster.ca.
authors.forename: Shamir R
authors.initials: SR
authors.lastname: Mehta
mesh_terms: D058186:Acute Kidney Injury / Q000097:blood / Q000139:chemically induced / Q000517:prevention & control*; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D006328:Cardiac Catheterization / Q000379:methods*; D003287:Contrast Media / Q000009:adverse effects; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis*; D003404:Creatinine / Q000097:blood; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000379:methods; D010865:Pilot Projects; D011300:Preoperative Care / Q000379:methods*; D051436:Renal Insufficiency, Chronic / Q000097:blood / Q000150:complications*; D016037:Single-Blind Method
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D003287:Contrast Media; D003404:Creatinine