The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
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Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: A Closer Look at Hyperkalemia

안지오텐신 전환효소 억제제/안지오텐신 수용체 차단제 사용과 고칼륨혈증

  • Chung, Sung-Jin (Department of Internal Medicine, The Catholic University of Korea College of Medicine) ;
  • Park, Cheol-Whee (Department of Internal Medicine, The Catholic University of Korea College of Medicine)
  • 정성진 (가톨릭대학교 의과대학 내과학교실) ;
  • 박철휘 (가톨릭대학교 의과대학 내과학교실)
  • Published : 2011.01.01
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Abstract

Therapeutic manipulation of the renin-angiotensin-aldosterone system (RAAS) is an important strategy for improving hypertension, diabetes, cardiovascular disease, and chronic kidney disease. Development of hyperkalemia after the administration of RAAS inhibitors is of particular concern because patients at highest risk for this complication are often the same patients who derive the greatest cardiovascular or renoprotective benefit. Based on an overview of the incidence of hyperkalemia during treatment with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers alone and in combination, this review suggests approaches for monitoring, detecting, and managing hyperkalemia in patients treated with RAAS inhibitors. Although the incidence of hyperkalemia with RAAS inhibitors is generally low, hyperkalemia can be associated with increased mortality. When using RAAS inhibitors, it is important to monitor on-treatment electrolyte levels and renal function parameters in patients with a high risk for hyperkalemia.

Keywords

References

  1. Schrier RW. Hyperkalemia: a threat to RAAS inhibition? Nat Rev Nephrol 2010;6:245-246.
  2. Chung S, Park CW, Shin SJ, et al. Tempol or candesartan prevents high-fat diet-induced hypertension and renal damage in spontaneously hypertensive rats. Nephrol Dial Transplant 2010;25: 389-399. https://doi.org/10.1093/ndt/gfp472
  3. Shin SJ, Lim JH, Chung S, et al. Peroxisome proliferator-activated receptor-alpha activator fenofibrate prevents high-fat diet-induced renal lipotoxicity in spontaneously hypertensive rats. Hypertens Res 2009;32:835-845. https://doi.org/10.1038/hr.2009.107
  4. Hou FF, Zhang X, Zhang GH, et al. Efficacy and safety of benazepril for advanced chronic renal insufficiency. N Engl J Med 2006;354:131-140. https://doi.org/10.1056/NEJMoa053107
  5. Weir MR, Rolfe M. Potassium homeostasis and renin- angiotensin- aldosterone system inhibitors. Clin J Am Soc Nephrol 2010;5:531-548. https://doi.org/10.2215/CJN.07821109
  6. Shlipak MG. Pharmacotherapy for heart failure in patients with renal insufficiency. Ann Intern Med 2003;138:917-924. https://doi.org/10.7326/0003-4819-138-11-200306030-00013
  7. Poggio R, Grancelli HO, Miriuka SG. Understanding the risk of hyperkalaemia in heart failure: role of aldosterone antagonism. Postgrad Med J 2010;86:136-142. https://doi.org/10.1136/pgmj.2008.072058
  8. Uribarri J, Oh MS, Carroll HJ. Hyperkalemia in diabetes mellitus. J Diabet Complications 1990;4:3-7. https://doi.org/10.1016/0891-6632(90)90057-C
  9. Palmer BF. A physiologic-based approach to the evaluation of a patient with hyperkalemia. Am J Kidney Dis 2010;56:387-393. https://doi.org/10.1053/j.ajkd.2010.01.020
  10. Rogulj D, Hauptfeld M, Iskra MS, Zorko VK, Strasek M. Extreme hyperkalaemia caused by concomitant use of a NSAID and an ace inhibitor in an elderly patient. Arh Hig Rada Toksikol 2010;61: 241-245.
  11. Antoniou T, Gomes T, Juurlink DN, Loutfy MR, Glazier RH, Mamdani MM. Trimethoprim-sulfamethoxazole-induced hyperkalemia in patients receiving inhibitors of the renin-angiotensin system: a population-based study. Arch Intern Med 2010;170: 1045-1049. https://doi.org/10.1001/archinternmed.2010.142
  12. Turgut F, Balogun RA, Abdel-Rahman EM. Renin-angiotensin- aldosterone system blockade effects on the kidney in the elderly: benefits and limitations. Clin J Am Soc Nephrol 2010; 5:1330-1339. https://doi.org/10.2215/CJN.08611209
  13. Fogari R, Zoppi A, Malamani GD, Marasi G, Vanasia A, Villa G. Effects of different antihypertensive drugs on plasma fibrinogen in hypertensive patients. Br J Clin Pharmacol 1995;39:471-476. https://doi.org/10.1002/j.1552-4604.1995.tb04090.x
  14. Reardon LC, Macpherson DS. Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors: how much should we worry? Arch Intern Med 1998;158:26-32. https://doi.org/10.1001/archinte.158.1.26
  15. Goldberg AI, Dunlay MC, Sweet CS. Safety and tolerability of losartan potassium, an angiotensin II receptor antagonist, compared with hydrochlorothiazide, atenolol, felodipine ER, and angiotensin- converting enzyme inhibitors for the treatment of systemic hypertension. Am J Cardiol 1995;75:793-795. https://doi.org/10.1016/S0002-9149(99)80413-5
  16. Puchler K, Laeis P, Stumpe KO. Blood pressure response, but not adverse event incidence, correlates with dose of angiotensin II antagonist. J Hypertens Suppl 2001;19:S41-S48. https://doi.org/10.1097/00004872-200101000-00006
  17. McGill JB, Reilly PA. Telmisartan plus hydrochlorothiazide versus telmisartan or hydrochlorothiazide monotherapy in patients with mild to moderate hypertension: a multicenter, randomized, double-blind, placebo-controlled, parallel-group trial. Clin Ther 2001;23:833-850. https://doi.org/10.1016/S0149-2918(01)80072-2
  18. Izzo JL Jr, Weinberg MS, Hainer JW, Kerkering J, Tou CK. Antihypertensive efficacy of candesartan-lisinopril in combination vs. up-titration of lisinopril: the AMAZE trials. J Clin Hypertens (Greenwich) 2004;6:485-493. https://doi.org/10.1111/j.1524-6175.2004.03511.x
  19. Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008; 358:1547-1559. https://doi.org/10.1056/NEJMoa0801317
  20. Working Party of the International Diabetes Federation (European Region). Hypertension in people with Type 2 diabetes: knowledge- based diabetes-specific guidelines. Diabet Med 2003;20: 972-987. https://doi.org/10.1046/j.1464-5491.2003.01021.x
  21. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin- converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 1993;329:1456-1462. https://doi.org/10.1056/NEJM199311113292004
  22. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345:861-869. https://doi.org/10.1056/NEJMoa011161
  23. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345: 851-860. https://doi.org/10.1056/NEJMoa011303
  24. Jennings DL, Kalus JS, Coleman CI, Manierski C, Yee J. Combination therapy with an ACE inhibitor and an angiotensin receptor blocker for diabetic nephropathy: a meta-analysis. Diabet Med 2007;24:486-493. https://doi.org/10.1111/j.1464-5491.2007.02097.x
  25. Mogensen CE, Neldam S, Tikkanen I, et al. Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ 2000;321:1440-1444. https://doi.org/10.1136/bmj.321.7274.1440
  26. Ruggenenti P, Mosconi L, Vendramin G, et al. ACE inhibition improves glomerular size selectivity in patients with idiopathic membranous nephropathy and persistent nephrotic syndrome. Am J Kidney Dis 2000;35:381-391. https://doi.org/10.1016/S0272-6386(00)70190-9
  27. Cupisti A, Rizza GM, D'Alessandro C, Morelli E, Barsotti G. Effect of telmisartan on the proteinuria and circadian blood pressure profile in chronic renal patients. Biomed Pharmacother 2003;57:169-172. https://doi.org/10.1016/S0753-3322(03)00013-1
  28. Bakris GL, Siomos M, Richardson D, et al. ACE inhibition or angiotensin receptor blockade: impact on potassium in renal failure. VAL-K Study Group. Kidney Int 2000;58:2084-2092. https://doi.org/10.1111/j.1523-1755.2000.00381.x
  29. MacKinnon M, Shurraw S, Akbari A, Knoll GA, Jaffey J, Clark HD. Combination therapy with an angiotensin receptor blocker and an ACE inhibitor in proteinuric renal disease: a systematic review of the efficacy and safety data. Am J Kidney Dis 2006; 48:8-20. https://doi.org/10.1053/j.ajkd.2006.04.077
  30. The Consensus Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: results of the cooperative north scandinavian enalapril survival study (CONSENSUS). N Engl J Med 1987;316:1429-1435. https://doi.org/10.1056/NEJM198706043162301
  31. Pitt B, Segal R, Martinez FA, et al. Randomised trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of Losartan in the Elderly Study, ELITE). Lancet 1997;349:747-752. https://doi.org/10.1016/S0140-6736(97)01187-2
  32. Granger CB, McMurray JJ, Yusuf S, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-alternative trial. Lancet 2003;362:772-776. https://doi.org/10.1016/S0140-6736(03)14284-5
  33. Desai AS, Swedberg K, McMurray JJ, et al. Incidence and predictors of hyperkalemia in patients with heart failure: an analysis of the CHARM program. J Am Coll Cardiol 2007;50:1959-1966. https://doi.org/10.1016/j.jacc.2007.07.067
  34. Phillips CO, Kashani A, Ko DK, Francis G, Krumholz HM. Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med 2007;167:1930-1936. https://doi.org/10.1001/archinte.167.18.1930
  35. McMurray JJ, Ostergren J, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-added trial. Lancet 2003;362:767-771. https://doi.org/10.1016/S0140-6736(03)14283-3
  36. Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 2001;345:1667-1675. https://doi.org/10.1056/NEJMoa010713
  37. Pfeffer MA, McMurray JJ, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003;349: 1893-1906. https://doi.org/10.1056/NEJMoa032292
  38. Kuenzli A, Bucher HC, Anand I, et al. Meta-analysis of combined therapy with angiotensin receptor antagonists versus ACE inhibitors alone in patients with heart failure. PLoS One 2010;5: e9946. https://doi.org/10.1371/journal.pone.0009946
  39. Desai A. Hyperkalemia associated with inhibitors of the renin- angiotensin-aldosterone system: balancing risk and benefit. Circulation 2008;118:1609-1611. https://doi.org/10.1161/CIRCULATIONAHA.108.807917
  40. Hayashi K, Homma K, Wakino S, et al. T-type Ca channel blockade as a determinant of kidney protection. Keio J Med 2010;59: 84-95. https://doi.org/10.2302/kjm.59.84