Ace In The Hole Use Of Angiotensin Converting Enzyme Inhibitors And Angiotensin Ii Receptor Blockers In The First Year After Heart Transplant

Purpose Angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) are first line agents for treatment of hypertension in the general population, particularly in the setting of diabetes. However, safety data for their use after heart transplant (HT) is limited due to concerns regarding renal insufficiency and hyperkalemia. Methods Retrospective single-center study of HT recipients from January 2017 to December 2019 who received ACEi or ARB therapy within the first-year post-transplant. Patients were evaluated for development of acute kidney injury (AKI), hyperkalemia or other complications after initiation of ACEi/ARB therapy. Results A total of 42 patients were included. The cohort was primarily male (81%), with a median (IQR) age of 55.3 (37.7-61.3) years at initiation of therapy. SMX-TMP was used in 39 (83%) while on ACEi/ARB therapy. Median (IQR) estimated glomerular filtration rate (eGFR) at initiation of therapy was 70.2 (56-102.2) mL/min/1.73 m2. The lowest eGFR within the first two weeks after initiation of ACEi/ARB was 57.7 (54.4-96.2) mL/min/1.73 m2 (Fig 1A). Only one (2.2%) patient had a \u003e50% decline in eGFR within the first 2 weeks of therapy. Hyperkalemia (potassium \u003e5.4 mmol/L) within in the first month after initiation of therapy was observed in 3 (6.5%) patients (Fig 1B). Within the first year post-transplant, therapy was discontinued in 12 (32.4%) patients receiving ACEi, mostly due to AKI or hyperkalemia, and therapy was discontinued in 1 (11.1%) patient receiving ARB (Fig 1B). Of the 9 ARB patients, 4 (44.4%) were previously on ACEi therapy. Conclusion ACEi and ARB therapies can be safely initiated in patients with preserved renal function within the first-year post-transplant; however, a third of patients eventually discontinued therapy, mainly due to worsening renal function and hyperkalemia. Close monitoring is required when initiating a patient on ACEi/ARB to ensure safety while using these medications.