Comparative renal safety: potassium-competitive acid blockers vs proton pump inhibitors

Proton pump inhibitors (PPIs) are associated with an increased risk of acute kidney injury and incident chronic kidney disease. Potassium-competitive acid blockers (P-CABs) have emerged as potent alternatives to PPIs, but their renal impact remains unclear.

This study compared renal outcomes between P-CAB and PPI in patients receiving either PPIs or P-CABs at a tertiary referral hospital in Korea between 2019 and 2023. Renal outcomes were defined as creatinine doubling and a decline in estimated glomerular filtration rate (eGFR) ≥50%, termed as "eGFR decline." We used Cox proportional hazard analyses to adjust for multiple covariates.

The study included 1820 and 5121 patients in the P-CAB and PPI groups, respectively. The P-CAB group had lower incidences of creatinine doubling (13.4 vs 36.5, log-rank P < .001) and eGFR decline (18.4 vs 39, log-rank P < .001) than the PPI group (per 1000 person-years). Hazard ratios (HRs) for creatinine doubling and eGFR decline with P-CAB use were 0.42 [95% confidence interval (CI) 0.30-0.59, P < .001] and 0.50 (95% CI 0.37-0.69, P < .001), respectively. After adjusting multiple covariates, HRs were 0.52 (95% CI 0.37-0.74, P < .001) for creatinine doubling and 0.63 (95% CI 0.46-0.87, P = .005) for eGFR decline.

P-CABs showed a lower risk of renal function decline compared with PPIs, suggesting that P-CABs may be a safer alternative for long-term acid suppression. Further studies incorporating other P-CABs and PPIs are needed to confirm these findings.