Key result
Continuing renin-angiotensin-aldosterone system inhibitors after adverse events or in advanced chronic kidney disease is associated with a lower risk of death and cardiovascular events compared to stopping.
Why the study?
Permanent discontinuation of RAASi after adverse events is common in clinical practice and may heighten cardiovascular disease risk, warranting a review of the benefits and harms of stopping versus continuing therapy.
Does continuing RAASi therapy improve clinical outcomes compared to stopping in patients with advanced CKD or after adverse events?
Does continuing RAASi therapy improve clinical outcomes compared to stopping in patients with advanced CKD or after adverse events?
Answers are grounded in this paper and cite their sources.
Continuing RAASi therapy after adverse events like hyperkalemia or AKI, or in advanced CKD, is associated with sustained cardioprotection and better clinical outcomes compared to discontinuation.
PURPOSE OF REVIEW: To discuss recent evidence on the benefits and harms of stopping therapy with renin-angiotensin-aldosterone system inhibitors (RAASi) after the occurrence of adverse events or in patients with advanced chronic kidney disease (CKD). RECENT FINDINGS: RAASi may result hyperkalemia or acute kidney injury (AKI), particularly in persons with CKD. Guidelines recommend to temporarily stop RAASi until the problem is resolved. However permanent discontinuation of RAASi is common in clinical practice with the potential to heighten subsequent cardiovascular disease (CVD) risk. A series of studies evaluating the consequences of stopping RAASi (vs. continuing) after an episode of hyperkalemia or AKI consistently report worse clinical outcomes, both higher risk of death and cardiovascular events. The STOP-angiotensin converting enzyme inhibitors (ACEi) trial and two large observational studies also favor the decision to continue ACEi/ angiotensin receptor blockers in advanced CKD, refuting old observations that use of these medications can accelerate the risk of kidney replacement therapy. SUMMARY: Available evidence suggests continuing with RAASi after the occurrence of adverse events or in patients with advanced CKD, primarily attributed to sustained cardioprotection. This is in line with current guideline recommendations.
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Leon et al. (2023) conducted a review in Chronic kidney disease with adverse events (hyperkalemia or acute kidney injury) on RAASi. Stopping renin-angiotensin-aldosterone system inhibitors (RAASi) vs. Continuing RAASi was evaluated on Death and cardiovascular events. Continuing renin-angiotensin-aldosterone system inhibitors after adverse events or in advanced chronic kidney disease is associated with a lower risk of death and cardiovascular events compared to stopping.
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