Discontinuing renin-angiotensin system inhibitors after incident hyperkalemia was not associated with a difference in the composite kidney outcome (HR 1.01) but was associated with a 16% higher hazard of mortality.
Observational (n=2,305)
Yes
Does discontinuing renin-angiotensin system inhibitors after incident hyperkalemia improve kidney outcomes or mortality in patients with chronic kidney disease?
Discontinuing renin-angiotensin system inhibitors after incident hyperkalemia is associated with higher mortality but a lower risk of severe hyperkalemia, without significantly affecting kidney outcomes.
Effect estimate: HR 1.01 (95% CI 0.81-1.26)
Absolute Event Rate: 20.7% vs 20.4%
Abstract Although renin-angiotensin system inhibitors (RASi) are the mainstay in the management of heart failure with reduced ejection fraction, chronic kidney disease, and other cardiovascular conditions, they are often discontinued due to hyperkalemia. The prognostic impact of discontinuing RASi after developing hyperkalemia remains uncertain. Using a target trial framework based on the cloning, censoring, and weighting method, we compared discontinuing RASi after incident hyperkalemia with continuing RASi. We identified 2305 patients with an estimated glomerular filtration rate (eGFR) of ≥10 ml/min/1.73 m 2 who developed hyperkalemia (serum potassium levels ≥5.5 mEq/L) while on RASi in the Osaka Consortium for Kidney Disease Research (OCKR) database. The primary outcome was a composite of initiation of kidney replacement therapy, a ≥50% decline in eGFR, or reaching eGFR <5 ml/min/1.73 m 2 . Secondary outcomes included all-cause death and severe hyperkalemia (serum potassium levels ≥6.5 mEq/L). The mean (standard deviation) age and eGFR were 68 (14) years and 29 (17) mL/min/1.73 m², respectively. After developing hyperkalemia, 346 (15%) discontinued RASi. Discontinuing RASi was associated with a 16% 95% confidence interval 2–33% higher hazard of mortality than continuing RASi while the composite kidney outcome did not differ between groups (adjusted hazard ratio HR 1.01 0.81–1.26). Severe hyperkalemia occurred less frequently in those who discontinued RASi than those who continued RASi (adjusted HR 0.83 0.69, 0.99). RASi discontinuation after incident hyperkalemia was associated with higher mortality despite a lower risk of severe hyperkalemia. It was not related to kidney outcome. Appropriate clinical decision-making regarding RASi discontinuation may depend on the clinical context.
Hashimoto et al. (Wed,) conducted a observational in Incident hyperkalemia while on renin-angiotensin system inhibitors (n=2,305). Discontinuing renin-angiotensin system inhibitors vs. Continuing renin-angiotensin system inhibitors was evaluated on Composite of initiation of kidney replacement therapy, ≥50% decline in eGFR, or reaching eGFR <5 ml/min/1.73 m² (HR 1.01, 95% CI 0.81-1.26). Discontinuing renin-angiotensin system inhibitors after incident hyperkalemia was not associated with a difference in the composite kidney outcome (HR 1.01) but was associated with a 16% higher hazard of mortality.