Issue: April 2021
Perspective from Nupur Gupta, MD
Disclosures: Fu reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
January 04, 2021
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Stopping renin-angiotensin system inhibitors show benefits, risks in advanced CKD

Issue: April 2021
Perspective from Nupur Gupta, MD
Disclosures: Fu reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Researchers from the Netherlands have identified benefits and risks associated with stopping renin-angiotensin system inhibitor therapy in patients with advanced chronic kidney disease.

“Whether renin-angiotensin system (RAS) inhibition is safe and effective in patients with advanced CKD is unknown,” Edouard L. Fu, BSc, of Leiden University Medical Center, and colleagues wrote. “Single-center studies suggest there is improved kidney function after stopping [renin-angiotensin system] RAS inhibition and possible delay in initiating kidney replacement therapy (KRT), but large prospective studies assessing cardiovascular and kidney outcomes are lacking.”

For the study, researchers included 10,254 Swedish adults who developed advanced CKD while on RASi therapy (median age, 72 years; 36% women). Of these, 15% stopped the therapy within 6 months. Researchers compared outcomes of these patients to those who continued therapy.

Results showed that, compared with continuing RAS inhibition, stopping therapy was associated with a higher absolute 5-year mortality risk (40.9% vs. 54.5%) and major adverse cardiovascular events (47.6% vs. 59.5). However, stopping therapy was also associated with a lower risk of kidney replacement therapy (36.1% vs. 27.9%).

“Results were consistent whether patients stopped RAS inhibition at higher or lower eGFR, across prespecified subgroups, after adjustment and stratification for albuminuria and potassium, and when modeling RAS inhibition as a time-dependent exposure using a marginal structural model,” Fu and colleagues wrote, noting that because the conclusions are observational, these do not “substitute for randomized trials.”

“However, until these trials are conducted, our findings may assist in informing clinical decisions,” they concluded.