A Four-Year Report on Renal Outcomes Following the Elective Withdrawal of Long-Term Renin-Angiotensin-Aldosterone Blockade in a Cohort of Patients With Otherwise Inexplicable New-Onset and Progressive Acute Kidney Injury

Abstract

BackgroundRenin-angiotensin-aldosterone (RAAS) blockade is acclaimed, by consensus, to be renoprotective in both diabetic and non-diabetic chronic kidney disease (CKD). Contradictory reports exist regarding renal and cardiovascular outcomes after stopping RAAS blockade in advanced CKD. A few prospective, nonrandomized, cohort studies have demonstrated improvement in kidney function after discontinuation of RAAS blockade. In this study, we investigated renal and mortality outcomes following the elective withdrawal of RAAS blockade after otherwise inexplicable acute kidney injury (AKI). MethodologyWe conducted a retrospective cohort analysis of patients enrolled between February 2018 and May 2021. Kidney function was monitored after elective withdrawal of long-term RAAS blockade in CKD patients presenting with new-onset otherwise inexplicable progressive AKI, defined by a >25% increase in baseline serum creatinine. ResultsIn total, 71 patients, 69 Caucasians, one African American, and one Hispanic, were included in the study, with a male-to-female ratio of 42:29, and a mean age of 69.4 (37-95) years. Through February 2022, 12 patients had died, with eight remaining on hemodialysis for end-stage renal disease. Of the remaining 51 patients followed for 706 (40-1,478) days, baseline serum creatinine was 1.30 ± 0.42 (0.66-2.70) mg/dL, peak enrollment serum creatinine was 2.17 ± 1.06 (1.1-8.3) mg/dL (n = 51, p < 0.0001, t = 6.4872, df = 135), and serum creatinine after four years was 1.58 ± 0.54 (0.84-3.3) mg/dL (n = 50, p < 0.0001, t = 5.1805, df = 119). Death in 11 of 12 (91%) patients was from non-renal causes, and most deaths occurred despite improved kidney function. ConclusionsOur results demonstrate clearly improved renal outcomes in most patients following the elective withdrawal of long-term RAAS blockade in CKD patients with new-onset progressive yet otherwise inexplicable AKI without increased cardiovascular mortality.

Renin-Angiotensin-Aldosterone System Blockade (RAASB) After Acute Kidney Injury: The Controversy Thickens on If and When to Discontinue RAASB

“…In the 2022 Cureus journal report, 71 patients who presented with otherwise inexplicable new-onset and progressive AKI while on RAASB, in general, had demonstrated sustained renal recovery, and this was without increased cardiovascular mortality, following the preemptive discontinuation of RAASB [5]. Death in 11 of 12 (91%) of our patients was from non-renal causes, and most deaths occurred despite improved kidney function [5].…”

“…Most pertinently, over 15 years ago, we had first described the syndrome of lateonset renal failure from angiotensin blockade (LORFFAB), and we recently replicated findings consistent with LORFFAB in an article published in the Cureus journal [4,5]. In the 2022 Cureus journal report, 71 patients who presented with otherwise inexplicable new-onset and progressive AKI while on RAASB, in general, had demonstrated sustained renal recovery, and this was without increased cardiovascular mortality, following the preemptive discontinuation of RAASB [5]. Death in 11 of 12 (91%) of our patients was from non-renal causes, and most deaths occurred despite improved kidney function [5].…”

“…In a large Swedish Registry observational study of people with advanced CKD, stopping RAASB was associated with higher absolute risks of mortality and major adverse cardiovascular events, but with a lower risk of kidney replacement therapy [2]. Most pertinently, over 15 years ago, we had first described the syndrome of lateonset renal failure from angiotensin blockade (LORFFAB), and we recently replicated findings consistent with LORFFAB in an article published in the Cureus journal [4,5]. In the 2022 Cureus journal report, 71 patients who presented with otherwise inexplicable new-onset and progressive AKI while on RAASB, in general, had demonstrated sustained renal recovery, and this was without increased cardiovascular mortality, following the preemptive discontinuation of RAASB [5].…”