Stopping RAS Inhibitors in Advanced Chronic Kidney Disease and Cardiorenal Outcomes—Several Unanswered Questions Remain

Abstract

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The Impact of Elective Withdrawal of Long-Term Renin Angiotensin Aldosterone System Blockade in Chronic Kidney Disease Patients with Progressive Acute Kidney Injury: A Prospective 40-Months’ Single-Unit Cohort Study

“…[1][2][3][4][5] Nevertheless, there is substantial disagreement regarding the renal and cardiovascular outcomes after the discontinuation of RAAS blockade in patients with advanced CKD. [6][7][8] A recent Swedish Renal Registry study examined the impact of stopping versus continuing RAAS inhibitor therapy in 10,254 prevalent RAAS inhibitor users (median age 72 years, 36% female) with newonset eGFR <30 ml/min per 1.73 m2, 1553 (15%). 6 Median eGFR was 23 ml/min per 1.73 m 2 .…”

“…7 We had in a recent editorial commentary in the American Journal of Medicine raised the concerns that such debate and controversy about cardiorenal outcomes following the discontinuation of RAAS blockade in advanced CKD remain unsettled. 8 Furthermore, we had earlier described the syndrome of late onset renal failure from angiotensin blockade (LORFFAB) and had demonstrated generally improved renal outcomes in patients presenting with progressive AKI after discontinuation of concurrent RAAS blockade without overt CV consequences. 9,10 The first author had therefore undertaken to complete a prospective study of similar patients with acutely presenting AKI on CKD following the elective withdrawal of concurrent RAAS blockade after moving to the University of Vermont, Burlington, VT in the US Northeast coast.…”

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

“…Unquestionably, there is a common consensus regarding cardiorenal protection with RAASB in both diabetic and nondiabetic CKD. Nevertheless, there remain conflicting retrospective reports regarding renal and cardiovascular mortality outcomes following discontinuation of RAASB in advanced CKD [2,3]. 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].…”

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

“…We revisited the conflicting results of these studies in a commentary in the American Journal of Medicine. In this commentary, we reexamined the continuing debate and controversies surrounding renal and cardiovascular outcomes following the preemptive withdrawal of RAAS blockade in patients with advanced CKD [ 8 ]. Moreover, a Korean study, reported in 2017, investigated renal death, all-cause mortality, hospitalization for hyperkalemia, and interactive factors as composite outcomes in 2,076 pre-dialysis patients with advanced CKD on RAAS blockers [ 9 ].…”