Prerenal success in chronic kidney disease

Area of Science:

• Nephrology
• Pharmacology

Background:

• Renin-angiotensin system inhibitors (RASi) and diuretics are standard treatments for hypertension in chronic kidney disease (CKD).
• RASi also reduce intraglomerular pressure, potentially causing initial serum creatinine elevations.
• Physician reluctance to continue these therapies due to creatinine increases can impede long-term renoprotection.

Purpose of the Study:

• To address physician hesitancy in continuing RASi and diuretics for CKD patients experiencing serum creatinine increases.
• To differentiate between hemodynamic and parenchymal causes of creatinine elevation.
• To propose a new term and diagnostic framework for beneficial hemodynamic changes.

Main Methods:

• Review of current clinical practices and reasons for treatment discontinuation.
• Analysis of the distinction between hemodynamic and parenchymal effects on kidney function.
• Literature review of studies on serum creatinine increases in various patient cohorts.
• Proposal of the term "prerenal success" and a new diagnostic algorithm.

Main Results:

• Initial serum creatinine increases from RASi are often hemodynamic and associated with improved prognosis.
• Failure to distinguish hemodynamic from parenchymal changes leads to premature treatment cessation.
• The proposed term "prerenal success" and algorithm aim to guide appropriate clinical decision-making.
• Extrapolation of findings from other patient cohorts to stable CKD patients is inappropriate.

Conclusions:

• The initial rise in serum creatinine during RASi therapy in CKD patients is frequently a sign of beneficial hemodynamic adaptation.
• "Prerenal success" is introduced to categorize these favorable changes, encouraging continued treatment.
• A revised diagnostic approach is needed to prevent unwarranted discontinuation of renoprotective therapies in CKD.