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Use of renin angiotensin system inhibitors in patients with chronic kidney disease
1Department of Rural Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.
Insights
Renin angiotensin system inhibitors (RASI) are crucial for hypertension in chronic kidney disease (CKD) patients. Monitor glomerular filtration rate (GFR) for acute drops, as a significant decline may necessitate RASI cessation.
Area of Science:
- Nephrology
- Pharmacology
- Hypertension Management
Background:
- Renin angiotensin system inhibitors (RASI) are recommended for hypertension in chronic kidney disease (CKD).
- RASI slow the decline of glomerular filtration rate (GFR) in CKD patients.
- A potential risk of RASI is a reversible, hemodynamically mediated fall in GFR.
Purpose of the Study:
- To evaluate the implications of acute glomerular filtration rate (GFR) changes during renin angiotensin system inhibitor (RASI) therapy in chronic kidney disease (CKD) patients.
- To provide guidance on managing GFR fluctuations in CKD patients treated with RASI.
- To assess the benefits and risks associated with acute GFR reduction from RASI initiation.
Main Methods:
- Review of current guidelines and clinical evidence regarding RASI use in CKD.
- Analysis of the relationship between acute GFR changes and long-term GFR decline.
- Examination of factors influencing GFR response and hyperkalemia risk in CKD patients on RASI.
Main Results:
- An acute GFR loss exceeding 25% after RASI initiation indicates cessation.
- A GFR loss less than 25% requires careful risk-benefit assessment.
- Falls in GFR on RASI often have a remediable cause; hopeful expectancy is advised if the cause is unclear and the fall is <25%.
Conclusions:
- RASI therapy requires careful monitoring of GFR in CKD patients.
- Management strategies should balance the risk of acute GFR decline against the benefit of slowed long-term GFR loss.
- Hyperkalemia is a significant concern in CKD patients on RASI, necessitating vigilant potassium level management.
Abstract:
Current guidelines recommend renin angiotensin system inhibitors (RASI) as key components of treatment of hypertension in patients with chronic kidney disease (CKD), because of their effect on reducing the future rate of loss of glomerular filtration rate (GFR). A common risk of RASI in CKD is a haemodynamically mediated, and reversible, fall in GFR of varying severity and duration, any time after commencement of the Inhibitors. A benefit of the acute reduction in filtration rate with RASI may be a reduction in the future rate of loss in GFR: the greatest benefit likely to be in those patients with a greater rate of loss of GFR prior to, and a lesser acute loss of GFR after, introduction of RASI; and in those patients with significant proteinuria. An acute loss of GFR of >25% following the introduction of RASI is an indication to cease the RASI. An acute loss of GFR < 25% requires consideration of the likely risks of the lower GFR and benefits of any future reduced rate of loss of GFR. A fall in GFR in patients while on RASI is usually associated with a remediable cause. When the cause for the fall in GFR is not revealed, and the fall is less than 25%, hopeful expectancy is recommended. Hyperkalaemia in patients with CKD on RASI is more common with more severe disease, potassium retaining diuretics and hypoaldosteronism. Treatment should be modified to maintain a plasma potassium <6 mmol/L.
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