Renin-angiotensin system inhibition in advanced chronic kidney disease: how low can the kidney function go?

Area of Science:

• Nephrology
• Pharmacology

Background:

• Angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB) are established treatments for mild-to-moderate chronic kidney disease (CKD), particularly with proteinuria.
• Data regarding ACEi/ARB use in advanced CKD (eGFR < 15 mL/min/1.73 m²) is limited and often conflicting.
• Definitions of advanced CKD vary across studies, complicating data interpretation.

Purpose of the Study:

• To review available data on the risks and benefits of ACEi/ARB therapy in patients with advanced CKD.
• To provide evidence-based recommendations for ACEi/ARB management in this patient population.

Main Methods:

• Literature review of studies investigating ACEi/ARB use in patients with advanced CKD.
• Analysis of data concerning efficacy, safety, and specific clinical scenarios.

Main Results:

• Evidence supports continuing ACEi/ARB therapy in advanced CKD unless significant adverse events like unresponsive hyperkalemia, hypotension, or rapid eGFR decline occur.
• There is insufficient evidence to recommend initiating ACEi/ARB therapy de novo in patients with advanced CKD.
• Close patient monitoring is crucial when ACEi/ARB therapy is continued or initiated in advanced CKD.

Conclusions:

• Continue ACEi/ARB therapy in advanced CKD patients under close observation, especially if they are already on the medication.
• Avoid initiating ACEi/ARB therapy de novo in advanced CKD due to lack of supporting data; if initiated, monitor closely.
• Manage adverse effects such as hyperkalemia and hypotension promptly to allow continued ACEi/ARB therapy.