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Published on: July 3, 2013
Discontinuation of RAAS Inhibition in Children with Advanced CKD
Sophie M van den Belt1, Hiddo J L Heerspink1, Marietta Kirchner2
1Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Insights
Discontinuing renin-angiotensin-aldosterone system inhibition (RAASi) in children with chronic kidney disease (CKD) accelerates kidney function decline. This occurs even in advanced CKD, highlighting the importance of continued RAASi treatment.
Area of Science:
- Pediatric Nephrology
- Chronic Kidney Disease (CKD) Research
- Cardiovascular Comorbidities in Children
Background:
- Renin-angiotensin-aldosterone system inhibition (RAASi) is crucial for managing pediatric CKD.
- RAASi is sometimes stopped when kidney function worsens, despite its benefits.
- Understanding reasons for RAASi discontinuation and its impact is vital for CKD progression management.
Purpose of the Study:
- To investigate physician-reported reasons for RAASi discontinuation in children with CKD.
- To analyze the association between RAASi discontinuation and markers of CKD progression.
- To evaluate the impact of RAASi discontinuation on estimated glomerular filtration rate (eGFR) decline.
Main Methods:
- Retrospective analysis of 69 children with CKD who discontinued RAASi.
- Assessment of blood pressure, albuminuria, and potassium levels post-discontinuation.
- Estimation of eGFR decline rates before and after RAASi discontinuation using linear mixed-effects modeling.
Main Results:
- Common reasons for RAASi discontinuation included rising creatinine, hyperkalemia, and hypotension.
- Following discontinuation, blood pressure and albuminuria increased, while potassium decreased.
- eGFR declined significantly faster after RAASi discontinuation (-3.9 ml/min/1.73 m²/year) compared to during RAASi treatment (-1.5 ml/min/1.73 m²/year).
Conclusions:
- Discontinuation of RAASi in pediatric CKD patients accelerates kidney function decline.
- This acceleration in eGFR decline was observed even in children with advanced CKD.
- Continued RAASi therapy is associated with a slower rate of eGFR decline in children with CKD.
Background And Objectives:
Although renin-angiotensin-aldosterone system inhibition (RAASi) is a cornerstone in the treatment of children with CKD, it is sometimes discontinued when kidney function declines. We studied the reasons of RAASi discontinuation and associations between RAASi discontinuation and important risk markers of CKD progression and on eGFR decline in the Cardiovascular Comorbidity in Children with CKD study.
Design, Setting, Participants, & Measurements:
In this study, 69 children with CKD (67% male, mean age 13.7 years, mean eGFR 27 ml/min per 1.73 m2) who discontinued RAASi during prospective follow-up were included. Initial change in BP, albuminuria, and potassium after discontinuation were assessed (median time 6 months). Rate of eGFR decline (eGFR slope) during a median of 1.9 years before and 1.2 years after discontinuation were estimated using linear mixed effects modeling.
Results:
Physician-reported reasons for RAASi discontinuation were increase in serum creatinine, hyperkalemia, and symptomatic hypotension. After discontinuation of RAASi, BP and albuminuria increased, whereas potassium decreased. eGFR declined more rapidly after discontinuation of RAASi (-3.9 ml/min per 1.73 m2 per year; 95% confidence interval, -5.1 to -2.6) compared with the slope during RAASi treatment (-1.5 ml/min per 1.73 m2 per year; 95% confidence interval, -2.4 to -0.6; P=0.005). In contrast, no change in eGFR slope was observed in a matched control cohort of patients in whom RAASi was continued.
Conclusions:
Discontinuation of RAASi in children with CKD is associated with an acceleration of kidney function decline, even in advanced CKD.
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