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Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy
Rishi V Parikh1, Danielle M Nash2,3,4, K Scott Brimble5
1Division of Research, Kaiser Permanente Northern California, Oakland (R.V.P., T.C.T., F.K.-R., A.S.G.).
Insights
Routine monitoring of kidney function and potassium after starting ACE inhibitors or ARBs did not lower mortality. Targeted testing may identify patients needing closer observation for adverse effects.
Area of Science:
- Nephrology
- Pharmacology
- Clinical Medicine
Background:
- Clinical guidelines recommend kidney function and serum potassium tests within 30 days of initiating ACE inhibitors or ARBs.
- Evidence is lacking on whether this routine follow-up testing reduces adverse outcomes.
Purpose of the Study:
- To evaluate the association of routine follow-up laboratory testing with 30-day all-cause mortality and hospitalization for acute kidney injury or hyperkalemia after initiating ACE inhibitors or ARBs.
- To develop and validate a risk score for identifying patients at risk of abnormal serum creatinine and potassium levels.
Main Methods:
- Two population-based retrospective cohort studies were conducted in Kaiser Permanente Northern California and Ontario, Canada.
- Patients were matched 1:1 based on follow-up testing status within 30 days of therapy initiation.
- Cox regression was used to assess the association of follow-up testing with adverse outcomes.
Main Results:
- Routine follow-up testing was not significantly associated with a lower risk of 30-day mortality in Kaiser Permanente Northern California.
- Follow-up testing was associated with higher mortality in Ontario.
- Testing was significantly associated with higher rates of hospitalization for acute kidney injury and hyperkalemia in both cohorts.
- A risk score for abnormal potassium showed good discrimination (AUC, 0.75), while the score for abnormal creatinine had moderate discrimination (AUC, 0.62).
Conclusions:
- Routine laboratory monitoring after ACE inhibitor or ARB initiation was not associated with reduced 30-day mortality.
- Targeted testing strategies may be more effective in identifying patients at risk for therapy-related adverse events.
Background:
Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker therapy. However, evidence is lacking about whether follow-up testing reduces therapy-related adverse outcomes.
Methods And Results:
We conducted 2 population-based retrospective cohort studies in Kaiser Permanente Northern California and Ontario, Canada. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACE inhibitor or angiotensin II receptor blocker therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression. We also developed and externally validated a risk score to identify patients at risk of having abnormally high serum creatinine and potassium values in follow-up. We identified 75 251 matched pairs initiating ACE inhibitor or angiotensin II receptor blocker therapy between January 1, 2007, and December 31, 2017, in Kaiser Permanente Northern California. Follow-up testing was not significantly associated with 30-day all-cause mortality in Kaiser Permanente Northern California (hazard ratio, 0.75 [95% CI, 0.54-1.06]) and was associated with higher mortality in 84 905 matched pairs in Ontario (hazard ratio, 1.32 [95% CI, 1.07-1.62]). In Kaiser Permanente Northern California, follow-up testing was significantly associated with higher rates of hospitalization with acute kidney injury (hazard ratio, 1.66 [95% CI, 1.10-2.22]) and hyperkalemia (hazard ratio, 3.36 [95% CI, 1.08-10.41]), as was observed in Ontario. The risk score for abnormal potassium provided good discrimination (area under the curve [AUC], 0.75) and excellent calibration of predicted risks, while the risk score for abnormal serum creatinine provided moderate discrimination (AUC, 0.62) but excellent calibration.
Conclusions:
Routine laboratory monitoring after ACE inhibitor or angiotensin II receptor blocker initiation was not associated with a lower risk of 30-day mortality. We identified patient subgroups in which targeted testing may be effective in identifying therapy-related changes in serum potassium or kidney function.
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