Renin-angiotensin system blockade in patients with chronic kidney disease: benefits, problems in everyday clinical...

Area of Science:

• Nephrology
• Pharmacology
• Internal Medicine

Background:

• Hypertension and albuminuria management are key to slowing chronic kidney disease (CKD) progression.
• Renin-angiotensin system (RAS) blockers, including ACE inhibitors (ACEIs) and ARBs, are primary treatments for these goals.
• Evidence supports RAS blockers' renoprotective effects in CKD patients with high albuminuria, with benefits potentially greater in advanced CKD.

Purpose of the Study:

• To review existing literature on the use of RAS blockers in patients with advanced CKD (Stages 4 and 5).
• To address the scarcity of randomized trials and clinician uncertainty regarding RAS blocker initiation or continuation in advanced CKD.
• To discuss concerns about hyperkalemia and acute kidney injury that lead to underprescription or discontinuation of RAS blockers.

Main Methods:

• Literature review of studies on RAS blocker use in advanced CKD.
• Analysis of post hoc trial data examining renoprotective effects in different CKD stages.
• Synthesis of evidence addressing clinical concerns and prescribing patterns.

Main Results:

• RAS blockers show significant renoprotective effects, particularly in CKD patients with high albuminuria.
• Post hoc analyses suggest enhanced benefits in more advanced CKD stages.
• Limited randomized trials specifically target RAS blocker use in advanced CKD, contributing to clinical hesitancy.

Conclusions:

• RAS blockers are essential for managing hypertension and albuminuria in CKD.
• Despite evidence, their use in advanced CKD is often limited by concerns over side effects and lack of specific trial data.
• Further research is needed to solidify guidelines for RAS blocker therapy in advanced CKD stages.