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Stopping renin-angiotensin-aldosterone system inhibitors in kidney disease

Eva Glenn Lecea1, Krystle Frazier1, Elaine Ku1,2

  • 1University of California, San Francisco, Department of Pediatrics.

Current Opinion in Nephrology and Hypertension
|March 14, 2026
PubMed

Insights

Discontinuing renin-angiotensin system inhibitors (RASi) in chronic kidney disease (CKD) offers no kidney or survival benefits and is linked to worse outcomes. Reinitiating RASi after acute kidney injury (AKI) or hyperkalemia improves survival and slows kidney disease progression.

Area of Science:

  • Nephrology
  • Cardiology
  • Pharmacology

Background:

  • The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines advocate for renin-angiotensin system inhibitors (RASi) in chronic kidney disease (CKD) due to renal and cardiovascular advantages.
  • Real-world evidence indicates suboptimal RASi utilization and frequent discontinuation in CKD patients.

Purpose of the Study:

  • To review the clinical outcomes associated with discontinuing RASi in patients with CKD, hyperkalemia, and acute kidney injury (AKI).

Main Methods:

  • Systematic review of trial-grade and observational data.
  • Analysis of outcomes related to RASi discontinuation versus continuation in specific patient cohorts.

Main Results:

  • Discontinuation of RASi in CKD patients with low estimated glomerular filtration rate (eGFR) does not improve kidney or mortality outcomes.
  • Continuation of RASi during the perioperative period shows comparable outcomes to discontinuation.
  • Reinitiation of RASi post-AKI and hyperkalemia is linked to enhanced survival and reduced CKD progression.

Conclusions:

  • Discontinuation of RASi in the context of CKD, hyperkalemia, and AKI is generally associated with adverse clinical outcomes.
  • Maintaining or reinitiating RASi therapy may be beneficial for patients with CKD, hyperkalemia, and AKI.
Abstract

Keywords:
acute kidney injurychronic kidney diseasehyperkalemiarenin–angiotensin–aldosterone system inhibitors

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