To RAASi or Not to RAASi, That is the Question
Clinical question: Should angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) be discontinued or continued in advanced chronic kidney disease (CKD) patients?
Background: Guidelines do not provide specific guidance on continuing or stopping ACEi or ARB for advanced CKD.
Study design: Multi-center, randomized, open-label trial
Setting: United Kingdom
Synopsis: Randomizing 411 adult patients across 37 centers with stage 4 or 5 CKD (estimated glomerular filtration rate < 30 ml/min/1.73 m2), the STOP ACEi study demonstrated that at three years the discontinuation of renin-angiotensin-aldosterone system inhibitors (RAASi) was not associated with a significant difference in the rate of eGFR decreasing. Specifically, the investigators found the least-squares mean eGFR was 12.6 ±0.7 ml/min/1.73 m2 in the discontinuation group and 13.3 ±0.6 ml/min/1.73 m2 in the continuation group (-0.7 difference; 95% CI, -2.5–1.0), with the negative value favoring the outcome in the continuation arm.
Bottom line: Discontinuation of RAASi in advanced CKD patients does not cause a clinically relevant change in the eGFR or difference in the rate of eGFR decline. They should not be stopped purely based on a low eGFR.
Citation: Bhandari S, Mehta S, et al. Renin-angiotensin system inhibition in advanced chronic kidney disease. N Engl J Med. 2022;387(22):2021-32.
Ms. Chen is an outpatient nurse practitioner in the nephrology clinic at Stanford Medicine in Stanford, Calif.