From the Guidelines
For patients with stage 5 chronic kidney disease (CKD), angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) should generally be discontinued or used with extreme caution, as recommended by the most recent guidelines 1.
Rationale
The use of ACEIs and ARBs in stage 5 CKD is a complex issue, with potential benefits and risks that need to be carefully weighed. While these medications have been shown to be beneficial in earlier stages of CKD, their use in advanced kidney disease is more controversial. The primary concern is that they can worsen kidney function, increase potassium levels dangerously (hyperkalemia), and cause other metabolic complications.
Key Considerations
- The most recent study 1 suggests that ACEIs and ARBs should not be used in patients with stage 5 CKD, unless absolutely necessary, due to the increased risk of adverse events.
- If these medications must be used, they should be prescribed at reduced doses with very close monitoring of kidney function (creatinine, BUN), potassium levels, and blood pressure.
- Examples of reduced doses include lisinopril at 2.5-5mg daily (instead of 10-40mg) or losartan at 25mg daily (instead of 50-100mg).
- Monitoring should occur within 1-2 weeks of starting or adjusting doses.
Clinical Context
In real-life clinical practice, the decision to use ACEIs and ARBs in stage 5 CKD should be made on a case-by-case basis, taking into account the individual patient's risk factors, comorbidities, and potential benefits and risks of treatment. The risk-benefit assessment changes significantly once a patient reaches dialysis; for hemodialysis patients, these medications may be reintroduced primarily for blood pressure control or heart failure management, as hyperkalemia can be addressed during dialysis sessions.
Supporting Evidence
The evidence from recent studies 1 suggests that the use of ACEIs and ARBs in stage 5 CKD is not recommended, due to the increased risk of adverse events, including hyperkalemia and acute kidney injury. However, the most recent study 1 provides the strongest evidence for this recommendation, and should be prioritized in clinical decision-making.
From the Research
Angiotensin II Receptor Blockers (ARBs) and Angiotensin-Converting Enzyme Inhibitors (ACEIs) for CKD Stage 5 Patients
- The use of ARBs and ACEIs in patients with chronic kidney disease (CKD) stage 5 is a topic of interest, with studies suggesting their potential benefits in reducing kidney failure and managing hypertension 2, 3.
- A cross-sectional study based on real-world data found that ARBs and ACEIs were prescribed in only 28% of hypertensive patients with CKD stage G1-G5 or aged ≥75 years with CKD stage G1-G3, despite Japanese guidelines recommending their use as first-line therapy in these patients 2.
- Another study found that ACEIs or ARBs reduced kidney failure compared to placebo or non-RAAS inhibitors at 34 months in advanced CKD patients 3.
Effectiveness of ARBs and ACEIs in Combination with Other Therapies
- A retrospective database analysis compared the effectiveness of dihydropyridine calcium channel blockers (DHPs), ACE inhibitors, and ARBs added to diuretics or beta-blockers, and found that DHPs, ACE inhibitors, and ARBs improved blood pressure when added to patients' beta-blocker or diuretic therapy 4.
- A systematic review evaluated the comparative efficacy and safety of antihypertensive therapies, including ACEIs, ARBs, and calcium channel blockers (CCBs), in managing hypertension among CKD patients, and found that ACEIs and ARBs were superior in reducing proteinuria and slowing CKD progression, particularly in proteinuric patients 5.
Considerations for CKD Stage 5 Patients
- The prescription rate of ARBs and ACEIs was lower in patients aged <75 years with CKD stage G1-G5 compared to patients aged ≥75 years with CKD stage G1-G3 2.
- The use of ARBs and ACEIs in CKD stage 5 patients may need to be individualized based on patient-specific factors, such as proteinuria and cardiovascular risk 5.