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. The use of ACEIs and ARBs in stage 5 CKD is a complex issue, as these medications can worsen kidney function, increase potassium levels dangerously (hyperkalemia), and cause other metabolic complications in advanced kidney disease.
Key Considerations
- The decision to use these medications in end-stage kidney disease involves weighing potential benefits for heart failure or significant proteinuria against risks of worsening kidney function and hyperkalemia.
- Many patients at this stage are transitioning to dialysis, where the risk-benefit profile of these medications changes.
- The mechanism behind these concerns relates to how these drugs affect kidney hemodynamics by blocking the renin-angiotensin-aldosterone system, which can reduce glomerular filtration pressure in already severely compromised kidneys.
Recommendations
- If these medications must be used in stage 5 CKD, they should only be prescribed under close nephrologist supervision with frequent monitoring of kidney function and electrolytes (especially potassium, which should be checked within 1 week of starting or adjusting doses) 1.
- Lower doses are typically required, such as lisinopril 2.5-5mg daily or losartan 25mg daily.
- The combined use of ACE inhibitors and ARBs should be avoided due to higher adverse event rates (hyperkalemia and/or AKI) 1.
Evidence Summary
- Recent studies have shown that ACEIs and ARBs do not provide significant benefits in patients with stage 5 CKD, and may even increase the risk of adverse events 1.
- The American Diabetes Association and Kidney Disease: Improving Global Outcomes (KDIGO) recommend avoiding the combined use of ACE inhibitors and ARBs in patients with CKD 1.
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 proteinuria 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, despite being recommended as first-line therapy by Japanese guidelines 2.
- Another study found that ACEIs or ARBs reduced kidney failure compared to placebo or non-RAAS inhibitors in advanced CKD patients 3.
Optimal Dose and Combination Therapy
- The optimal dose of ACEIs or ARBs for renoprotection is still a topic of debate, with some studies suggesting that higher doses may be beneficial in reducing proteinuria and improving renal outcomes 4.
- A retrospective database analysis found that adding ACEIs, ARBs, or calcium channel blockers to diuretics or beta-blockers was effective in treating hypertension, with ACEIs showing the greatest benefits 5.
Comparative Efficacy and Safety
- A systematic review found that ACEIs and ARBs were superior in reducing proteinuria and slowing CKD progression, particularly in proteinuric patients, while calcium channel blockers were effective in blood pressure control and improving cardiovascular parameters 6.
- However, the review noted that there were no head-to-head trials directly comparing RAAS inhibitors (ACEIs/ARBs) and calcium channel blockers, limiting definitive conclusions regarding their relative efficacy 6.