Abstract
Hyperkalemia is common in patients treated with renin–angiotensin–aldosterone system inhibitors (RAASis), and it represents the main cause of the large gap reported between guideline recommendations and real-world practice in chronic kidney disease (CKD). We conducted a CKD-population-based restrospective study to determine the prevalence of patients with CKD treated with RAASis, incidence of hyperkalemia in patients with CKD treated with RAASis, and proportion of patients with RAASi medication change after experiencing incident hyperkalemia. Among 809 patients with CKD analyzed, 556 (68.7%) were treated with RAASis, and RAASi prescription was greater in stages 2–4 of CKD. Hyperkalemia occurred in 9.2% of RAASi-treated patients, and the adjusted rate of hyperkalemia among patients with stage 4–5 CKD was 3-fold higher compared with patients with eGFR > 60 ml/min/1.73 m2. RAASi treatment was discontinued in 55.3% of the patients after hyperkalemia event (74.2% discontinued therapy, 3.2% received a reduced dose, and 22.6% reduced the number of RAASi drugs). This study shows that the incidence of hyperkalemia is frequently observed in patients with CKD patients with RAASis, and that rates increase with deteriorating levels of kidney function from stages 1 to 3. RAASi medication change following an episode of hyperkalemia occurred in almost half of the patients after experiencing hyperkalemia.
Highlights
Chronic kidney disease (CKD), defined as decrease in kidney function manifested as presence of structural or functional kidney abnormalities or estimated glomerular filtration rate < 60 ml/min/1.73 m2, has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease
The prevalence of patients with CKD patients with renin-angiotensin aldosterone system (RAAS) inhibitors (RAASis) was 68.7%; RAASis were distributed among stages 2, 3, and 4 (Table 1)
angiotensin-converting enzyme inhibitors (ACEis) prescription was less frequent in stages 3, 4, and 5 than in stage 1, whereas angiotensin II receptor blockers (ARBs) were more frequent in stages 3, 4, and 5 than in stage 1; combination therapy was distributed among all the CKD stages (Table 1)
Summary
Chronic kidney disease (CKD), defined as decrease in kidney function manifested as presence of structural or functional kidney abnormalities or estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2, has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease (which is the leading cause of death in CKD). Blood pressure lowering therapy has shown to prevent the onset of poor cardiovascular outcomes and delay the progression of kidney disease [1, 2]. Several randomized clinical trials have clearly shown that inhibition of the renin-angiotensin aldosterone system (RAAS) can reduce the risk of death and slow disease progression in patients with heart failure (HF), CKD, and diabetes [3–7]. Evidence-based treatment guidelines recommend the use of RAAS inhibitors (RAASis) as first-line blood pressure lowering therapy for patients with CKD and proteinuria, and diabetes and hypertension [8–10]. The guidelines recommend the use of maximum tolerated dose of RAASis, since results of clinical trials demonstrated that best treatment benefits were obtained with moderate to high doses [8–10]. The use of these drugs may be limited, since they can cause hyperkalemia [11] (typically defined as serum potassium levels > 5.5 mmol/L), which can be further exacerbated when these drugs are used in combination [12]
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