When to stop-acei in ckd
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When to Stop ACE Inhibitors in Chronic Kidney Disease
Introduction to ACE Inhibitors in CKD
Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are commonly prescribed for managing chronic kidney disease (CKD) due to their benefits in reducing blood pressure and proteinuria, which are critical in slowing CKD progression . However, their use in advanced stages of CKD (Stage 4 or 5) remains controversial due to potential adverse effects and the unclear balance between benefits and risks .
Evidence from the STOP-ACEi Trial
The STOP-ACEi trial is a significant study designed to evaluate the impact of discontinuing ACEi/ARBs in patients with advanced CKD. This multicenter, randomized controlled trial included 410 participants with Stage 4 or 5 CKD. The primary outcome was the estimated glomerular filtration rate (eGFR) over three years. Preliminary findings suggest that stopping ACEi/ARBs may stabilize or even improve renal function in these patients, potentially delaying the need for renal replacement therapy (RRT).
Pediatric Considerations
A case series involving children with advanced CKD who had their ACEi therapy discontinued showed promising results. Six to twelve months post-discontinuation, 71% of the children experienced an increase in eGFR, indicating potential benefits of stopping ACEi in pediatric patients with rapidly declining kidney function.
Impact on Renal Function and Cardiovascular Outcomes
Several studies have explored the effects of stopping ACEi/ARBs on renal function and cardiovascular outcomes. One study observed that 12 months after discontinuation, patients with advanced CKD had a significant increase in eGFR and a reversal of the negative eGFR slope, suggesting improved renal function. However, there was a slight increase in mean arterial blood pressure, though most patients remained within target ranges.
Conversely, other studies highlight the risks associated with stopping ACEi/ARBs, particularly concerning cardiovascular health. Discontinuation has been linked to worse clinical outcomes, including higher risks of death and cardiovascular events, especially after episodes of hyperkalemia or acute kidney injury (AKI) . This underscores the importance of careful patient selection and monitoring when considering discontinuation.
Clinical Guidelines and Recommendations
The 2021 KDIGO guidelines recommend the use of RAS inhibitors as first-line antihypertensive agents in patients with CKD and severely increased albuminuria. However, they also suggest down-titration or discontinuation in advanced CKD to manage uremic symptoms and prepare for RRT. This nuanced approach reflects the need to balance the benefits of ACEi/ARBs in reducing kidney failure risk against the potential for adverse events in advanced CKD.
Conclusion
The decision to stop ACEi/ARBs in patients with advanced CKD should be individualized, considering the potential benefits in renal function stabilization against the risks of adverse cardiovascular outcomes. Ongoing research, including the results from the STOP-ACEi trial, will provide further clarity on this complex clinical decision. For now, clinicians should carefully monitor patients and consider both renal and cardiovascular health when making treatment decisions.
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