Discontinuation of RAAS inhibitors Might Worsen Kidney Function in Kids With CKD

Although RAASi is a cornerstone in the treatment of children with CKD, clinicians frequently decide to discontinue RAASi in the course of kidney disease progression. However, it is unknown whether discontinuation of RAASi will affect risk markers for CKD and possibly accelerate kidney function decline. Therefore, Dr Sophie M. van den Belt and her team conducted a study to evaluate the reasons for RAASi discontinuation and associations between RAASi discontinuation and important risk markers of CKD progression and on eGFR decline in the Cardiovascular Comorbidity in Children with CKD study.

In this study, the researchers included the data of 69 children with CKD who discontinued RAASi from the Cardiovascular Comorbidity in Children with CKD (4C) study. They assessed the initial change in BP, albuminuria, and potassium after discontinuation. They used the linear mixed-effects modelling to assess the rate of eGFR decline (eGFR slope) during a median of 1.9 years before and 1.2 years after discontinuation.

Key findings of the study were:

• The researchers noted that the physicians commonly discontinued RAASi in patients due to increased serum creatinine (33%), hyperkalemia (23%), and hypotension (17%). RAASi was immediately replaced by other antihypertensive medications in 20% of children.
• Upon analysis, they found that after discontinuation of RAASi, BP and albuminuria increased, whereas potassium decreased.
• They found that the eGFR declined faster after RAASi discontinuation than before: -3.9 vs -1.5 mL/min/1.73 m2 per year before discontinuation.
• However, they observed no change in eGFR slope in a matched control cohort of patients in whom RAASi was continued.

The authors concluded, " Discontinuation of RAASi in children with CKD is associated with an acceleration of kidney function decline. These results are consistent with the notion that RAASi is important for kidney protection in advanced pediatric CKD, and that clinicians should consider the possible adverse effect on long-term kidney function when discontinuing RAASi."

In an accompanying editorial comment Dr Marie-Michéle Gaudreault-Tremblay and Dr Bethany J. Foster wrote, "Discontinuation of RAASi remains a reasonable response to hyperkalemia in advanced CKD, but if no improvement in potassium follows, van den Belt et al. findings suggest that reinitiation of RAASi should be considered."

They further added, " the work of van den Belt et al. reminds us that children, and even younger adults, may respond differently."

For further information:

https://cjasn.asnjournals.org/content/15/5/625