RAS Inhibitor Use in End-Stage CKD

Recommendations for RAS Inhibitors

RAS inhibitors (ACEi or ARB) should be continued in patients with CKD even when eGFR falls below 30 ml/min/1.73 m², as they provide cardiovascular and renal protection 1, 2
Consider reducing the dose or discontinuing ACEi or ARB in end-stage CKD (eGFR <15 ml/min/1.73 m²) only if experiencing symptomatic hypotension 3
Consider reducing the dose or discontinuing ACEi or ARB in end-stage CKD (eGFR <15 ml/min/1.73 m²) only if experiencing uncontrolled hyperkalemia despite medical treatment 3
Consider reducing the dose or discontinuing ACEi or ARB in end-stage CKD (eGFR <15 ml/min/1.73 m²) only if needing to reduce uremic symptoms 2, 3

Monitor serum potassium closely when using RAS inhibitors in end-stage CKD 3
Hyperkalemia associated with RAS inhibitors can often be managed by measures to reduce serum potassium levels rather than decreasing the dose or stopping therapy 2
Consider potassium binders if hyperkalemia develops 3
Check changes in blood pressure, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase 2
Continue ACEi or ARB unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 2

Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy as this increases risk of hyperkalemia and acute kidney injury without additional benefits 2

RAS inhibitors should be administered using the highest approved dose that is tolerated to achieve maximum benefits 2, 4
Dose adjustments may be needed based on individual patient response and laboratory parameters 3

In patients with heart failure and end-stage CKD, ACEi/ARB therapy provides additional cardiovascular benefits 3
For patients with type 2 diabetes and CKD, consider adding an SGLT2 inhibitor if eGFR ≥20 ml/min/1.73 m² 3