KDIGO Recommendations for RAAS Inhibitor Use Across CKD Stages

Indications for Continuation (CKD Stages G1–G4)

The KDIGO 2021 guideline recommends initiating and maintaining ACE inhibitors or ARBs in patients with hypertension and CKD stages G1–G4 who have moderately‑to‑severely increased albuminuria (A2–A3), with a strong 1B evidence grade for diabetic patients. 1
Continuation is advised even when eGFR falls below 30 mL/min/1.73 m² (stage G4), provided hyperkalemia is managed with potassium‑lowering strategies rather than stopping the drug. 1

Dose reduction or discontinuation should be considered only when eGFR drops below 15 mL/min/1.73 m² and the patient develops uremic symptoms that require active management. 1
Symptomatic hypotension that persists despite appropriate therapy warrants reduction or cessation of the RAAS inhibitor. 1
Uncontrolled hyperkalemia despite dietary restriction, loop diuretics, or potassium binders is an indication to lower the dose or stop the medication. 1
A rise in serum creatinine >30 % within 4 weeks of initiation or dose escalation mandates discontinuation, whereas rises ≤30 % are expected and linked to long‑term renal protection. 1

Serum creatinine, serum potassium, and blood pressure should be re‑checked 2–4 weeks after starting a RAAS inhibitor or after any dose increase, with subsequent testing frequency adjusted according to the current eGFR and potassium level. 1

Use the highest approved dose that the patient tolerates to achieve the renoprotective benefits demonstrated in trials (e.g., lisinopril 40 mg daily, losartan 100 mg daily, ramipril 10 mg daily, enalapril up to 40 mg daily). 1

Combining an ACE inhibitor with an ARB or a direct renin inhibitor is prohibited, as dual RAAS blockade increases adverse events without added benefit. 1

The KDIGO 2021 recommendations for RAAS inhibitor use in CKD stages G1–G4 carry a 1B evidence grade (strong recommendation, moderate‑quality evidence) for patients with diabetes and moderately‑to‑severely increased albuminuria. 1