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NDT Advance Access published online on October 10, 2009
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfp511
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© The Author 2009. Published by Oxford University Press [on behalf of ERA-EDTA]. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


The impact of stopping inhibitors of the renin–angiotensin system in patients with advanced chronic kidney disease

Aimun K. Ahmed, Neetha S. Kamath, Mohsen El Kossi and A. Meguid El Nahas

Sheffield Kidney Institute, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

Correspondence and offprint requests to: A. Meguid El Nahas; E-mail: m.el-nahas{at}sheffield.ac.uk



  Abstract

Background. Inhibition of the renin–angiotensin–aldosterone system (RAAS) has shown to slow chronic kidney disease (CKD) progression. This is most notable at the earlier stages of diabetic and proteinuric nephropathies.

Objective. Here, we observed the impact of discontinuation of angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptors blockers (ARB) in patients with advanced kidney disease.

Methods. 52 patients (21 females and 31 males) with advanced CKD (stages 4 and 5), who attended our low clearance clinic (LCC) in preparation for renal replacement therapy (RRT). Mean age was 73.3 ± 1.8 years with an estimated glomerular filtration rate (eGFR) of 16.38 ± 1 ml/min/1.73 m2. Baseline urine protein:creatinine ratio (PCR) was 77 ± 20 mg/mmol. 46% suffered from diabetes mellitus. Patients were followed for at least 12 months before and after ACEi/ARB were stopped.

Results. 12 months after discontinuation of ACEi/ARB eGFR increased significantly to 26.6 ± 2.2 ml/min/ 1.73 m2 (p = 0.0001). 61.5% of patients had more than a 25% increase in eGFR, whilst 36.5% had an increase exceeding 50%. There was a significant decline in the eGFR slope –0.39 ± 0.07 in the 12 months preceding discontinuation. The negative slope was reversed +0.48 ± 0.1 (p = 0.0001). Mean arterial blood pressure (MAP) increased from 90 ± 1.8 mmHg to 94 ± 1.3 mmHg (p = 0.02), however ≥50% of patients remained within target. Overall proteinuria was not affected (PCR before = 77 ± 20 and after = 121.6 ± 33.6 mg/mmol).

Conclusion. Discontinuation of ACEi/ARB has undoubtedly delayed the onset of RRT in the majority of those studied. This observation may justify a rethink of our approach to the inhibition of the RAAS in patients with advanced CKD who are nearing the start of RRT.

Keywords: advanced CKD; angiotensin II receptor blockade; angiotensin-converting enzyme inhibition; low clearance clinic

Received for publication: 23. 6.09
Accepted in revised form: 1. 9.09


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