Rethinking RAS inhibitor risk in the treatment of diabetes
Diabetes is a leading cause of heart disease, stroke, and kidney failure in Hong Kong and worldwide. RAS inhibitors are effective in reducing the risks of proteinuria, inflammation, and multiple organ damage in patients with diabetes. One of the side effects of these inhibitors is an increased risk of hyperkalemia which has led to a debate weighing the risk versus benefits of continued use of RAS inhibitors for those with advanced chronic kidney disease.
Researchers from the Chinese University of Hong Kong’s Faculty of Medicine found that patients with type 2 diabetes treated with RAS inhibitors, in the discontinuation of the treatment, would likely increase their chances of cardiorenal complications. These findings have been published in the leading peer-reviewed journal eClinicalMedicine under the international journal The Lancet.
The medical school has tracked the trends of kidney outcomes in people with diabetes over the past three decades. The research team examined outcomes in 10,400 patients with type 2 diabetes and advanced chronic kidney disease treated with RAS inhibitors between 2002 and 2018 from the Hong Kong Diabetes Surveillance Database. Results showed that compared with continuation of the treatment, discontinuation was associated with 30% increased risk of end-stage kidney disease, 27% increased risk of major adverse cardiovascular events, 85% increased risk of heart failure but no difference in all-cause mortality.
The kidney is the key organ that regulates levels of essential substances, such as potassium, in the blood stream for optimal bodily functioning. People with advanced kidney disease cannot excrete potassium effectively, which leads to high potassium levels. RAS inhibitors showed no obvious link to risk of hyperkalemia in patients with diabetes and advanced chronic kidney disease. Nevertheless, 15% to 30% of patients with advanced chronic kidney disease had discontinued RAS indicators due to concerns of hyperkalemia or acute decline in kidney function.
“Treatment with RASi was often discontinued for various reasons in patients with chronic kidney disease, and not restarted,“Dr Elaine Chow, the lead senior author of the paper explained. “In fact, by avoiding drugs that can compromise kidney function, moderating dietary potassium intake and measuring kidney function regularly, many patients with chronic kidney disease can safely continue and benefit from the treatment.”