BALANCING CARDIOVASCULAR RISK: RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITION IN HEMODIALYSIS PATIENTS AMID POTASSIUM CHALLENGES AND HYPOTENSION RISK

Introduction:

Chronic kidney disease (CKD) is a significant public health issue, impacting around 850 million individuals globally(1). The prevalence of renal replacement therapy (RRT) varies widely, from 4.4 cases per million people (pmp) in Rwanda to 3,679 cases pmp in Taiwan(2). In Spain, 39.8% of patients with CKD undergoing RRT are on hemodialysis (HD)(3). Among CKD patients, cardiovascular disease (CVD) remains the leading cause of hospitalization and mortality(3,4). The hyperactivation of the renin-angiotensin-aldosterone system (RAAS)(5) is closely associated with CVD, providing a rationale for the use of RAAS inhibitors (RAASi) in association with sodium-glucose transport protein 2 inhibitors (SGLT2i) to reduce the risk of CVD and mortality(6-10). Limitations for the use of RAASi in dialysis population include hyperkalemia and hypotension. This study aims to evaluate the use of RAASi and its association with intradialytic hypotension (IDH) and hyperkalemia in adult CKD patients undergoing HD.

Methods:

This cross-sectional, multicenter study assessed the frequency of IDH—defined as Nadir90 (intradialytic systolic blood pressure <90 mmHg)(11)—and hyperkalemia in adult CKD on maintenance HD. The use of RAASi was compared to other antihypertensive agents across four hemodialysis centers in Castille-La Mancha, Spain (Alcázar de San Juan, Cuenca, Puertollano, and Talavera de la Reina), from December 2023 to February 2024. Statistical analysis was performed using the x2 test with Bonferroni correction and odds ratio.

Results:

Only 25.4% (N=283, Table 1) of patients received RAASi therapy (Figure 1). In contrast, patients with diabetic kidney disease (65%) and CVD (56.7%) (defined by myocardial infarction, heart failure, cerebrovascular disease, and/or peripheral arterial disease) (Figure 2AB) were treated with non-RAASi agents. The frequency of IDH (Figure 3), hyperkalemia (Figure 4), and the use of potassium binders (Figure 5) was higher in patients treated with non-RAASi agents. No significant association was found between the risk of IDH or hyperkalemia and the use of RAASi compared to other hypotensive agents.

Conclusions:

Despite a well-established benefit of RAASi in reducing cardiovascular events, hospitalizations, and mortality, our findings indicate an underutilization of these agents in CKD patients undergoing HD, even though a lower frequency of IDH and hyperkalemia was observed in those treated with RAASi. Further studies are needed to evaluate the safety, reduction of cardiovascular risk, and mortality in hemodialysis patients treated with RAASi.

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I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.