Kidney Week

Abstract: TH-OR044

Should RAAS Inhibition Be Discontinued in Children with Advanced CKD? Results of the 4C Study

Session Information

• Featured Research in Pediatric Nephrology
  October 25, 2018 | Location: 26A, San Diego Convention Center
  Abstract Time: 05:06 PM - 05:18 PM

Category: Pediatric Nephrology

• 1600 Pediatric Nephrology

Authors

• Gracchi, Valentina, University Medical Center Groningen, Groningen, GRONINGEN, Netherlands

Valentina Gracchi, MD



After obtaining a medical degree at the University of Milan (Italy), Valentina Gracchi trained to become a pediatrician at the University Medical Center in Utrecht (NL) and did a fellowship in pediatric nephrology at the Amsterdam Medical Center (NL). She currently works as a pediatric nephrologist at the University Medical Center Groningen (NL) and is doing a PhD on (micro)albuminuria in children.

• Van den Belt, Sophie, University Medical Center Groningen, Groningen, GRONINGEN, Netherlands

Sophie Van den Belt,

• Lambers Heerspink, Hiddo Jan, University Medical Center Groningen, Groningen, GRONINGEN, Netherlands

Hiddo Jan Lambers Heerspink,

• Wuehl, Elke, University of Heidelberg, Heidelberg, Germany

Elke Wuehl,

• de Zeeuw, Dick, University Medical Center Groningen, Groningen, GRONINGEN, Netherlands

Dick de Zeeuw,

• Schaefer, Franz S., University of Heidelberg, Heidelberg, Germany

Franz S. Schaefer,

Group or Team Name

• 4C Study group

Background

RAAS inhibition (RAASi) is used for renoprotection in children with Chronic Kidney Disease (CKD). RAASi is sometimes discontinued in advanced stages of CKD. We studied the reasons and impact of RAASi discontinuation on important markers of CKD progression and on eGFR decline in the Cardiovascular Comorbidity in Children with CKD (4C) study.

Methods

69 children with CKD (67% male, mean age 13.7 years, mean eGFR 27 ml/min/1.73m2) who discontinued RAASi during prospective follow-up were studied. Initial 6-month changes in blood pressure, albuminuria and potassium after discontinuation were assessed. The rate of eGFR decline (eGFR slope) during a median of 1.9 years before and 1.2 years after discontinuation were estimated using a linear mixed effects model.

Results

Reported reasons for RAASi discontinuation were increase in serum creatinine (33%), hyperkalemia (23%), and symptomatic hypotension (17%). After discontinuation of RAASi, blood pressure and albuminuria increased whereas potassium decreased. eGFR loss accelerated after RAASi discontinuation from -1.5 (95%CI -2.4 to -0.6) during RAASi treatment to -3.9 (95%CI -5.1 to -2.6) ml/min/1.73m² per year (p=0.005). In a matched control group of children who continued RAASi, renal function decline was stable before and after timepoint of matching (eGFR slope -1.8 (95%CI -2.6 to -1.1) versus -1.2 (95%CI -2.0 to -0.4) ml/min/1.73m2/year; p=0.30; Figure).

Conclusion

Discontinuation of RAASi in children with CKD is associated with an acceleration of renal function decline. These results indicate that RAASi is nephroprotective even in advanced CKD and that stopping this therapy, even for good clinical reasons, should be weighed against a potential negative impact on long term renal function.

eGFR over time in patients who discontinued RAASi (blue) and matched controles (red). Grey area: 95%CI per group.