Prescription of renin-angiotensin-aldosterone system inhibitors (RAASi) and its determinants in patients with advanced CKD under nephrologist care

Roberto Pecoits-Filho, Danilo Fliser, Charlotte Tu, Jarcy Zee, Brian Bieber, Michelle M Y Wong, Friedrich Port, Christian Combe, Antonio A Lopes, Helmut Reichel, Ichiei Narita, Benedicte Stengel, Bruce M Robinson, Ziad Massy, CKDopps Investigators, Christian Duttlinger, Johannes Duttlinger, Gerhard Lonnemann, Takashi Wada, Kunihiro Yamagata, Ron Pisoni, Viviane Calice da Silva, Ricardo Sesso, Elodie Speyer, Koichi Asahi, Junichi Hoshino, Rachel Perlman, Nidhi Sukul, Eric Young, Roberto Pecoits-Filho, Danilo Fliser, Charlotte Tu, Jarcy Zee, Brian Bieber, Michelle M Y Wong, Friedrich Port, Christian Combe, Antonio A Lopes, Helmut Reichel, Ichiei Narita, Benedicte Stengel, Bruce M Robinson, Ziad Massy, CKDopps Investigators, Christian Duttlinger, Johannes Duttlinger, Gerhard Lonnemann, Takashi Wada, Kunihiro Yamagata, Ron Pisoni, Viviane Calice da Silva, Ricardo Sesso, Elodie Speyer, Koichi Asahi, Junichi Hoshino, Rachel Perlman, Nidhi Sukul, Eric Young

Abstract

Renin-angiotensin-aldosterone system inhibitors (RAASi) are recommended for chronic kidney disease (CKD) patients. In this study, we describe RAASi prescription patterns in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, Germany, France, and the United States (US). 5870 patients (mean age 66-72 years; congestive heart failure [CHF] in 11%-19%; diabetes in 43%-54%; serum potassium ≥5 in 20%-35%) were included. RAASi prescription was more common in Germany (80%) and France (77%) than Brazil (66%) and the United States (52%), where the prevalence of prescription decreases particularly in patients with CKD stage 5. In the multivariable regression model, RAASi prescription was least common in the United States and more common in patients who were younger, had diabetes, hypertension, or less advanced CKD. In conclusion, RAASi prescription patterns vary by country, and by demographic and clinical characteristics. RAASi appear to be underused, even among patients with strong class-specific recommendations. Although the reasons for this variation could not be fully identified in this cross-sectional observation, our data indicate that the risk of hyperkalemia may contribute to the underuse of this class of agents in moderate to advanced CKD.

Keywords: albuminuria; chronic kidney disease; diabetes; heart failure; renin-angiotensin-aldosterone system inhibitors.

Conflict of interest statement

Roberto Pecoits‐Filho serves on advisory boards and/or speaks at scientific meetings for Janssen, AstraZeneca, Novartis, Akebia, Baxter Healthcare, and Fresenius Medical Care. He received research grants from Baxter Healthcare, and Fresenius Medical Care. All relationships are modest. Danilo Fliser reports honoraria: Astra‐Zeneca, Bayer Vital, Boehringer Ingelheim and Roche; expert witness and honoraria: Amgen and Vifor FMC. All relationships are modest. Christian Combe received grants for the French CKD‐REIN study from Amgen, Baxter, Fresenius Medical Care, GlaxoSmithKline (GSK), Lilly France, Merck Sharp & Dohme‐Chibret (MSD France), Otsuka Pharmaceutical, and Sanofi‐Genzyme, as well as lecture fees from Fresenius and Amgen. All relationships are modest. Benedicte Stengel received grants for the French CKD‐REIN study from Amgen, Baxter, Fresenius Medical Care, GlaxoSmithKline (GSK), Lilly France, Merck Sharp & Dohme‐Chibret (MSD France), Otsuka Pharmaceutical, and Sanofi‐Genzyme, as well as lecture fees from Lilly and MSD. All relationships are modest. Ziad Massy reports grants for the French CKD‐ REIN study and other research projects from Amgen, Baxter, Fresenius Medical Care, GlaxoSmithKline, Merck Sharp and Dohme‐Chibret, Sanofi‐Genzyme, Lilly, Otsuka, as well as fees and grants to charities from Amgen, Bayer, and Sanofi‐Genzyme. These sources of funding are not necessarily related to the content of the present manuscript. All relationships are significant. All other authors declare “none.”

©2019 The Authors. The Journal of Clinical Hypertension Published by Wiley Periodicals, Inc.

Figures

Figure 1
Figure 1
Study flowchart
Figure 2
Figure 2
Potassium levels by CKD stage and country. *Includes ACEi (angiotensin‐converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), direct renin inhibitors, and aldosterone receptor antagonists
Figure 3
Figure 3
Prevalence of RAASi* prescription by CKD stage and country. *Includes ACEi (angiotensin‐converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), direct renin inhibitors, and aldosterone receptor antagonists
Figure 4
Figure 4
Prevalence of RAASi* prescription, by indication for use and country. A, by level of albuminuria/proteinuria†. *Includes ACEi (angiotensin‐converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), direct renin inhibitors, and aldosterone receptor antagonists. †KDIGO 2012 guidelines: normal or mildly increased (A1, 300 mg/g). ‡% Missing of albuminuria data ranges from 11% in France to 44% in Germany. B, by diabetes status and by albuminuria status. *Includes ACEi (angiotensin‐converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), direct renin inhibitors, and aldosterone receptor antagonists. C, by congestive heart failure status and by albuminuria status. *Includes ACEi (angiotensin‐converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), direct renin inhibitors, and aldosterone receptor antagonists

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