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When should we start and stop ACEi/ARB in paediatric chronic kidney disease?

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Abstract

Renin-angiotensin-aldosterone inhibitors (RAASi) are the mainstay therapy in both adult and paediatric chronic kidney disease (CKD). RAASi slow down the progression of kidney failure by optimization of blood pressure and reduction of proteinuria. Despite recommendations from published guidelines in adults, the evidence related to the use of RAASi is surprisingly scarce in children. Moreover, their role in advanced CKD remains controversial. Without much guidance from the literature, paediatric nephrologists may discontinue RAASi in patients with advanced CKD due to apparent worsening of kidney function, hyperkalaemia and hypotension. Current data suggest that this strategy may in fact lead to a more rapid decline in kidney function. The optimal approach in this clinical scenario is still not well defined and there are varying practices worldwide. We will in this review describe the existing evidence on the use of RAASi in CKD with particular focus on paediatric data. We will also address the use of RAASi in advanced CKD and discuss the potential benefits and harms. At the end, we will suggest a practical approach for the use of RAASi in children with CKD based on current state of knowledge.

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Acknowledgements

The authors would like to thank Ms. Fiona Lai and Ms. Serena Wong for preparing the summary table on licensed use of RAASi in the paediatric population.

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Authors and Affiliations

  1. Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK

    Eugene Yu-hin Chan, Alison Lap-tak Ma & Kjell Tullus

  2. Paediatric Nephrology Centre, Hong Kong Children’s Hospital, Ngau Tau Kok, Hong Kong

    Eugene Yu-hin Chan & Alison Lap-tak Ma

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  1. Eugene Yu-hin Chan
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Correspondence to Eugene Yu-hin Chan.

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1. C; 2. B; 3. A; 4.D

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Chan, E.Yh., Ma, A.Lt. & Tullus, K. When should we start and stop ACEi/ARB in paediatric chronic kidney disease?. Pediatr Nephrol 36, 1751–1764 (2021). https://doi.org/10.1007/s00467-020-04788-w

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