#1792 Renin-angiotensin-aldosterone system inhibitor utilization and hyperkalemia in patients with chronic kidney disease – results from ZORA China

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Abstract Background and Aims Renin-angiotensin-aldosterone system inhibitors (RAASi) are a cornerstone of chronic kidney disease (CKD) management, but they can also increase the risk of hyperkalemia (HK). RAASi reduction or discontinuation is common following the occurrence of HK. However, suboptimal use of RAASi is detrimental to renal and cardiovascular outcomes, and recent guidelines recommend using novel potassium binders (PB) to manage HK rather than reducing RAASi. To address the evidence gap in RAASi utilization and HK management in Chinese patients, this study assessed RAASi treatment patterns and the occurrence and management of HK among patients with stage 3–5 CKD in real-world clinical settings. Method This observational cohort study utilized real-world medical data between Jan 1, 2018 and Jan 1, 2023 from 24 tertiary hospitals in the China Renal Data System. This analysis included two cohorts: the CKD cohort included adult patients with prevalent stage 3–5 CKD (based on estimated glomerular filtration rate) as of Jan 1, 2022 (the index date for this cohort). The HK cohort included adult patients with prevalent stage 3–5 CKD who experienced HK (indexed at the date of the first HK event). All patients were required to have ≥12 months of available data prior to their respective index dates and were followed for up to 12 months. The primary outcomes were (1) the proportion of patients in the CKD cohort with hospital-issued RAASi prescription(s) within 90 days prior to or at index (baseline), among patients with any recorded prescriptions during the baseline period; (2) the 12-month prevalence of HK (>5.0 mmol/L) during the post-index follow-up in the CKD cohort; and (3) the 12-month cumulative risk of HK recurrence (by Kaplan-Meier analysis) among HK cohort patients with baseline hospital-issued RAASi prescription(s). The secondary endpoint was the proportion of HK events followed by a PB prescription within 10 days, in the HK cohort. Results A total of 25,604 eligible patients were included in the CKD cohort. Their mean age was 65.6 years (SD: 16.1) and 57.1% were male. Among the 7,310 patients with any hospital-issued prescription at baseline, 2,605 (35.6%) had ≥1 hospital-issued RAASi prescription. This proportion decreased with increasing CKD severity (stage 3: 39.8%, stage 4: 33.6%, stage 5: 15.9%) (Fig. 1). The most common RAASi class was angiotensin receptor blockers (N = 2,035, 27.8%), followed by mineralocorticoid receptor antagonists (N = 753, 10.3%). During the 12-month post-index follow-up, 16.6% (N = 4,260) of the CKD cohort experienced ≥1 HK event; the majority of (83.7%) their first HK events were mild (>5.0–≤5.9 mmol/L), 8.8% were moderate (6.0–≤6.4 mmol/L), and 5.4% were severe (≥6.5 mmol/L). The 12-month prevalence of HK, stratified by CKD stage, was somewhat higher in patients with hospital-issued RAASi prescription(s) at baseline than those without hospital-issued RAASi (stage 3: 12.7% vs. 11.0%, stage 4: 32.6% vs. 27.3%, stage 5: 36.3% vs. 28.2%) (Fig. 2). The HK cohort included 27,481 patients. Their mean age was 67.1 years (SD: 16.2), and 57.1% were male. The index HK event was mild for most patients (84.0%), moderate for 8.7% and severe for 6.8%. Among HK cohort patients with hospital-issued RAASi prescription(s) at baseline, the 12-month cumulative risk of recurrent HK was 48.3% (95% CI 46.8–49.7). This increased with CKD stage (stage 3: 41.5% [39.7–43.3], stage 4: 55.5% [52.5–58.2], stage 5: 62.4% [58.6–65.9]). Of the 82,691 HK events recorded in the HK cohort (including index events and those during the follow-up), 3,272 (4.0%) were followed by a hospital-issued PB prescription within 10 days. Conclusion ZORA China investigated the use of RAASi and the occurrence and management of HK among Chinese patients with stage 3–5 CKD in real-world clinical practice. Our results demonstrate that RAASi treatment is often suboptimal, and HK is frequent and with a substantial risk of recurrence, which increases with CKD stage. These findings, together with the low PB prescription rate after HK, signal a need for improved management of CKD and HK in line with current guideline recommendations.

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