RAAS Inhibitor Use and Hyperkalemia in Chinese Patients with Comorbid CKD and Heart Failure

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Background: Renin-angiotensin-aldosterone system inhibitors (RAASi) are a cornerstone in the management of both chronic kidney disease (CKD) and heart failure (HF), yet their use may be disrupted by hyperkalemia (HK). To optimize RAASi use, recent guidelines recommend using potassium binders to manage HK rather than reducing RAASi. However, data on RAASi prescription and HK burden in Chinese patients with comorbid CKD and HF are limited. This study was conducted to address this evidence gap. Methods: This observational cohort study used real-world data from 28 tertiary hospitals in the China Renal Disease Data System between Jan 1, 2018 and Jan 1, 2023. Patients with prevalent stage 3–5 CKD by eGFR as of January 1, 2022 (index date) and ≥12 months of lookback data were identified. HF comorbidity was defined using ICD-10CN2016 diagnosis codes pre-index. This analysis assessed hospital-issued RAASi prescriptions at index, and HK occurrence and recurrence during 12-month follow-up in patients with comorbid CKD and HF. Results: Among 25,604 patients with stage 3–5 CKD at index, 5,231 (20.4%) had comorbid HF. These patients were older than the overall CKD cohort (mean age: 73.0 vs. 65.6 years old) and a similar proportion of patients were male (56.8% vs. 57.1%). Among those with ≥1 hospital-issued prescription recorded with 90 days prior to or at index, 54.0% (1,049/1942) had hospital-issued RAASi prescription. This proportion was higher than that in the overall CKD cohort (35.6%, 2,605/7,310). The most prescribed RAASi class was ARB (39.9%), followed by MRA (26.9%), ARNi (21.4%) and ACEi (4.4%). Among patients with 12-month post-index follow-up, 19.7% (237/1,205) had ≥1 HK event, higher than the overall CKD cohort (17.4%, 1,239/7,139). This proportion was higher in those with RAASi prescription at index than those without (24.6% vs. 20.4%). Among patients with an index HK, 111 (46.8%) also had ≥1 recurrent HK during follow-up; this proportion was rather similar to that in the overall CKD cohort (47.3%). Conclusion: In Chinese patients with comorbid CKD and HF, we saw approximately half receiving hospital-issued RAASi and a substantial risk of HK. Patients with comorbid HF had both higher rates of RAASi prescription and HK occurrence than the overall CKD cohort. These findings underscore the need to support guideline-directed therapy to improve outcomes in this high-risk population. Funding: Commercial Support - AstraZeneca

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