Discontinuation of RAS Inhibitors in Advanced CKD — Has Equipoise Occurred?

This editorial evaluates the STOP-ACEi randomized controlled trial, which assessed the clinical impact of continuing versus discontinuing renin-angiotensin system (RAS) inhibitors in patients with advanced chronic kidney disease (CKD). While earlier observational studies suggested potential benefits from stopping RAS inhibitors—such as modest eGFR improvement or reduced hyperkalemia risk—the STOP-ACEi trial found no significant difference in eGFR after 3 years between continuation and discontinuation groups. Rates of renal replacement therapy and adverse events were also similar, though cardiovascular events were slightly more frequent in the discontinuation group. The trial’s limitations include its open-label design, restricted generalizability, low representation of patients with diabetic nephropathy, limited racial diversity, and underuse of newer kidney-protective agents like SGLT2 inhibitors and GLP-1 agonists. The editorial concludes that while STOP-ACEi fills a crucial evidence gap, clinical decisions about RAS inhibitor use in advanced CKD should be individualized, incorporating newer therapies, potassium management advances, and patient-specific risk–benefit considerations

This editorial evaluates the STOP-ACEi randomized controlled trial, which assessed the clinical impact of continuing versus discontinuing renin-angiotensin system (RAS) inhibitors in patients with advanced chronic kidney disease (CKD). While earlier observational studies suggested potential benefits from stopping RAS inhibitors—such as modest eGFR improvement or reduced hyperkalemia risk—the STOP-ACEi trial found no significant difference in eGFR after 3 years between continuation and discontinuation groups. Rates of renal replacement therapy and adverse events were also similar, though cardiovascular events were slightly more frequent in the discontinuation group. The trial’s limitations include its open-label design, restricted generalizability, low representation of patients with diabetic nephropathy, limited racial diversity, and underuse of newer kidney-protective agents like SGLT2 inhibitors and GLP-1 agonists. The editorial concludes that while STOP-ACEi fills a crucial evidence gap, clinical decisions about RAS inhibitor use in advanced CKD should be individualized, incorporating newer therapies, potassium management advances, and patient-specific risk–benefit considerations