Underprescription of renin-angiotensin system blockers in moderate to severe chronic kidney disease

Am J Med Sci. 2015 Jun;349(6):510-5. doi: 10.1097/MAJ.0000000000000475.


Background: Renin-angiotensin system (RAS) blockers slow the progression of chronic kidney disease (CKD). Despite this, up to 40% of patients with CKD and an indication for RAS blockade do not receive these medications. The purpose of this study was to examine variables associated with the prescription of RAS blockers in patients with CKD and to identify opportunities to increase their use.

Methods: The electronic medical records of patients with moderate to severe CKD and an indication for RAS blockade were reviewed. For patients with an indication for RAS blockade who were not prescribed these medications, previous notes were reviewed to ascertain reasons why RAS blockade was not prescribed.

Results: Six hundred twenty-seven patients with moderate to severe CKD and an indication for RAS blockade were identified. Of these patients, 225 (36%) were not prescribed RAS blockade. This group was found to have significantly less diabetes, to be significantly older and to have significantly lower estimated glomerular filtration rate and blood pressure than the group on RAS blockade. For the majority (59%), no documented reason for not being prescribed RAS blockade was found. Among documented reasons, hyperkalemia and a history of acute kidney injury were the most common.

Conclusions: The authors found that a large proportion of patients with CKD and an indication for RAS blockade were not prescribed these medications. For the majority, there was no provider-documented reason explaining why these medications were not prescribed, and the findings suggest that there may be opportunities to increase RAS blocker prescribing.

MeSH terms

  • Acute Kidney Injury* / blood
  • Acute Kidney Injury* / chemically induced
  • Aged
  • Aged, 80 and over
  • Angiotensin Receptor Antagonists / administration & dosage
  • Angiotensin Receptor Antagonists / adverse effects*
  • Angiotensin-Converting Enzyme Inhibitors / administration & dosage
  • Angiotensin-Converting Enzyme Inhibitors / adverse effects*
  • Blood Pressure / drug effects
  • Cross-Sectional Studies
  • Electronic Health Records*
  • Female
  • Glomerular Filtration Rate / drug effects
  • Humans
  • Hyperkalemia* / blood
  • Hyperkalemia* / chemically induced
  • Male
  • Middle Aged
  • Renal Insufficiency, Chronic* / blood
  • Renal Insufficiency, Chronic* / drug therapy
  • Renin-Angiotensin System / drug effects*
  • Retrospective Studies
  • Severity of Illness Index


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors