Optimization of RAASi Therapy Toolkit


Kidney diseases are intricately linked to increased morbidity with, and mortality from, other diseases and infections. An integrated approach to noncommunicable disease (NCD) prevention and management that recognizes the burden of kidney disease and concomitant co-morbidities is critical to ensure no disease is left behind.

In 2021, the International Society of Nephrology (ISN) convened a group of nephrologists and cardiologists from the American Society for Preventative Cardiology (ASPC), the Heart Failure Association of the European Society of Cardiology (HFA), Kidney Disease Improving Global Outcomes (KDIGO), the Renal Physicians Association (RPA), and the ISN, to co-create toolkits for advancing the prevention and management of cardio-kidney complications. The first topic selected by the group for such tools is the optimization of RAASi therapy.

The toolkit on the optimization of RAASi therapy and management of related complications consists of focused and practical infographics, serving as hands-on references for nephrologists, cardiologists and other healthcare professionals involved in the multidisciplinary care of patients with cardio-kidney complications.

Scroll down for educational and clinical infographics on:

  • Nuts & bolts of RAASi therapy
  • Management of hyperkalemia
  • Dietary approaches to hyperkalemia
  • Monitoring and managing acute changes in kidney function related to RAASi
  • Talking to your patients about RAASi

Monitor and Manage Hyperkalemia Related to RAASi

English  |  Spanish  |  Japanese 
 |  Chinese

Monitor & Manage Acute Changes in Kidney Function Related to RAASi

English  |  Spanish  |  Japanese
 |  Chinese

Roberto Pecoits-Filho

Angela Wang

Charles Herzog

Debasish Banerjee

Giuseppe Rosano

Martha Gulati

Edgar Lerma

Amina Rakisheva

Henry Wu

Priyanka Satish

Gates Colbert

Michelle Wong

Fadi Jouhra

Viviane Calice-Silva

Kershaw Patel

Suman Behera

Yazied Chothia

Priti Meena

Denissa Arellano Mendez

Thank you to our reviewers and translators: Seiya Urae, Rolando Claure, Chuan-Ming Hao and Henry Wu.
Thank you also to the ISN Patient Liaison Advisory Group for their input into the patient tool.
  1. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1-S87. doi: 10.1016/j.kint.2020.11.003.
  2. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102(5S):S1-S127. doi: 10.1016/j.kint.2022.06.008.
  3. Heidenreich PA, Bozkurt B, Aguillar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–e1032. doi.org/10.1161/CIR.0000000000001063.
  4. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. doi: 10.1093/eurheartj/ehab368. Erratum in: Eur Heart J. 2021 Oct 14.
  5. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324. doi: 10.1161/HYP.0000000000000066. Erratum in: Hypertension. 2018;71(6):e136-e139. Erratum in: Hypertension. 2018;72(3):e33.
  6. Xie X, Liu Y, Perkovic V, et al. Renin-Angiotensin System Inhibitors and Kidney and Cardiovascular Outcomes in Patients With CKD: A Bayesian Network Meta-analysis of Randomized Clinical Trials. Am J Kidney Dis. 2016;67(5):728-741. doi: 10.1053/j.ajkd.2015.10.011.
  7. Agarwal R, Filippatos G, Pitt B, et al. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J. 2022;43(6):474-484. doi: 10.1093/eurheartj/ehab777. Erratum in: Eur Heart J. 2022;43(20):1989.
  8. Chung EY, Ruospo M, Natale P, et al. Aldosterone antagonists in addition to renin angiotensin system antagonists for preventing the progression of chronic kidney disease. Cochrane Database Syst Rev. 2020;10(10):CD007004. doi: 10.1002/14651858.CD007004.
  9. Vijayakumar S, Butler J, Bakris GL. Barriers to guideline mandated renin-angiotensin inhibitor use: focus on hyperkalaemia. Eur Heart J Suppl. 2019;21(Suppl A):A20-A27. doi: 10.1093/eurheartj/suy030.
  10. Greene SJ, Butler J, Albert NM, et al. Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry. J Am Coll Cardiol. 2018;72(4):351-366. doi: 10.1016/j.jacc.2018.04.070.
  11. Thorvaldsen T, Benson L, Dahlström U, et al. Use of evidence-based therapy and survival in heart failure in Sweden 2003-2012. Eur J Heart Fail. 2016;18(5):503-511. doi: 10.1002/ejhf.496.
  12. Maggioni AP, Anker SD, Dahlström U, et al. Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2013;15(10):1173-1184. doi: 10.1093/eurjhf/hft134.
  13. Pecoits-Filho R, Fliser D, Tu C, et al. Prescription of renin-angiotensin-aldosterone system inhibitors (RAASi) and its determinants in patients with advanced CKD under nephrologist care. J Clin Hypertens (Greenwich). 2019;21(7):991-1001. doi: 10.1111/jch.13563.
  14. Patel RB, Fonarow GC, Greene SJ, et al. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol. 2021;78(4):330-343. doi: 10.1016/j.jacc.2021.05.002.
  15. Damman K, Tang WH, Felker GM, et al. Current evidence on treatment of patients with chronic systolic heart failure and renal insufficiency: practical considerations from published data. J Am Coll Cardiol. 2014;63(9):853-871. doi: 10.1016/j.jacc.2013.11.031.
  16. Ahmed AK, Kamath NS, El Kossi M, et al. The impact of stopping inhibitors of the renin-angiotensin system in patients with advanced chronic kidney disease. Nephrol Dial Transplant. 2010;25(12):3977-3982. doi: 10.1093/ndt/gfp511.
  17. Bhandari S, Mehta S, Khwaja A, et al. Renin-Angiotensin System Inhibition in Advanced Chronic Kidney Disease. N Engl J Med. 2022;387(22):2021-2032. doi: 10.1056/NEJMoa2210639.
  18. Xu Y, Fu EL, Trevisan M, et al. Stopping renin-angiotensin system inhibitors after hyperkalemia and risk of adverse outcomes. Am Heart J. 2022;243:177-186. doi: 10.1016/j.ahj.2021.09.014.
  19. Epstein M, Reaven NL, Funk SE, et al. Evaluation of the treatment gap between clinical guidelines and the utilization of renin-angiotensin-aldosterone system inhibitors. Am J Manag Care. 2015;21(11 Suppl):S212-220.
  20. Fu EL, Evans M, Clase CM, et al. Stopping Renin-Angiotensin System Inhibitors in Patients with Advanced CKD and Risk of Adverse Outcomes: A Nationwide Study. J Am Soc Nephrol. 2021;32(2):424-435. doi: 10.1681/ASN.2020050682.
  21. Mullens W, Martens P, Testani JM, et al. Renal effects of guideline-directed medical therapies in heart failure: a consensus document from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2022;24(4):603-619. doi: 10.1002/ejhf.2471.
  22. Acker CG, Johnson JP, Palevsky PM, et al. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998;158(8):917-924. doi: 10.1001/archinte.158.8.917.
  23. Ahuja TS, Freeman D Jr, Mahnken JD, et al. Predictors of the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors. Am J Nephrol. 2000;20(4):268-272. doi: 10.1159/000013599.
  24. Reardon LC, Macpherson DS. Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors. How much should we worry? Arch Intern Med. 1998;158(1):26-32. doi: 10.1001/archinte.158.1.26.
  25. Rosano GMC, Tamargo J, Kjeldsen KP, et al. Expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors: coordinated by the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. Eur Heart J Cardiovasc Pharmacother. 2018;4(3):180-188. doi: 10.1093/ehjcvp/pvy015.
  26. Massicotte-Azarniouch D, Canney M, Sood MM, et al. Managing Hyperkalemia in the Modern Era: A Case-Based Approach. Kidney Int Rep. 2023;8(7):1290-1300. doi: 10.1016/j.ekir.2023.04.016.
  27. Pitt B, Kober L, Ponikowski P, et al. Safety and tolerability of the novel non-steroidal mineralocorticoid receptor antagonist BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease: a randomized, double-blind trial. Eur Heart J. 2013;34(31):2453-2463. doi: 10.1093/eurheartj/eht187.
  28. Lakkis JI, Weir MR. Hyperkalemia in the Hypertensive Patient. Curr Cardiol Rep. 2018;20(2):12. doi: 10.1007/s11886-018-0954-2.
  29. Leon SJ, Whitlock R, Rigatto C, et al. Hyperkalemia-Related Discontinuation of Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in CKD: A Population-Based Cohort Study. Am J Kidney Dis. 2022;80(2):164-173.e1. doi: 10.1053/j.ajkd.2022.01.002.
  30. Atiquzzaman M, Birks P, Bevilacqua M, et al. Prescription Pattern of Cation Exchange Resins and Their Efficacy in Treating Chronic Hyperkalemia Among Patients With Chronic Kidney Diseases: Findings From a Population-Based Analysis in British Columbia, Canada. Can J Kidney Health Dis. 2022;9:20543581221137177. doi: 10.1177/20543581221137177.
  31. Butler J, Anker SD, Lund LH, et al. Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial. Eur Heart J. 2022;43(41):4362-4373. doi: 10.1093/eurheartj/ehac401.

The optimisation of RAASi therapy toolkit is supported by an unrestricted educational grant from AstraZeneca and CSL Vifor.

This toolkit material is freely available for download by health care professionals and individual usage. For-profit organizations may link to toolkit materials with appropriate referencing but are not allowed to use the materials directly (including screenshots) in their own activities; and, where the toolkit materials are referenced with a link, society logos may not be used or displayed with the link. Non-profit organizations may link to the toolkit materials with appropriate referencing, and may promote the materials directly, but must seek permission for this first. If you have any questions concerning the rights to use these materials, please contact mmoorthy@theisn.org.

This toolkit is intended to facilitate decision making of health professionals in their daily practice. However, final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate. All societies represented in this project decline any responsibilities for any damage caused by the use that may be made of the information provided in this toolkit.