Abstract Background and hypothesis Renin-angiotensin-aldosterone-system inhibitors (RAASIs) are widely used anti-hypertensive drugs. Due to the hyperkalemic effect, previous 2012 KDIGO guidelines discouraged RAASIs use in patients with severe CKD. However, due to the recently discovered s cardioprotective and nephroprotective effect, new 2022 KDIGO guidelines suggest their use also in CKD stage IV-V. To our knowledge, only very little studies have explored the use of RAASI in dialysis patients. This study aims to evaluate the impact of RAASIs on kalemia and on mortality in a large sample of dialysis patients. Methods We included 4764 dialysis patients from the Sicilian Registry of Nephrology, Dialysis and Transplantation. The longitudinal association between RAASIs intake and serum potassium was analyzed by univariate and multivariate Linear Mixed Models. The survival models were computed through univariate and multivariate Cox model and Cox models with mixed effect. Results The study included 4764 patients, of whom 1207 (25%) were treated with RAASi. Multivariate longitudinal model showed a direct association between RAASIs intake and serum potassium adjβ = 0.10, 95%CI 0.05/0.15, p 0.001); however multivariate Cox analysis did not show any association between RAASIs intake and mortality adjHR = 0.76, 95%CI 0.43/1.30, p = 0.31. No differences in the impact of RAASIs on mortality were found in the analysis stratified for potassium levels (cut-off 5.1 mmol/L). Conclusion In the present study we found, in a large cohort of dialysis patients, an independent, direct association between RAASIs and serum potassium. However, no association was found between RAASIs intake and mortality. Although specific RCTs are needed to confirm our findings, RAASIs intake did not seem to have a negative impact on patients’ survival, thus suggesting a reevaluation of RAASIs use in this population.
Calabrese et al. (2026) studied this question.