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The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this episode, Jeremy and Andrew revisit one of the most fundamental yet persistently misunderstood areas in kidney care: the use and misuse of renin–angiotensin system inhibitors (RAASIs). Despite being cheap, powerful, and backed by decades of evidence, these cornerstone drugs remain under-dosed, frequently interrupted, and poorly optimised in real-world practice. The hosts examine why so many patients remain on subtherapeutic doses, how unnecessary caution and slow titration in primary care can blunt benefits, and why maximal dosing matters far more than blood pressure alone.

They then take listeners through the “patient journey” of being on a RAASI, exploring predictable bumps in the road, especially hyperkalemia and how proactive preparation could prevent the all-too-common cycle of unnecessary emergency visits and abrupt drug cessation. They unpack practical strategies: identifying high-risk patients, simple steps to minimise potassium rises, the role of constipation and diet, and the increasingly important place of modern potassium binders. Ultimately, Jeremy and Andrew make a compelling case: RAASIs only work when the patient actually stays on them, and with the right approach, nearly every patient can.

Top 5 Takeaways

1️⃣ Maximal doses matter — Subtherapeutic RAASI dosing is common, but full doses offer far greater cardio-renal protection than BP reductions alone.
2️⃣ Titrate faster — safely — Most patients can start on higher doses (e.g., Ramipril 5 mg, not 1.25 mg). Slow, cautious uptitration often delays benefits.
3️⃣ Hyperkalemia is predictable, not surprising — It’s a physiologic effect of RAAS blockade, not an adverse event. High-risk patients can be anticipated.
4️⃣ Prepare patients for the journey — Early education on potassium, diet, constipation, and reversible triggers prevents unnecessary drug interruption.
5️⃣ Don’t stop RAASIs too quickly — Most potassium rises are fixable; newer potassium binders allow continued, safe use of ACEi/ARB therapy.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

CaReMe UK - British Cardiovascular Society

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

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