A new clinical decision support tool for primary care providers (PCPs) led to a modest improvement in reinitiation of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) within 30 days among veterans with chronic kidney disease (CKD) who had previously discontinued these treatments.

“These drugs have been available for over three decades but are still underutilized,” said Sankar D. Navaneethan, MD, MS, MPH, with Baylor College of Medicine and chief of the Renal Section at the Michael E. DeBakey VA Medical Center, Houston.

In addition, discontinuation of ACE inhibitor or ARB therapy is common in patients with CKD despite data that show treatment discontinuation in those with lower eGFR is associated with higher mortality, explained Navaneethan, who presented the data at the Kidney Week 2025: American Society of Nephrology Annual Meeting.

Understanding and Addressing Reasons for Discontinuation

To develop the personalized clinical support tool, the researchers analyzed adverse drug reactions in electronic medical records and used natural language processing to understand the reasons for ACE inhibitor and ARB discontinuation in patients with CKD.

They also conducted semi-structured interviews with 15 providers and 10 patients to understand the challenges that they face in prescribing and taking these medications.

The main challenges reported by clinicians included being unclear on kidney indications for prescribing, uncertainty about current guidelines, and not being sure how to manage patient side effects. For patients, the main challenges were lack of knowledge around their diagnosis, polypharmacy, and experiencing side effects.

To address these issues, the clinical support tool included an algorithm for prescribing, dosing, uptitration, and reinitiation of ACE inhibitors and ARBs, along with communication aids to facilitate patient education and guidance on when to consult nephrology or cardiology.

The researchers then tested the tool in a group of patients from the Michael E. DeBakey VA Medical Center and VA Tennessee Valley Healthcare System (Nashville, Tennessee) Primary Care Clinics. PCPs at these clinics were contacted about eligible veterans with CKD who had an ACE inhibitor or ARB discontinuation.

The study began in June 2024 and ended in August 2025. There were 1363 control patients and 1363 patients in the decision support group. There was a median age of 76 years (96.3% male) in the decision support group and 77 years (93.8% male) in the control group.

In the decision support group, 36.1% of participants were Black, 58.9% were White, and 58.5% had diabetes. In the control group, 40.8% of participants were Black, 52.5% were White, and 62.5% had diabetes. In both groups, 93% had hypertension. The median estimated glomerular filtration rate (eGFR) was 43.9 in the decision support group and 44.2 in the control group.

The primary outcome for the study was reinitiation of an ACE inhibitor or an ARB.

The results showed that among the decision support group, 245 patients (18%) reinitiated within 30 days compared with 175 patients (13%) in the control group (P = .001). In the decision support group, 82% either did not reinitiate or reinitiated after 30 days, which was similar to the control group at 87%.

There are new therapies available for managing the CKD population, but “as we adopt them, we must optimize the utilization of existing therapies,” Navaneethan told Medscape Medical News.

A tool like the one tested in the study could be implemented within electronic medical records to facilitate adoption or reinitiation of these agents, he added.

Navaneethan told meeting attendees that additional studies are warranted to better understand the perspectives of physicians who didn’t restart these medications, noting that it may be possible to improve clinical decision-making by studying their reasons.

Commenting on the study, Chia-Ter Chao, MD, PhD, with the National Taiwan University Hospital and College of Medicine, Taipei, Taiwan, who was not involved in the research, said, “Yes, I do believe that ACE inhibitors and ARBs are underutilized in CKD patients, especially those with advanced CKD.”

That the study demonstrates the tool modestly improves use of these medications is laudable, he said, adding, however, that “it would be even better to test this in those with an eGFR less than 30 or lower.”

Funding for the study came from a Department of Veterans Affairs Health Service Research & Development Services Investigator-Initiated Grant (IIR 19-069).

Navaneethan reported having relationships with AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, and other companies. Chia-Ter Chao reported having no financial disclosures or conflicts.