How to restart ACEI or ARB in patients after acute kidney injury (AKI)?!
A common scenario that leads to kidney injury is when patients on an ACEI or ARB start an NSAIDs, diuretic, or become dehydrated. Many references suggest using an ACEI or ARB after acute kidney injury is linked to lower mortality. BUT still at the risk of hyperkalemia. If it was stopped because of acute kidney injury, weigh benefits and risks to help decide about restarting. For example, don't generally recommend restarting an ACEI or ARB just for hypertension, the risks likely outweigh benefits in this case.
On the other hand, advise restarting an ACEI or ARB when they're known to improve outcomes, such as for patients with heart failure with reduced ejection fraction, recent heart attack, or chronic kidney disease. Scenario for restarting ACEI or ARB ― see, Figure 1. algorithm of using ACEI or ARB after AKI.
Suggest waiting until serum creatinine (SCr) stabilizes to restart which may take up to 6 weeks. Recommend restarting at a low dose, such as lisinopril (Zestril) 5 mg/day or losartan (Cozaar) 25 mg/day. Advise checking SCr and potassium after one to 2 weeks and titrating up if labs continue to stay stable. Suggest halving the dose if SCr bumps up more than 30%. But expect the ACEI or ARB to be held if SCr is still high at the next check, or for potassium 5.5 mEq/L or above. Advise trying to restart when labs improve. When patients are stable on target doses, recommend checking labs once or twice a year, or up to every 3 months in higher-risk patients.
Advise monitoring more frequently if patients start other medications that raise potassium (spironolactone, TMP/SMX, etc). Encourage patients to stay hydrated and avoid NSAIDs, especially chronically. And educate to avoid salt substitutes, since these contain potassium.
References
- Alpern RJ, Peixoto AJ. Use of Renin Angiotensin System Blockers After Acute Kidney Injury: Balancing Tradeoffs. JAMA Intern Med. 2018;178(12):1690-1692.
- Acute Kidney Injury -potentially problematic drugs and actions to take in Primary Care. [online] Available at: https://www.thinkkidneys.nhs.uk
