How to safely use ACEIs or ARBs in patients with chronic kidney disease
ACEIs or ARBs can slow the progression of kidney disease. But initially they can bump up serum creatinine (SCr) and potassium, sometimes causing the ACEI or ARB to be stopped too soon. Think of ACEIs and ARBs as the "beta-blockers of the kidney." Expect increases in serum creatinine (SCr) just as you expect beta-blockers to decrease heart rate. Although the numbers may look worse, the kidneys will be better off. Use these steps to help your patients tolerate and benefit from an ACEI or ARB and consider requesting labs from the physician if needed...
- Recommend starting with a moderate dose such as lisinopril (Zestril) 10 to 20 mg/day for most patients with moderate renal impairment.
- Suggest a lower starting dose for those with severe renal impairment or over age 80.
- Suggest titrating every 1 to 2 weeks to reach target doses and BP goals.
- Recommend monitoring SCr and potassium at baseline and within 1 to 2 weeks after starting or increasing the dose.
- Keep in mind that the ACEI or ARB can be continued if the SCr increases LESS than 30% above baseline. In fact, SCr should stabilize and move back toward baseline as blood pressure improves.
Keep in mind, there's no "max SCr" beyond which an ACEI or ARB can't be started. But patients with severe renal impairment are more prone to increases in SCr and K and need more frequent monitoring. Recommend halving the ACEI or ARB dose if the SCr creeps up MORE than 30% or potassium approaches 5.5 mEq/L.
Suggest cutting back on diuretics and reducing the dose or stopping medications that raise potassium (potassium-sparing diuretics, TMP/SMX, etc). Recommend holding the ACEI or ARB if SCr stays 30% above baseline despite dose reductions or potassium is 5.5 mEq/L or above. Suggest trying to restart the ACEI or ARB once the labs improve. Encourage plenty of fluids to avoid dehydration. Caution to avoid NSAIDs especially chronically. Tell patients that dehydration or NSAIDs can further compromise kidney function. Get our notes "How to restart ACEI or ARB in patients after acute kidney injury (AKI)?!" and algorithm of monitoring ACEIs and ARBs". More pharmacists will be monitoring labs to improve drug therapy.
References
- NKF KDOQI Guidelines. [online] Available at: https://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines_bp/guide_11.htm.
