How to safely use ACEIs or ARBs in patients with chronic kidney disease, this is an important question. We know these medications slow the progression of kidney disease. But blocking angiotensin can reduce kidney filtration and sometimes lead to a bump in serum creatinine (SCr) and potassium. See "Algorithm (1) of using ACEI or ARB after AKI".
Think of ACEIs and ARBs as the "beta-blockers of the kidney". Expect increases in 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 benefit from an ACEI or ARB. Start with a moderate dose (lisinopril 10 to 20 mg/day, etc) for most patients with moderate renal impairment. Start with a lower dose in patients with severe renal impairment, heart failure, or over age 80. Titrate every 1 to 2 weeks to reach target doses and blood pressure goals.
Monitor SCr and potassium at baseline and within 1 to 2 weeks after starting or increasing the dose. Continue the ACEI or ARB if SCr increases LESS THAN 30%. SCr should stabilize and move back toward baseline as blood pressure improves. Recheck SCr, potassium, and blood pressure in 2 to 3 weeks. Check labs once or twice yearly once stable or if the patient's condition or medications change.
Keep in mind there's no "max SCr" beyond which an ACEI or ARB can't be used. But patients with severe renal insufficiency are more prone to bumps in SCr and potassium and need more frequent monitoring. Cut the dose in half if SCr creeps up MORE THAN 30% or potassium approaches 5.5 mEq/L. Cut back on diuretics and reduce the dose or stop medications that raise potassium (potassium-sparing diuretics, TMP/SMX, etc). Hold the ACEI or ARB if SCr STAYS 30% above baseline despite dose reductions or potassium is 5.5 mEq/L or above. Try to restart the ACEI or ARB once the labs improve. Encourage plenty of fluids to avoid dehydration. Try to avoid NSAIDs especially chronically. Tell patients that dehydration or NSAIDs can further compromise kidney function.
REFERENCES
-
kidneyfoundation.cachefly.net. NKF KDOQI Guidelines. [online] Available at: https://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines_bp/guide_11.htm.
Hsu TW, Liu JS, Hung SC, Kuo KL, Chang YK, Chen YC, Hsu CC, Tarng DC. Renoprotective effect of renin-angiotensin-aldosterone system blockade in patients with predialysis advanced chronic kidney disease, hypertension, and anemia. JAMA Intern Med. 2014 Mar;174(3):347-54. Available at: https://pubmed.ncbi.nlm.nih.gov/24343093.