Management for a patient with an elevated Creatinine/Albumin ratio on ACEI (Angiotensin-Converting Enzyme Inhibitor)?

From the Guidelines

Management of Elevated Creatinine/Albumin Ratio on ACEI Stop ACE inhibitor (ACEI) immediately and consider alternative antihypertensive medication, such as an angiotensin receptor blocker (ARB) like losartan 50mg daily, and consult a nephrologist for further evaluation and management of potential kidney damage 1.

• Monitor creatinine and albumin levels closely to assess the progression of kidney disease 1.
• Consider reducing protein intake to minimize kidney strain, with a recommended daily allowance of 0.8 g/kg/day 1.
• If the creatinine rises above 265 mmol/L (3.0 mg/dL), but below 310 mmol/L (3.5 mg/dL), halve the dose of ACEI and monitor blood chemistry closely 1.
• An increase in creatinine of up to 50% from baseline or to an absolute concentration of 265 mmol/L (3 mg/dL), whichever is lower, is acceptable 1.
• Hyperkalemia associated with the use of an ACEI or ARB can often be managed by measures to reduce serum potassium levels rather than decreasing the dose or stopping the ACEI or ARB immediately 1. Key considerations for managing patients with elevated creatinine/albumin ratio on ACEI include:
• Regular monitoring of blood pressure, serum creatinine, and serum potassium within 2–4 weeks of initiation or increase in the dose of an ACEI or ARB 1.
• Continued monitoring of urine albumin excretion to assess both response to therapy and progression of disease 1.
• Evaluation and management of potential complications of chronic kidney disease (CKD) when eGFR is <60 mL/min/1.73 m² 1.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).

The management for a patient with an elevated Creatinine/Albumin ratio on ACEI (Angiotensin-Converting Enzyme Inhibitor) may involve the use of losartan, as it has been shown to reduce the risk of doubling of serum creatinine and end-stage renal disease (ESRD) in patients with type 2 diabetes and nephropathy 2.

• Losartan has been found to reduce proteinuria by an average of 34% and the rate of decline in glomerular filtration rate by 13%.
• However, the use of losartan in combination with ACE inhibitors should be avoided due to the increased risk of hyperkalemia and acute kidney injury 2.
• The patient's blood pressure, renal function, and electrolytes should be closely monitored while on losartan therapy.

From the Research

Management of Elevated Creatinine/Albumin Ratio on ACEI

• The management of a patient with an elevated Creatinine/Albumin ratio on Angiotensin-Converting Enzyme Inhibitor (ACEI) is a complex issue, and the current evidence does not provide a clear answer 3, 4, 5, 6, 7.
• According to the study published in The Cochrane database of systematic reviews, ACEi may prevent kidney failure, but the evidence is of low certainty 3.
• The STOP-ACEi trial found that withdrawing ACEi or angiotensin receptor blockers (ARB) did not slow the rate of decline in estimated glomerular filtration rate (eGFR) 4, 5.
• Another study published in Nephron discussed the controversy surrounding the use of ACEi/ARB in advanced kidney disease and the potential benefits and harms of stopping these medications 6.
• In patients with resistant hypertension, which may be related to an elevated Creatinine/Albumin ratio, treatment options include lifestyle optimization, escalation of antihypertensive medication, and the use of mineralocorticoid receptor antagonists (MRA) 7.

Considerations for ACEI Use

• The use of ACEi in patients with kidney disease is a common practice, but the evidence for its effectiveness in preventing kidney failure is limited 3, 4, 5.
• The potential benefits of ACEi in reducing cardiovascular events and slowing the progression of kidney disease must be weighed against the potential risks, such as hyperkalemia and worsening kidney function 3, 4, 5.
• The decision to continue or stop ACEi in a patient with an elevated Creatinine/Albumin ratio should be made on a case-by-case basis, taking into account the individual patient's medical history, kidney function, and other factors 4, 5, 6.

Monitoring and Follow-up

• Regular monitoring of kidney function, including serum creatinine and eGFR, is essential in patients with kidney disease, particularly those on ACEi 3, 4, 5.
• Patients with an elevated Creatinine/Albumin ratio on ACEi should be closely monitored for signs of kidney failure, such as a decline in eGFR or an increase in serum creatinine 4, 5.
• The use of other medications, such as MRA, may be considered in patients with resistant hypertension or those at risk of kidney failure 7.