Will increasing lisinopril (angiotensin-converting enzyme inhibitor) falsely lower elevated blood pressure in a patient with acute liver failure and hypertension?

From the Guidelines

Increasing lisinopril in a patient with acute liver failure is not recommended and could be dangerous, rather than simply causing falsely lowered blood pressure readings. In acute liver failure, the liver's ability to metabolize medications is severely compromised, which can lead to increased drug concentrations and enhanced effects of lisinopril, as noted in the management of hemodynamic balance in patients with acute liver failure 1. This ACE inhibitor already causes vasodilation and blood pressure reduction, and in liver failure, these effects may be exaggerated due to impaired drug clearance. Some key points to consider in the management of acute liver failure include:

• Hemodynamic derangements consistent with multiple organ failure occur in ALF, with complex and incompletely understood underlying mechanisms 1
• Preservation of renal function is imperative in this setting, and patients with ALF resemble physiologically the patient with cirrhosis and hepatorenal syndrome 1
• Low systemic vascular resistance results in low blood pressures even in the fluid-resuscitated patient, and placement of a pulmonary artery catheter may aid in assessing volume status and guiding further management 1 Additionally, patients with acute liver failure often develop a hyperdynamic circulation with naturally lower systemic vascular resistance, making them particularly sensitive to blood pressure-lowering medications. The combination of reduced hepatic metabolism and baseline hemodynamic changes can lead to profound hypotension, not just falsely lowered readings. Furthermore, acute liver failure patients may have hepatorenal syndrome or other forms of kidney dysfunction, which further increases the risk of adverse effects from lisinopril, as they may require fluid resuscitation and management of hemodynamic balance 1. Blood pressure management in these patients should be approached cautiously, often requiring reduced doses of antihypertensives or alternative agents with less dependence on hepatic metabolism.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Acute Liver Failure

• The management of acute liver failure (ALF) involves a multidisciplinary approach, including the management of cerebral edema, coagulopathy, and infection 2, 3.
• The use of continuous renal replacement therapy (CRRT) and plasma exchange may be considered in the management of ALF 4.
• The management of blood pressure in patients with ALF is crucial, as both hypotension and hypertension can have adverse effects.

Effect of Lisinopril on Blood Pressure

• Lisinopril is an ACE inhibitor that is commonly used to manage hypertension and heart failure 5.
• The effect of lisinopril on blood pressure in patients with ALF is not directly addressed in the available studies.
• However, it is known that ACE inhibitors can cause a decrease in blood pressure, which may be beneficial in patients with hypertension but potentially harmful in patients with hypotension 5.

Considerations for Patients with Acute Liver Failure

• Patients with ALF are at risk of developing cerebral edema and intracranial hypertension, which can be exacerbated by changes in blood pressure 2, 6.
• The management of blood pressure in patients with ALF should be individualized, taking into account the patient's underlying condition and the potential risks and benefits of different treatments.
• There is no direct evidence to suggest that increasing lisinopril would falsely lower elevated blood pressure in patients with ALF, but caution should be exercised when using ACE inhibitors in these patients due to the potential risks of hypotension and worsening renal function 5.