What is the best management approach for a patient with impaired renal function who is taking lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) and experiencing a decline in renal function, as evidenced by hyperkalemia and elevated creatinine levels?

From the Guidelines

For a patient with impaired renal function taking lisinopril who is experiencing worsening renal function with hyperkalemia and elevated creatinine, the recommended approach is to discontinue the lisinopril immediately. This medication should be held while closely monitoring serum potassium and creatinine levels, typically checking labs within 48-72 hours after discontinuation. If hyperkalemia is severe (>6.0 mEq/L), urgent treatment with calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium binders like sodium polystyrene sulfonate (Kayexalate) or patiromer may be necessary. After stabilization, the patient should be evaluated for alternative antihypertensive medications that have less impact on renal function, such as calcium channel blockers (amlodipine) or certain beta-blockers (metoprolol) 1. The decline in renal function is likely due to lisinopril's effect on renal hemodynamics, as ACE inhibitors dilate the efferent arteriole in the glomerulus, reducing glomerular filtration pressure. This effect is particularly problematic in patients with bilateral renal artery stenosis or volume depletion. Additionally, ACE inhibitors block aldosterone production, which normally promotes potassium excretion, leading to potassium retention and hyperkalemia. Renal function often improves within 1-2 weeks after discontinuing the medication, though some patients may require temporary supportive care during this period. It is also important to consider the patient's current medication regimen, including amlodipine, and adjust as necessary to ensure optimal blood pressure control while minimizing the risk of further renal deterioration 1. The most recent guidelines suggest that ACE inhibitors can be continued in patients with declining renal function, but close monitoring of renal function and electrolytes is necessary 1. However, in this case, the patient's significant decline in renal function and hyperkalemia suggest that discontinuation of lisinopril is the most appropriate course of action. Regular monitoring of renal function and electrolytes is crucial in patients taking ACE inhibitors, especially in those with pre-existing renal impairment 1. In summary, the best management approach for this patient is to discontinue lisinopril and closely monitor renal function and electrolytes, with consideration of alternative antihypertensive medications as needed.

From the FDA Drug Label

5.3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].

The patient has experienced a decline in renal function as evidenced by an increase in creatinine levels from 1.2 mg/dL to 1.7 mg/dL and a decrease in estimated glomerular filtration rate from 50 mL/min/1.73 m2 to 33 mL/min/1.73 m2, along with hyperkalemia (potassium level of 5.7 mEq/L). Given this significant decline in renal function, the most appropriate management approach would be to discontinue lisinopril. Adding furosemide may help manage the hyperkalemia and fluid overload, as it is a loop diuretic that can increase potassium excretion. Therefore, the best course of action is to discontinue lisinopril and add furosemide 2, 2. Key considerations:

• Monitor renal function and electrolytes closely after discontinuing lisinopril and initiating furosemide.
• Adjust the dose of furosemide as needed to manage hyperkalemia and fluid overload.
• Consider alternative antihypertensive agents that may be safer in patients with impaired renal function.

From the Research

Management Approach

The patient is experiencing a decline in renal function, as evidenced by hyperkalemia and elevated creatinine levels, while taking lisinopril. The most appropriate management approach would be to:

• Continue lisinopril, as discontinuing it may not be necessary, and add furosemide to manage the hyperkalemia and edema.
• Monitor the patient's renal function, potassium levels, and blood pressure closely.

Rationale

• Lisinopril is an ACE inhibitor that can cause hyperkalemia, especially in patients with impaired renal function 3.
• The patient's elevated creatinine levels and hyperkalemia suggest a decline in renal function, which may be exacerbated by the lisinopril 4.
• Adding furosemide, a loop diuretic, can help manage the hyperkalemia and edema, while continuing lisinopril to control blood pressure 5.
• Discontinuing lisinopril may not be necessary, as the patient's blood pressure is well-controlled, and the benefits of continuing the medication may outweigh the risks 6, 7.

Considerations

• The patient's renal function should be monitored closely, and the lisinopril dose may need to be adjusted based on the patient's creatinine levels and potassium levels 4.
• The patient's blood pressure should also be monitored closely, and the lisinopril dose may need to be adjusted to maintain optimal blood pressure control 3, 5.
• Alternative management options, such as switching to a different ACE inhibitor or adding a potassium-binding agent, may be considered if the patient's hyperkalemia and renal function do not improve with the addition of furosemide 6, 7.