From the Guidelines
Neither hydrochlorothiazide (HCTZ) nor lisinopril should be automatically stopped in patients with chronic kidney disease (CKD), but their use requires careful monitoring and individualized assessment. For lisinopril, an ACE inhibitor, it's generally beneficial in CKD as it reduces proteinuria and slows disease progression, particularly in patients with diabetes or hypertension, as noted in the 2021 guideline synopsis 1. However, monitor for acute kidney injury, hyperkalemia, and avoid in bilateral renal artery stenosis. For HCTZ, a thiazide diuretic, it may be less effective when eGFR falls below 30 ml/min/1.73m², at which point loop diuretics like furosemide are typically preferred, as suggested by the 2019 KDOQI US commentary on the 2017 ACC/AHA hypertension guideline 1.
Key considerations for the use of these medications in CKD include:
- Monitoring serum creatinine and potassium levels during treatment or dose escalation, as guided by Figure 1 in the 2021 study 1
- Adjusting doses based on kidney function and individual patient factors
- Regular monitoring of electrolytes, blood pressure, and kidney function tests
- Avoiding abrupt discontinuation to prevent fluid retention or blood pressure spikes
- Considering the stage of CKD, presence of proteinuria, blood pressure control needs, and individual patient factors when deciding to continue or discontinue these medications, as recommended by the 2019 KDOQI US commentary 1.
Overall, the decision to continue or discontinue HCTZ or lisinopril in patients with CKD should be based on a careful assessment of the individual patient's needs and circumstances, with a focus on minimizing morbidity, mortality, and improving quality of life.
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)].
Lisinopril should be used with caution in patients with Chronic Kidney Disease (CKD). The decision to stop lisinopril in patients with CKD should be based on the patient's individual response and renal function.
- Consider withholding or discontinuing lisinopril in patients who develop a clinically significant decrease in renal function.
- Monitor renal function periodically in patients treated with lisinopril.
2.4 Dose in Patients with Renal Impairment No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose i.e., hypertension, 5 mg; systolic heart failure, 2.5 mg and acute MI, 2. 5 mg.
Hydrochlorothiazide does not have direct information regarding stopping the medication in patients with CKD.
- However, hydrochlorothiazide can be used in patients with renal impairment, but with caution and close monitoring of renal function and electrolyte balance.
- The FDA drug label for hydrochlorothiazide does not provide specific guidance on stopping the medication in patients with CKD.
From the Research
Treatment of Hypertension in CKD
In patients with Chronic Kidney Disease (CKD), the management of hypertension is crucial to slow disease progression and reduce cardiovascular risk. The choice of antihypertensive medication is important, and both hydrochlorothiazide (HCTZ) and lisinopril are commonly used.
Hydrochlorothiazide in CKD
- HCTZ, a thiazide diuretic, has been shown to be effective in reducing blood pressure in patients with CKD, even in advanced stages 4.
- However, the use of thiazides in CKD requires close monitoring of electrolyte levels, as abnormalities are common 4.
- The addition of HCTZ to a renin-angiotensin system blocker may be beneficial in treating hypertension in patients with renal disease 5.
Lisinopril in CKD
- Lisinopril, an angiotensin-converting enzyme inhibitor (ACEI), is recommended for the treatment of hypertension in patients with CKD, particularly those with proteinuria 6, 7.
- ACEIs, such as lisinopril, have been shown to slow disease progression and reduce cardiovascular risk in patients with CKD 8.
- The use of ACEIs, including lisinopril, is generally preferred over other antihypertensive medications in patients with CKD, unless contraindicated 6, 7.
Stopping HCTZ or Lisinopril in CKD
- There is no clear evidence to suggest that HCTZ should be stopped in patients with CKD, as it may still be effective in reducing blood pressure 4.
- Lisinopril, on the other hand, is generally recommended to be continued in patients with CKD, unless there are specific contraindications or adverse effects 6, 7.
- The decision to stop either medication should be made on a case-by-case basis, taking into account the individual patient's response to treatment, disease progression, and potential side effects 6, 7.