From the Guidelines
Yes, ACE inhibitors can be used in patients with chronic renal failure (CRF) and are often beneficial in this population. ACE inhibitors like lisinopril, enalapril, and ramipril are frequently prescribed for CRF patients to slow disease progression, particularly in those with proteinuria or diabetic nephropathy [ 1 ]. However, dosing adjustments are typically necessary based on the patient's glomerular filtration rate (GFR). For example, lisinopril might be started at 2.5-5 mg daily in advanced CRF instead of the standard 10 mg.
When initiating ACE inhibitors in CRF patients, close monitoring is essential. Serum creatinine and potassium levels should be checked within 1-2 weeks of starting therapy, as these medications can cause an initial decrease in GFR and may lead to hyperkalemia [ 1 ]. If creatinine increases by more than 30% or potassium exceeds 5.5 mEq/L, the medication may need to be reduced or discontinued. ACE inhibitors work by blocking the conversion of angiotensin I to angiotensin II, reducing intraglomerular pressure and proteinuria, which helps preserve kidney function over time [ 1 ].
Some key considerations when using ACE inhibitors in CRF patients include:
- Monitoring for hyperkalemia, particularly in patients with diabetes or chronic renal failure [ 1 ]
- Avoiding precipitating factors for acute renal failure (ARF), such as systemic hypotension, ECF volume depletion, or nephrotoxin administration [ 1 ]
- Temporarily discontinuing ACE inhibitors during acute illness, especially with volume depletion, and reconsidering their use once the underlying condition is managed [ 1 ]
- Being aware that ACE inhibitors can generally be safely restarted after resolution of an ARF episode, particularly if the underlying condition is managed [ 1 ].
From the FDA Drug Label
3 Non-Steroidal Anti-Inflammatory Agents Including Selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors) In patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, coadministration of NSAIDs, including selective COX-2 inhibitors, with ACE inhibitors, including lisinopril, may result in deterioration of renal function, including possible acute renal failure.
4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy. Avoid use of aliskiren with lisinopril in patients with renal impairment (GFR <60 ml/min).
ACE inhibitors can be used in patients with chronic renal failure (CRF), but with caution. The use of ACE inhibitors in patients with CRF requires careful monitoring of:
- Renal function
- Blood pressure
- Electrolytes
- Potential interactions with other medications, such as NSAIDs, lithium, and diuretics It is also important to avoid combined use of RAS inhibitors and to monitor serum potassium frequently when using potassium-sparing diuretics with ACE inhibitors 2.
From the Research
Use of ACE Inhibitors in CRF
- ACE inhibitors can be used in patients with chronic renal failure (CRF) as they have been shown to lower glomerular capillary pressure, decrease proteinuria, and may halt progressive glomerular injury and loss of renal function 3.
- The reduction in proteinuria appears to be variable and may depend on pretreatment glomerular haemodynamics and/or the activity of the renin-angiotensin-aldosterone system 3.
- ACE inhibitors may slow the progression of renal disease in humans with CRF, although this effect has not been observed consistently in all patients 3, 4.
Benefits and Safety Considerations
- ACE inhibitors have a pronounced antihypertensive and antiproteinuric action in patients with CRF, and may inhibit the growth of creatinine levels 4.
- However, the use of ACE inhibitors in CRF requires careful monitoring of blood creatinine levels, especially within the first 1-2 months of treatment 4, 5.
- The main adverse effects of ACE inhibitors are hypotension, renal function impairment, and hyperkalemia, which can be mitigated by reduction in dietary sodium or addition of diuretics 6, 7.
Dosage and Administration
- Dosage recommendations for ACE inhibitors in CRF depend on the specific pharmacokinetic properties of the various agents, and dosage adjustment is recommended in moderate and severe impairment of renal function 5.
- For most ACE inhibitors, resultant dosages are 25 to 50% of those recommended for patients with normal renal function 5.
- The use of ACE inhibitors in combination with other antihypertensive agents, such as diuretics, may provide additional renoprotective effects 7.