ACEi or ARB Use in CKD Patients
Yes, CKD patients should be treated with ACEi or ARB therapy, especially those with albuminuria (≥200 mg/g creatinine) or diabetes, as these medications reduce the risk of CKD progression to end-stage kidney disease and provide cardiovascular protection. 1
Indications for ACEi/ARB in CKD
ACEi or ARB therapy is recommended based on the following criteria:
Strong Indications (Highest Priority)
- CKD with severely increased albuminuria (≥300 mg/g creatinine) without diabetes 1
- CKD with moderately-to-severely increased albuminuria (≥30 mg/g creatinine) with diabetes 1
- CKD with hypertension (target BP <130/80 mmHg) 1
Moderate Indications
- CKD with moderately increased albuminuria (30-299 mg/g creatinine) without diabetes 1
- CKD with normal to mildly increased albuminuria when treating hypertension or heart failure 1
Benefits of ACEi/ARB in CKD
- Reduces progression to more advanced albuminuria 1
- Slows CKD progression 1
- Reduces risk of end-stage kidney disease (ESKD) in patients with established CKD and albuminuria ≥300 mg/g creatinine 1
- Reduces cardiovascular events 1
- Provides blood pressure control 1
Practical Recommendations for ACEi/ARB Use
Dosing
- Use the highest approved dose that is tolerated to achieve maximum benefits 1
- Benefits in clinical trials were achieved using maximum tolerated doses 1
Monitoring
- Check serum creatinine, potassium, and blood pressure within 2-4 weeks of initiation or dose increase 1
- Continue therapy unless serum creatinine rises by more than 30% within 4 weeks of starting treatment 1
- A small initial decline in eGFR (up to 30%) is expected and not a reason to discontinue therapy 1
When to Consider Dose Reduction or Discontinuation
- Symptomatic hypotension 1
- Uncontrolled hyperkalemia despite medical treatment 1
- To reduce uremic symptoms when eGFR <15 ml/min/1.73 m² 1
- Serum creatinine rise >30% within 4 weeks of initiation 1
Important Cautions
- Never combine ACEi with ARB - this combination increases risk of hyperkalemia and acute kidney injury without additional benefits 1
- Monitor closely in patients at risk for hyperkalemia (reduced GFR, diabetes, concomitant potassium-sparing diuretics) 2
- Consider temporarily withholding during acute illness with volume depletion 2
Special Considerations
Kidney Transplant Recipients
- In kidney transplant recipients with hypertension, dihydropyridine calcium channel blockers or ARBs are recommended as first-line agents 1
Advanced CKD
- Continue ACEi or ARB even when eGFR falls below 30 ml/min/1.73 m² 1
- In the RENAAL study, losartan reduced the risk of ESKD by 28.6% in patients with type 2 diabetes and nephropathy 3
Hyperkalemia Management
- Hyperkalemia associated with ACEi/ARB use can often be managed with measures to reduce serum potassium rather than decreasing the dose or stopping the medication 1
Combination with Other Medications
- For patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m², add an SGLT2 inhibitor to the treatment regimen 1
- For patients with CKD and eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g, add an SGLT2 inhibitor 1
- Mineralocorticoid receptor antagonists can be effective for management of refractory hypertension but may cause hyperkalemia, particularly in patients with low eGFR 1
Common Pitfalls to Avoid
- Discontinuing ACEi/ARB too quickly after an initial rise in creatinine (up to 30% increase is acceptable)
- Using combination ACEi and ARB therapy (increases adverse effects without additional benefits)
- Underdosing - not titrating to maximum tolerated doses
- Failure to monitor serum potassium and creatinine after initiation or dose changes
- Not starting ACEi/ARB in patients with albuminuria due to concerns about mild renal function decline
In summary, ACEi or ARB therapy is a cornerstone of CKD management, particularly for patients with albuminuria or diabetes, and should be used at the highest tolerated doses with appropriate monitoring to slow CKD progression and reduce cardiovascular risk.