Can lisinopril (angiotensin-converting enzyme inhibitor) be given to a patient with end-stage renal disease (ESRD) on dialysis?

Lisinopril Use in Dialysis Patients

Lisinopril can be safely administered to patients on dialysis, but requires dose adjustment and careful monitoring due to reduced clearance and potential for adverse effects.

Pharmacokinetics and Dosing in Dialysis

• Lisinopril is primarily eliminated through the kidneys and is removed by hemodialysis with approximately 47% reduction in serum concentration during dialysis sessions 1
• The FDA label specifically states that dose adjustment is required for patients undergoing hemodialysis 2
• In dialysis patients, lisinopril has a prolonged half-life requiring modified dosing schedules:
  • Initial dose should be low (2.5mg)
  • May require reduced frequency (alternate day or once-weekly dosing) 1
  • Post-dialysis administration is recommended to maintain therapeutic levels

Benefits in Dialysis Patients

• ACE inhibitors like lisinopril are recommended as first-line therapy for hypertension in dialysis patients 3
• Benefits include:
  • Reduction of left ventricular hypertrophy
  • Preservation of residual renal function in dialysis patients 4, 3
  • Reduction in blood pressure through multiple mechanisms including decreased arterial stiffness

Potential Risks and Monitoring

• Hyperkalemia: Regular monitoring of serum potassium is essential 2
• Anaphylactoid reactions: Can occur during dialysis with high-flux membranes when used with ACE inhibitors 2
• Hypotension: May cause symptomatic hypotension during dialysis sessions 1
• Blood pressure monitoring: Check pre-dialysis, intradialytic, and post-dialysis blood pressure 3

Clinical Evidence in Dialysis Patients

• A study of hypertensive dialysis patients found that lisinopril effectively reduced blood pressure when administered at appropriate doses, with sitting diastolic BP decreasing from 107±7 to 87±10 mmHg 1
• The KDIGO controversies conference noted that ACE inhibitors may preserve residual kidney function, especially in peritoneal dialysis patients 4
• However, a study comparing lisinopril to atenolol in hemodialysis patients with hypertension and left ventricular hypertrophy found fewer heart failure hospitalizations with atenolol 4

Practical Approach to Lisinopril Use in Dialysis

1. Start with a low dose (2.5mg)
2. Administer after dialysis sessions
3. Monitor for:
   • Hypotension during dialysis
   • Hyperkalemia
   • Anaphylactoid reactions with certain dialysis membranes
4. Adjust dosing schedule based on blood pressure response (may need alternate day or once-weekly dosing)
5. Consider alternative agents if adverse effects occur:
   • Calcium channel blockers (amlodipine)
   • Beta-blockers (carvedilol)

Special Considerations

• Avoid lisinopril in patients with:
  • History of anaphylactoid reactions during dialysis
  • Persistent hyperkalemia despite management
  • Severe hypotension during dialysis
• For patients with residual kidney function, ACE inhibitors may help preserve remaining function 4

Remember that while lisinopril can be used in dialysis patients, it requires careful monitoring and dose adjustment to balance efficacy with safety.