Can lisinopril (Angiotensin-Converting Enzyme (ACE) inhibitor) cause Impaired renal function?

Lisinopril Can Cause Impaired Renal Function

Yes, lisinopril can cause impaired renal function, particularly in patients with pre-existing renal insufficiency, volume depletion, or those taking certain medications that affect kidney function. 1

Mechanisms of Renal Impairment

• ACE inhibitors like lisinopril can cause changes in renal function including acute renal failure, particularly in patients whose renal function depends on the activity of the renin-angiotensin system 1
• Patients at highest risk include those with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction, or volume depletion 1
• The decline in glomerular filtration is related to the withdrawal of angiotensin II actions, which normally maintains efferent arteriolar vasoconstriction 2

High-Risk Patient Populations

• Patients with bilateral renal artery stenosis or stenosis of a dominant/single kidney 2
• Patients with pre-existing chronic renal insufficiency of any cause 2
• Patients taking NSAIDs, cyclosporine, or other nephrotoxic medications 2
• Patients with volume depletion from diuretic therapy 2
• Patients with severe heart failure and systolic blood pressure below 100 mmHg 1
• Elderly patients who may have lower baseline glomerular filtration rates 3

Expected Changes in Renal Function

• A 10-20% increase in serum creatinine can be anticipated in patients with chronic renal insufficiency and is actually an indication that the drug is exerting its desired actions 2
• In patients with normal renal function, a smaller rise in serum creatinine (approximately 10% above baseline) may occur, mostly during the first week of therapy 3
• In patients with renal insufficiency, a more significant rise (approximately 25% above baseline) may occur, with about 15% increase during the first 2 weeks and an additional 10% during weeks 3-4 3

Monitoring Recommendations

• Monitor renal function periodically in all patients treated with lisinopril 1
• Check renal function and serum electrolytes before starting treatment 2
• Re-check renal function and serum electrolytes within 1-2 weeks of starting treatment and after any dose increase 2
• For patients with diabetes mellitus who are on an ACE inhibitor, renal function and serum potassium levels should be monitored within 1-2 weeks of initiation, with each dose increase, and at least yearly 2

Management of Renal Impairment

• Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function 1
• In patients with moderate renal impairment, dose adjustment or reduced dosing frequency may be required 4
• For patients with severe renal failure, adjustment of dose or dosing frequency according to the degree of renal failure is recommended 4
• If serum creatinine rises more than 30% above baseline during the first 2 months of therapy or if hyperkalemia develops (serum potassium ≥5.6 mmol/L), consider discontinuation 3

Paradoxical Renoprotective Effects

• Despite the initial decline in renal function, long-term ACE inhibitor therapy may actually provide renoprotection in certain patient populations 5
• In diabetic patients with nephropathy, lisinopril has shown renoprotective effects compared to other antihypertensive medications 5
• The EUCLID trial demonstrated that lisinopril is renoprotective in normotensive patients with insulin-dependent diabetes mellitus and microalbuminuria 5

Precautions to Minimize Risk

• Start with low doses in patients with renal impairment (2.5 mg in patients with GFR <30 ml/minute) 6
• Avoid concomitant use of NSAIDs when possible 2
• Avoid excessive diuresis and volume depletion 2
• Consider reducing diuretic dose if significant worsening of renal function occurs 2
• Monitor serum potassium levels, as hyperkalemia is more common in patients with impaired renal function 1

Remember that while lisinopril can cause impaired renal function, this effect must be balanced against its potential benefits in specific patient populations, particularly those with heart failure, hypertension, or diabetic nephropathy 2, 5.