Can lisinopril (angiotensin-converting enzyme inhibitor) cause impaired renal function?

Lisinopril and Kidney Function: Benefits and Risks

Lisinopril can both protect kidney function and potentially cause kidney problems depending on individual patient factors, underlying conditions, and monitoring practices. While ACE inhibitors like lisinopril are generally renoprotective, especially in patients with albuminuria or diabetic kidney disease, they require careful monitoring of renal function and potassium levels 1.

Potential Kidney Benefits of Lisinopril

• ACE inhibitors like lisinopril are recommended for patients with hypertension and chronic kidney disease, particularly those with albuminuria, as they provide renoprotective effects beyond blood pressure control 1
• In patients with diabetic kidney disease or glomerulonephritis, ACE inhibitors have been associated with a decrease in the slope of decline in kidney function 2
• In peritoneal dialysis patients with residual kidney function, ACE inhibitors have been shown to slow the decrease in glomerular filtration rate (GFR) compared to those not receiving these medications 2
• For normotensive patients with residual kidney function, ACE inhibitors may provide kidney protection independent of their blood pressure-lowering effects 2

Potential Kidney Risks of Lisinopril

• The FDA label warns that lisinopril can cause changes in renal function including acute renal failure, particularly in patients whose renal function depends on the renin-angiotensin system 3
• Patients at particular risk include those with renal artery stenosis, chronic kidney disease, severe heart failure, or volume depletion 3
• Minor increases in blood urea nitrogen and serum creatinine, reversible upon discontinuation of therapy, were observed in about 2% of hypertensive patients treated with lisinopril alone 3
• Increases in creatinine were more common in patients receiving concomitant diuretics and in patients with renal artery stenosis 3

Patient Monitoring Requirements

• The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends checking changes in blood pressure, serum creatinine, and serum potassium within 2-4 weeks of initiation or dose increase of ACE inhibitors 1
• Patients on ACE inhibitors should have renal function and serum potassium levels monitored within 1-2 weeks of initiation of therapy, with each dose increase, and at least yearly 2
• Some patients may experience a transient decrease in GFR upon initiation of therapy, which is not necessarily indicative of kidney injury 1
• Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril 3

Special Populations and Considerations

• In patients with diabetes, ACE inhibitors like lisinopril have well-established renoprotective effects, especially in those with diabetic nephropathy 2
• Older adults may be more susceptible to reductions in renal function related to ACE inhibitors 2
• Hyperkalemia is a common limiting adverse effect when using ACE inhibitors in patients with heart failure and chronic kidney disease 2
• In patients with heart failure and renal impairment, lisinopril can improve cardiac function while maintaining stable renal function when properly dosed 1

Practical Management Approach

1. Before starting lisinopril:

   • Assess baseline renal function and serum potassium 1
   • Identify high-risk patients (renal artery stenosis, severe heart failure, volume depletion) 3

2. During lisinopril therapy:

   • Monitor renal function and potassium within 1-2 weeks of initiation and dose increases 2
   • Expect possible small, transient increases in creatinine that often stabilize 3
   • Continue monitoring at least yearly even in stable patients 2

3. When to be concerned:

   • Clinically significant decrease in renal function 3
   • Development of hyperkalemia (serum potassium >5.7 mEq/L) 3
   • Symptomatic hypotension, which may compromise renal perfusion 3

Common Pitfalls to Avoid

• Don't discontinue lisinopril prematurely for small, expected increases in creatinine that often stabilize 1
• Avoid combining with other medications that can increase potassium levels (potassium-sparing diuretics, potassium supplements) in patients with impaired renal function 3
• Be cautious with volume depletion from excessive diuretic use, which can precipitate acute kidney injury in patients on ACE inhibitors 3
• Don't miss the opportunity for renoprotection in appropriate patients (diabetes, proteinuria) by avoiding ACE inhibitors due to unfounded concerns 1

In summary, while lisinopril can cause acute changes in kidney function in some patients, it often provides long-term renoprotective benefits when used appropriately with proper monitoring. The risk-benefit assessment should consider the patient's underlying conditions, especially the presence of proteinuria or diabetes, where the renoprotective effects are most pronounced 1, 2.