From the Guidelines
Antihypertensive medications can be administered in the presence of Acute Kidney Injury (AKI) with caution, particularly ACE inhibitors and ARBs, as they should not be discontinued for minor increases in serum creatinine (<30%) in the absence of volume depletion.
Key Considerations
- ACE inhibitors and ARBs can be used in patients with AKI, but it is essential to monitor serum creatinine and potassium levels closely, as there is an increased risk of hyperkalemia, especially in patients with CKD or those on K+ supplements or K-sparing drugs 1.
- Diuretics, such as thiazide or thiazide-type diuretics, can be used in patients with AKI, but with caution, as they can reduce intravascular volume, renal blood flow, and/or glomerular filtration 1.
- Calcium Channel Blockers (CCBs), such as amlodipine, felodipine, and verapamil, can be used in patients with AKI, but with caution, as they can cause dose-related pedal edema and interact with other medications 1.
Medication-Specific Guidance
- ACE inhibitors: Benazepril, Captopril, Enalapril, Fosinopril, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, and Trandolapril can be used in patients with AKI, with usual doses ranging from 10-40 mg/d and daily frequencies of 1 or 2 1.
- ARBs: Azilsartan, Candesartan, Eprosartan, Irbesartan, Losartan, Olmesartan, Telmisartan, and Valsartan can be used in patients with AKI, with usual doses ranging from 40-320 mg/d and daily frequencies of 1 or 2 1.
- CCBs: Amlodipine, Felodipine, Isradipine, Nicardipine SR, Nifedipine LA, and Nisoldipine can be used in patients with AKI, with usual doses ranging from 2.5-10 mg/d and daily frequencies of 1 or 2 1.
Important Notes
- Monitor serum creatinine and potassium levels closely when using ACE inhibitors, ARBs, and diuretics in patients with AKI 1.
- Avoid using ACE inhibitors and ARBs in combination with direct renin inhibitors or other medications that can increase the risk of hyperkalemia or acute renal failure 1.
- Use diuretics with caution in patients with AKI, as they can reduce intravascular volume, renal blood flow, and/or glomerular filtration 1.
From the Research
Antihypertensive Medications in Acute Kidney Injury (AKI)
The administration of antihypertensive medications in the presence of Acute Kidney Injury (AKI) requires careful consideration. Several studies have investigated the risk of AKI associated with various antihypertensive medications, including:
- Angiotensin converting enzyme inhibitors (ACEis) [or angiotensin receptor blockers (ARBs)]
- Diuretics
- Non-steroidal anti-inflammatory drugs (NSAIDs)
Medications to be Used with Caution
The following medications have been associated with an increased risk of AKI:
- Diltiazem, particularly at higher doses 2
- Triple therapy combination of diuretics, ACEis or ARBs, and NSAIDs 3, 4, 5
- Combination of thiazide diuretic and aldosterone antagonist 6
Medications that May be Considered
While there is limited evidence on the safest antihypertensive medications to use in AKI, the following medications may be considered:
- Labetalol, which was not found to be associated with an increased risk of AKI in one study 2
- Furosemide and spironolactone combination, which was found to have a lower risk of AKI compared to other diuretic combinations 6
Key Considerations
When administering antihypertensive medications in patients with AKI, it is essential to:
- Monitor renal function closely
- Adjust medication doses according to renal function
- Avoid using medications that may exacerbate AKI, such as NSAIDs and certain diuretic combinations 3, 4, 5
- Consider alternative medications that may have a lower risk of AKI, such as labetalol or certain diuretic combinations 2, 6