From the Guidelines
Lisinopril should be discontinued in patients with renal arterial stenosis who experience a spike in blood pressure, as it can cause acute kidney injury due to reduced efferent arteriolar tone and compromised renal perfusion. This recommendation is based on the most recent and highest quality study available, which highlights the importance of careful management of patients with renal artery stenosis and hypertension 1.
Key Considerations
- ACE inhibitors like lisinopril can reduce glomerular filtration pressure in patients with bilateral renal artery stenosis or stenosis in a solitary functioning kidney, leading to acute kidney injury 1.
- A paradoxical rise in blood pressure after starting lisinopril, along with worsening kidney function, suggests underlying renal artery stenosis that was previously undiagnosed 1.
- Alternative antihypertensive medications, such as calcium channel blockers (like amlodipine) or beta-blockers (like metoprolol), may be safer in this situation 1.
- Patients with renal artery stenosis should be evaluated with renal artery imaging and referred to a nephrologist or interventional radiologist to discuss potential revascularization options for the stenosis 1.
Management Strategies
- Discontinue lisinopril and evaluate the patient with renal artery imaging to confirm the diagnosis of renal artery stenosis.
- Consider alternative antihypertensive medications that may be safer in this situation, such as calcium channel blockers or beta-blockers.
- Refer the patient to a nephrologist or interventional radiologist to discuss potential revascularization options for the stenosis.
- Monitor the patient's blood pressure and kidney function closely to prevent further complications.
From the FDA Drug Label
Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].
Lisinopril discontinuation in patients with renal arterial stenosis who experience a spike in blood pressure (hypertension) may be necessary if there is a clinically significant decrease in renal function. However, the decision to discontinue should be based on the overall clinical assessment and the presence of other risk factors. 2
From the Research
Lisinopril and Renal Arterial Stenosis
- Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is effective in lowering blood pressure in patients with renovascular hypertension, including those with renal arterial stenosis 3.
- However, in patients with bilateral renal artery stenosis, ACE inhibitors like lisinopril can cause a decrease in glomerular filtration rate (GFR) and potentially lead to renal failure 4, 5.
- A study found that a patient with renal artery stenosis developed reversible renal failure after taking lisinopril, which was discontinued due to nonspecific symptoms 4.
- Another study suggested that the dose of lisinopril should be adjusted in patients with advanced renal failure to prevent drug accumulation and adverse effects 6.
- In patients with bilateral renal artery stenosis who have undergone successful renal artery stent revascularization, ACE inhibitors like lisinopril may be safely used 7.
Considerations for Discontinuing Lisinopril
- If a patient with renal arterial stenosis experiences a spike in blood pressure while taking lisinopril, the decision to discontinue the medication should be made on a case-by-case basis, considering the individual's overall clinical condition and the potential risks and benefits of continuing or discontinuing the medication 3, 5.
- It is essential to monitor renal function and blood pressure closely in patients with renal arterial stenosis who are taking ACE inhibitors like lisinopril 4, 6.
- Alternative antihypertensive medications may be considered if lisinopril is discontinued due to adverse effects or inadequate blood pressure control 5, 7.