Lisinopril Use in End-Stage CKD
Consider reducing the dose or discontinuing lisinopril in patients with end-stage CKD (eGFR <15 ml/min per 1.73 m²), particularly when managing uremic symptoms or in the setting of symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment. 1
Key Considerations for End-Stage CKD
When to Continue ACE Inhibitors
- ACE inhibitors are not contraindicated in end-stage renal disease and are frequently used in dialysis patients 1
- The KDIGO 2024 guidelines explicitly state to continue ACE inhibitors even when eGFR falls below 30 ml/min per 1.73 m² in most circumstances 1
- For patients with residual kidney function on dialysis, ACE inhibitors may help preserve remaining kidney function 2
- In hemodialysis patients ≤65 years old, ACE inhibitors reduced mortality by 79% (RR 0.211) independent of blood pressure effects 3
When to Reduce or Discontinue
Practice Point 3.6.5 from KDIGO 2024 provides clear guidance to consider reducing dose or discontinuing ACE inhibitors in three specific scenarios: 1
- Symptomatic hypotension that cannot be managed with volume adjustment
- Uncontrolled hyperkalemia despite medical treatment (dietary restriction, diuretics, potassium binders)
- To reduce uremic symptoms while treating kidney failure (eGFR <15 ml/min per 1.73 m²)
Critical Safety Monitoring
Hyperkalemia Management:
- Hyperkalemia is the primary concern in end-stage CKD, with risk factors including renal insufficiency, diabetes, and concomitant potassium-sparing diuretics 4
- Monitor serum potassium within 2-4 weeks of any dose adjustment 1
- Attempt to manage hyperkalemia with medical measures (dietary restriction, diuretics, potassium binders) rather than immediately discontinuing the ACE inhibitor 1
- Only discontinue if hyperkalemia remains uncontrolled despite these interventions 1
Dialysis-Specific Considerations:
- Avoid lisinopril in patients using polyacrylonitrile dialysis membranes due to risk of anaphylactoid reactions 1
- Lisinopril is significantly removed by hemodialysis (approximately 50% reduction in plasma concentration after 4 hours), requiring post-dialysis dosing 5
- Haemodialysis clearance of lisinopril averages 40 ml/min 5
Dosing Adjustments
For patients with eGFR <30 ml/min per 1.73 m²: 4, 6
- Dose reduction is necessary for lisinopril (unlike fosinopril which does not require adjustment)
- Start with low doses and titrate slowly ("start low - go slow") 6
- Consider post-dialysis administration timing due to significant dialytic removal 5
Clinical Decision Algorithm
Step 1: Assess current clinical status
- Is the patient symptomatic from hypotension?
- Is potassium >5.5 mmol/L despite medical management?
- Are uremic symptoms present that might improve with ACE inhibitor discontinuation?
Step 2: If YES to any above → Consider dose reduction or discontinuation 1
Step 3: If NO to all above → Continue ACE inhibitor with:
- Reduced dosing appropriate for eGFR 6
- Close monitoring of potassium every 2-4 weeks 1
- Verification of dialysis membrane type (avoid polyacrylonitrile) 1
- Post-dialysis dosing schedule 5
Common Pitfalls to Avoid
- Do not automatically discontinue ACE inhibitors simply because a patient reaches end-stage CKD; the mortality benefit may persist, especially in younger patients 3
- Do not combine with ARBs or direct renin inhibitors as this increases adverse effects without additional benefit 1, 4
- Do not ignore the dialysis schedule when dosing, as significant drug removal occurs during hemodialysis 5
- Do not use with NSAIDs in this population, as the combination significantly increases acute kidney injury risk 4
Quality of Life Considerations
The decision to continue or discontinue should prioritize: