From the Guidelines
ACE inhibitors can be used in patients with a solitary kidney and mild Chronic Kidney Disease (CKD), as they have been shown to reduce cardiovascular event rates and kidney end points among patients with CKD, according to the 2021 KDIGO clinical practice guideline 1. When considering the use of ACE inhibitors in these patients, it is essential to weigh the potential benefits against the risks, including hyperkalemia, hypokalemia, and acute kidney injury. The guideline recommends starting RASI therapy (ACEI or ARB) for people with high BP, CKD, and severely increased albuminuria (CKD G1 to G4; albuminuria category A3) without diabetes (1B) 1. Key considerations for using ACE inhibitors in patients with a solitary kidney and mild CKD include:
- Starting with a low dose (such as lisinopril 2.5-5mg daily) and gradually titrating up while monitoring kidney function and potassium levels
- Performing blood tests within 1-2 weeks of initiation or dose changes to check creatinine and potassium
- Maintaining adequate hydration and avoiding NSAIDs, which can worsen kidney function when combined with ACE inhibitors
- Using potassium supplements and potassium-sparing diuretics cautiously due to increased hyperkalemia risk The 2021 KDIGO guideline also suggests starting RASI therapy (ACEI or ARB) for people with high BP, CKD, and moderately increased albuminuria (CKD G1 to G4; albuminuria category A2) without diabetes (2C) 1. Overall, the use of ACE inhibitors in patients with a solitary kidney and mild CKD requires careful monitoring and consideration of the potential risks and benefits, but can be a valuable treatment option for reducing cardiovascular event rates and kidney end points, as supported by the highest quality evidence from the 2021 KDIGO clinical practice guideline 1.
From the Research
ACE Inhibitors in Patients with Solitary Kidney and Mild CKD
- The use of Angiotensin-Converting Enzyme (ACE) inhibitors in patients with a solitary kidney and mild Chronic Kidney Disease (CKD) is a topic of interest, with several studies providing insights into their effectiveness and safety 2, 3, 4, 5, 6.
- According to a study published in 2003, ACE inhibitors are effective in patients with type 1 diabetes and renal disease, as well as in those with nondiabetic renal disease and proteinuria >0.5 g/d, and may be beneficial in patients with mild-to-moderate renal insufficiency 2.
- Another study from 1996 suggests that treatment with ACE inhibitors results in kidney protection due to reduction of systemic blood pressure, intraglomerular pressure, and proteinuria, but notes that dose reduction is necessary in patients with renal insufficiency and that there is a risk of hyperkalemia 3.
- A 2018 review recommends ACE inhibitors as the first-line treatment for patients with established CKD and/or diabetes with albuminuria, with a blood pressure goal of <130/80 mmHg 4.
- A 2014 review discusses the safety of ACE inhibitor therapies in patients with CKD, noting that the main adverse effects are hypotension, renal function impairment, and hyperkalemia, but suggests that combination with moderate reduction in dietary sodium intake may be a better alternative to dual RAAS-blockade 5.
- A 2017 study specifically addresses the use of anti-RAAS agents in patients with congenital or acquired solitary kidney, concluding that available data suggest anti-RAAS drugs may be reno-protective in these patients, with the use of ARBs potentially more appropriate in children and women 6.
Key Considerations
- Patients with a solitary kidney and mild CKD may benefit from ACE inhibitors, but caution should be exercised due to the potential risks of hyperkalemia and renal function impairment 2, 3, 5.
- Regular monitoring of serum creatinine and potassium levels is recommended, particularly in patients with a glomerular filtration rate <30 mL/min 2.
- The use of ACE inhibitors in combination with other medications, such as diuretics, may be effective in reducing blood pressure and proteinuria, but requires careful consideration of potential interactions and adverse effects 2, 3, 4, 5.